Azria Health Prairie Ridge

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility policy review, and staff interviews the facility failed to ensure that residents are free from financial exploitation for 1 of 9 residents (Resident #3) reviewed. The facility reported a census of 62 residents.Findings include: Review of Resident #3 Minimum Data Set (MDS) assessment, dated 8/11/25 revealed a diagnoses list that included adult failure to thrive, type 2 diabetes with unspecified complications, alcoholic cirrhosis of liver without ascites (fluid accumulation in the abdomen), anxiety, and depression. The Brief Interview for Mental Status (BIMS) score of 10 out of 15 points indicated a moderate cognitive impairment. The MDS indicated Resident #3 always able to make herself understood and always understood others. The MDS identified the resident totally dependent on staff for substantial assistance to reposition in bed, transfer to and from bed or chair, and unable to stand or ambulate. Review of a Facility Self-Reported Incident, dated 12/7/25, revealed When having a discussion with Resident [name redacted, Resident #3], bims of 13. It was brought to the Administrators attention that [name redacted, Resident #3] let CNA [name redacted, Staff H, Certified Nursing Assistant (CNA)] her food stamp card to spend on herself.Review of Resident #3 Care Plan revealed a problem labeled I have actual and/or the potential for inability to cope with my lifestyle changes, limitations in my functional abilities and my husband no longer being able to act as my caregiver due to his own health complications, initiated 8/29/25. The plan directed staff to:a. Assist the resident to identify, access and use support systems of family, initiated 8/29/25.b. Encourage and allow me time to express my feelings re: difficulty coping with lifestyle changes. Allow me time to grieve, initiated 8/29/25.c. Encourage the resident to express feelings of anger, frustration and/or concerns, as appropriate. She likes 1:1 conversation, initiated 8/29/25.d. The resident needs assistance with problem solving, initiated 8/29/25.The Care Plan included a new problem labeled Involved in an allegation of misappropriation of funds by staff member, initiated 12/9/25, which directed staff to: a. Psychosocial wellbeing check in 2x a week for 2 weeks, then as needed, initiated 12/10/25.b. Resident education completed that only administrative staff will use personal money cards for personal items. Resident understood and agreed with education, initiated 12/9/25.During an interview 1/12/26 at 12:14 p.m., Resident #3 stated she had an EBT (Electronic Benefits Transfer) Food Stamp card for several years. She stated she received $171 monthly in benefits. Resident #2 stated she didn't always like the food served at the facility and wanted some snacks, so she asked Staff H, CNA to use her EBT Food Stamp card to purchase some snacks for her. She told Staff H that she could buy some things for herself with the card as well. Resident #3 stated she did not give Staff H an amount that she could spend and didn't know what she'd purchased for herself. Resident #3 stated she recalled the total purchased was for a little over $100, and Staff H returned the EBT Food Stamp card. Resident #3 stated she didn't think she did anything wrong, as she didn't think she had any way to get the food and Staff H was helping her. The resident stated she didn't want anyone to be in trouble over this and after it happened was when she found out there were staff at the facility that could have shopped for her.During another interview on 1/14/26 at 1:10 p.m., Resident #3 stated some of the items purchased required refrigeration, she didn't have access to the refrigerator and sort of lost track of those items. She stated Staff H, CNA gave her the receipt for the purchase but she didn't have it any more.During an interview on 1/8/26 at 12:40 p.m., the Director of Nursing (DON) stated they learned Resident #3 gave her EBT Food Stamp card to Staff H, CNA when a nurse reported the situation after a conversation with the resident. The DON explained Resident #3 stated she gave the card to Staff H to get food items for her and told Staff H she could get some food for herself. The DON stated Staff H was questioned and she stated she got food for the resident and for herself. DON stated Staff H didn't say what she spent on herself. The DON added that Staff H was terminated as a result and the facility reported the matter as required to the State Agency and the local police. During an interview on 1/14/26 at 10:30 a.m., Staff H, CNA, stated the resident wanted some snacks and asked her to take her [Resident #3's] EBT Food Stamp card to the store, purchase food for her [Resident #3] and said she [Staff H] could buy some food for herself as well. Staff H stated this occurred in October and she shopped at a grocery store located in [NAME]. Staff H stated she spent a little over $100 and used the resident's EBT Food Stamp card for the purchase. Staff H stated the resident checked the balance on the card before she gave it to her and it was $230 or $300. Staff H couldn't recall what she purchased for herself, then said it was a bag of chips, a 20-ounce soda and she couldn't remember what else, but was only a few items. Staff H stated she brought the resident's requested groceries to the facility in 4 or 5 grocery bags, refrigerated items were placed in the refrigerator in the beauty shop, and she returned the EBT Food Stamp card to the resident with the receipt. Staff H stated she had been a CNA since 2014, and had education on dependent adult abuse and didn't think she had done anything wrong because the resident told her she could purchase items for herself with the EBT Food Stamp card.During an interview on 1/12/26 at 12:20 p.m. Staff A, CNA and Restorative Aide (RA) stated she did not know about the situation with the resident's EBT Food Stamp card until after it occurred. She stated she was questioned by management staff. Staff A stated she knew it was wrong to use a resident's resources or accept gifts from a resident and that information was covered in the dependent adult abuse education that she received prior to employment at the facility. During an interview on 1/14/26 at 12:21 p.m., Staff L, [NAME] President of Operations for the facility's corporation stated they reimbursed the resident $25 for the items Staff H purchased for herself with the resident's EBT Food Stamp card, and would reimburse the total amount to the resident once known. Staff L stated the resident and staff were educated on dependent adult abuse that included financial exploitation, and there were designated staff at the facility that could shop for residents and who should shop for the residents when the need arose.A document received from Staff L, [NAME] President of Operations dated 1/30/26 described both she and the facility Social Worker met with the resident on 1/28/26, reviewed the purchases on the grocery store receipt dated 10/8/25 with the resident, the resident identified several items that she did not ask Staff H to purchase, those items totaled $115.96 and believed to be what Staff H had purchased for herself with the resident's EBT Food Stamp card.Review of a grocery store receipt dated 10/8/25, obtained by the State Agency on 1/22/26 revealed a total of 68 items purchased with Resident #3 EBT Food Stamp card for a total of $268.93.The facility's Abuse, Neglect, Exploitation and Misappropriation Prevention policy, version 10/2023 directed staff:a. Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. This policy consists of a facility-wide commitment and resource allocation to support the following objectives that include, but are not limited to:a. Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including, but not necessarily limited to facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, and any other individual.b. Develop and implement policies and protocols to prevent and identify abuse, neglect, or mistreatment of residents, and/or theft, exploitation or misappropriation of resident property.c. Establish and maintain a culture of compassion and caring for all residents and particularly those with behavioral, cognitive or emotional problems.d. Provide staff orientation and training/orientation programs that include topics such as abuse prevention, identification and reporting of abuse, stress management, and handling verbally or physically aggressive resident behavior.e. Identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property.f. Investigate and report any allegations within timeframes required by federal requirements.g. Protect residents from any further harm during investigations.

Based on clinical record review, facility policy review, and staff interviews the facility failed to ensure that residents remained free from resident to resident altercations for 1 of 9 resident records reviewed (Resident #2). The facility reported a census of 62 residents.Findings include: Review of a Facility Reported Incident, dated 12/24/25 revealed (resident name redacted, Resident #1) was sitting in front of doorway to the nurses' station when (resident name redacted, Resident #2) was trying to pass by him. As Resident #2 passed by, Resident #1 swung back hitting her in the upper back twice. This was witnessed by Restorative Aide (name redacted, Staff A) and (name redacted, Staff B, Registered Nurse (RN)). When altercation started, (name redacted, Staff A) tried to stop (name redacted, Resident #1) from hitting (name redacted, Resident #2) by holding arm, (name redacted, Resident #1) then hit (name redacted, Staff A) in the shoulder and grabbed at her abdomen pinching it and causing a bruise. Immediately separated, head to toe skin assessment and pain assessment completed. Primary care provider, Power of Attorney (POA) and law enforcement notified.Review of the Minimum Data Set (MDS) assessment, dated 11/14/25 revealed a list of diagnoses for Resident #1, which included cerebrovascular accident (a stroke), hemiplegia (paralysis on 1 side of the body), aphasia (inability or difficulty with speech), adjustment disorder with depressed mood, and a history of falls and diabetes. The Brief Interview for Mental Status (BIMS) score 9 out of 15 indicted a moderate cognitive impairment. The MDS indicated the resident usually able to make himself understood, usually able to understand others, and had behaviors from 1 to 3 days of the 7 days that preceded the assessment date that did not impact the resident or others. The MDS indicated Resident #1 required substantial staff assistance to reposition in bed, transfer to and from bed or chair, dressing, toileting and bathing, unable to stand or ambulate and wheelchair used as primary mode of transportation.Review of Resident #1 Care Plan revealed a problem labeled I have alteration in mood and behaviors, I often do not want to have clothes on, I can be verbally aggressive, initiated 11/11/25. The plan directed staff to:a. Administer medications as ordered. Monitor/document side effects and effectiveness, initiated 11/11/25.b. Anticipate and meet the resident's needs, initiated 11/11/25.c. Assist the resident to develop the most appropriate methods of coping and interacting. Encourage the resident to express feelings appropriately, initiated 11/11/25.d. Caregivers to provide opportunity for positive interaction, attention. Stop and talk with him/her as passing by, initiated 11/11/25.e. If reasonable, discuss the resident's behavior with them. Explain/reinforce why behavior is inappropriate and/or unacceptable, initiated 11/11/25.g. Intervene as necessary to protect the rights and safety of others. Approach/speak in a calm and controlled manner. Redirect. Remove from situation and take to alternate location as needed, initiated 11/11/25. A Nursing Progress Note transcribed by the Director of Nursing (DON) on 12/24/25 at 3:20 p.m. stated, in part: Resident watching another resident (name redacted, Resident #2) propelling self in her wheelchair around the nurse's station, as (name redacted, Resident #2) was trying to pass Resident #1 swung his arm back hitting (name redacted, Resident #2) in the upper back twice. A CNA (Certified Nursing Assistant) intervened holding Resident #1's arm and (name redacted, Resident #2) was able to get by. Resident #1 then hit the CNA in right shoulder and grabbed at her abdomen pinching her skin and causing a reddish/blue mark. Resident #1 was separated from (name redacted, Resident #2) and was placed on 1:1, Nurse Practitioner (NP) and law enforcement were notified.A Nursing Progress Note transcribed by the DON on 12/24/25 at 4:32 p.m. described the primary care provider was notified of Resident #1's transfer to the county jail by a Sheriff's vehicle.Review of Iowa Courts Online electronic records/data repository revealed Resident #1 arrested and taken into custody by the county Sheriff's office on 12/24/25, where he remained for the duration of the State Agency investigation. Resident #1 charged with assault on persons in certain occupations with bodily injury, and older individual assault.2. The MDS assessment for Resident #2, dated 12/18/25, revealed a list of diagnoses that included non-Alzheimer's dementia, cognitive communication deficit, adjustment disorder with mixed anxiety and depressed mood. The BIMS score of 6 out of 15 points indicated a severe cognitive impairment. The MDS indicated Resident #2 sometimes able to make herself understood and sometimes able to understand others. The MDS revealed Resident #2 unable to stand or ambulate, and used a wheelchair as primary method of transport.Review of the Care Plan revealed a problem labeled Resident has impaired cognitive function/dementia or impaired thought processes related to Dementia diagnosis, initiated 1/19/25. The plan directed staff to: a. Ask yes/no questions in order to determine the resident's needs, initiated 1/19/25.b. Cue, reorient and supervise as needed, initiated 1/19/25.c. Keep the resident's routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion, initiated 1/19/25.d. Present just one thought, idea, question or command at a time, initiated 1/19/25.A Nursing Progress Note in Resident #2's record, transcribed by the DON on 12/24/25 at 3:57 p.m. documented, in part: Resident was propelling self in her wheelchair around the nurse's station as per her routine every evening. When she was trying to pass (name redacted, Resident #1) he slung his arm back hitting her in the upper back twice. A CNA intervened and the resident was able to get by. Upon skin assessment no issues (redness, pain, or marks) were found, resident stated she had no pain.During an observation on 1/12/26 at 3:24 p.m., Resident #2 used her feet to self-propelled her wheelchair in the hallway near the Nurses Station area.During an interview on 1/12/26 at 12:20 p.m., Staff A, Certified Nursing Assistant (CNA) and Restorative Aide (RA) stated Resident #1 would become irritable if staff redirected him. On the afternoon of 12/24/25 Resident #2 self-propelled her wheelchair in the hall, and tried to get by Resident #1, while he talked on the phone at the nurse's station. Staff A stated she could not get to Resident #1 before he struck Resident #2 with his fist, twice on her back, as Resident #2 leaned forward in her wheelchair and continued to self-propel her wheelchair past him. Resident #1 then stood up and turned in the direction of Resident #2. Staff A stated she thought he was going to go after Resident #2, but was able to redirect him and asked him to sit down. Staff A stated that is when Resident #1 hit her with a closed fist on her right shoulder area, and then pinched her in the abdomen area. Staff A stated she was bruised on her shoulder and abdomen. During an interview 1/12/26 at 2:32 p.m., Staff B, Registered Nurse (RN) stated she worked on 12/24/25 and witnessed Resident #1 strike Resident #2 twice on the back. Staff B explained Resident #2 self-propelled her wheelchair around Resident #1 while he was on the phone at the nurse's station. Staff B stated Resident #1 then hit Resident #2 on her back. She stated it all happened so fast. She explained Resident #1 stood up, and Staff A, CNA/RA was able to stop him from hitting Resident #2 again. Staff B stated she then was able to direct Resident #1 to sit back down, and that is when he hit and pinched Staff A. Staff B stated they were able to get Resident #1 seated and separated from Resident #2, and notified the DON immediately. During an interview on 1/12/26 at 2:55 p.m., Staff I, CNA, stated Resident #1 had behaviors, explaining sometimes he was redirectable but other times he acted like he didn't understand staff and when redirected or a direction repeated, he would get agitated. Staff I stated she worked on 12/24/25 but did not witness the incident between Resident #1 and Resident #2.During an interview on 1/8/26 at 12:40 p.m., the DON stated Resident #1 had not had any physical altercations with any of the residents. She stated the resident planned to transfer to another facility on 12/29/25 to be closer to his family. The facility notified law enforcement of the incident on 12/24/25, county deputies arrived shortly after that and took the resident into custody and there were charges against him related to the incident. The DON stated they had re-assessed Resident #1's BIMS about 2 weeks before the incident and it was 13 at that time (indicated no cognitive impairment). The DON stated nursing staff assessed Resident #2 for injuries after the incident, and none were found. Review of the facility's policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention policy, dated 10/2023 directed staff:a. Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms.b. This policy consists of a facility-wide commitment and resource allocation to support the following objectives that include, but are not limited to:1. Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including, but not necessarily limited to facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, and any other individual.c. Develop and implement policies and protocols to prevent and identify abuse, neglect, or mistreatment of residents, and/or theft, exploitation or misappropriation of resident property.d. Establish and maintain a culture of compassion and caring for all residents and particularly those with behavioral, cognitive or emotional problems.e. Provide staff orientation and training/orientation programs that include topics such as abuse prevention, identification and reporting of abuse, stress management, and handling verbally or physically aggressive resident behavior.f. Identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property.g. Investigate and report any allegations within timeframes required by federal requirements.h. Protect residents from any further harm during investigations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff, resident and family interviews, the facility failed to make an attempt to meet resident needs prior to issuing emergency discharges for 2 of 2 residents (Resident #1 and Resident #5) reviewed. After a resident to resident altercation the facility issued emergency discharges to Resident #1 and Resident #5 upon their transfer to the hospital for an evaluation. The facility reported census was 57.Findings include: 1. According to a Minimum Data Set (MDS) with a reference date of July 17, 2025, Resident #1 had a Brief Mental Status (BIMS) score of 14 of 15, indicating an intact cognitive status. Resident #1 was coded independent to needing supervision assistance with transfers, mobility, dressing, toilet use and personal hygiene needs. Resident #1's diagnoses included coronary artery disease, atrial fibrillation and was always continent of bladder and bowel.According to the facilities Notice of Resident Transfer or Discharge form dated Sept. 16, 2025, directed to Resident #1's guardian, the form indicated Resident #1 was being discharged due to the safety of individuals in the facility being endangered due to the clinical or behavioral status of the resident. The form includes the placement facility and rights to appeal to the State agency with address and contact number along with other related advocacy agencies, addresses and numbers. The form was initialed by Resident #1.Clinical record review revealed Resident #1 was admitted on [DATE] and had a total of five recorded altercations with his peers. Altercations per the clinical record:a. On May 24, 2025 described as a disagreement with no threats of violence. Residents were moved to different rooms. b. On July 4, 2025 described as arguing about the TV being too loud. Residents were deescalated and volume turned down. c. On July 5, 2025 residents continued to argue and were moved to different rooms. d. On Sept. 12, 2025 arguing with roommate which escalated to both residents threatening to fight each other. The residents were separated and moved rooms. e. On Sept. 16, 2025 described as a verbal dispute with threats of violence leading to the facility doing an emergency discharge on both residents. 2. According to a Minimum Data Set (MDS) with a reference date of Sept. 16, 2025, Resident #5 had a Brief Mental Status (BIMS) score of 14 of 15, indicating an intact cognitive status. Resident #5 required maximal assistance with dressing and toileting hygiene and supervision with transfers, mobility and personal hygiene needs. Resident #5's diagnosis included coronary artery disease and atrial fibrillation. Resident #5 was coded as occasionally incontinent of bladder.According to the facilities Notice of Resident Transfer or Discharge form dated Sept. 16, 2025, directed to Resident #5's father or sister, the form indicated Resident #5 was being discharged due to the safety of individuals in the facility being endangered due to the clinical or behavioral status of the resident. The form includes the placement facility and rights to appeal to the State agency with address and contact number along with other related advocacy agencies, addresses and numbers. The form was initialed by Resident #5.In an interview on [DATE] at 5:30 p.m. the Administrator explained her reasoning to discharge Resident #1 and Resident #5 on Sept. 16, 2025. The Administrator stated there had been two resident to resident altercations days earlier involving Resident #1 and Resident #6 in a verbal and threatening altercation on Sept. 13, 2025 and Resident #5 and Resident #7 in a verbal and threatening altercation on Sept. 15, 2025. In both situations, the residents were roommates and the intervention were to separate by changing rooms, which eventually resulted in Resident #1 and Resident #5 becoming roommates and leading to the third verbal and threatening altercation on Sept. 16, 2025. The facility received orders for an emergency psychiatric evaluation and Resident #5 was the first to be sent out to the hospital #1 emergency department (ED), however the emergency room (ER) physician refused to complete an evaluation and wanted the resident returned to the facility. The Administrator stated she and the Director of Nursing (DON) decided to transport Resident #1 to a different hospital #2 emergency room. The Administrator explained what was happening and the ER physician stated they could do a psychiatric evaluation, but thought Resident #1 was fine. Hospital #2 staff then told the Administrator they could leave and they would be in contact with them. When Hospital #2 called the facility, the Administrator stated they had no more available rooms to accommodate residents with these behaviors and felt she had no choice but to discharge them. The Administrator stated Resident #1's guardian was called and informed and Resident #5's father and sister were called but never answered and the emergency discharge was explained to Resident #5 and signed by him.In an interview on Sept. 30, 2025 at 8:40 a.m. The Director of Nursing (DON) stated on the late evening of Sept. 16, 2025, she and the Administrator were called into the facility regarding a resident to resident conflict between Resident #1 and Resident #5. The two residents had gotten into a verbal argument which escalated into threats of physical violence. The DON stated they got an order for a psychiatric evaluation and began the emergency discharge process. They contacted emergency medical services (EMS) to have the residents transported to Hospital #1, but were told they would only take one. Resident #5 was initially sent. The Hospital #1 physician called the facility, refusing to do a psychiatric evaluation, noting Resident #5 was fine and they were discharging him back to the facility. The DON stated since Hospital #1 refused to complete a psychiatric evaluation on Resident #5, she and the Administrator would transport Resident #1 to Hospital #2 instead. When they arrived to Hospital #2, they explained why Resident #1 was there and the nurse began assessing him. There was a loud alarm going off and the DON and the Administrator were told they could leave and that they would call them with their evaluation. Sometime after 3:00 a.m. the facility received the call and was told Resident #1 did not meet the criteria to admit. The DON stated she was not aware of what else was discussed. The DON was then asked about family and guardian notifications and she stated she contacted Resident #1's daughter, guardian and informed her of their plans to discharge Resident #1 and depending on the outcome of the psychiatric evaluation, he may be readmitted . The DON stated she did not discuss the appeals process with Resident #1's daughter, guardian, noting she thought Resident #1 was his own person and had him sign the discharge papers. The DON was unaware that Resident #1's daughter was also his guardian. The DON stated they attempted to contact Resident #5's father and sister unsuccessfully, but explained the discharge papers to Resident #5 and had him sign the paper work. In an interview on Sept. 30, 2025 at 10:13 a.m. Resident #1's guardian, stated she received a call from the facility sometime after 10:00 p.m. on Sept. 16, 2025. The guardian stated the nurse was very kind and stated there was an altercation between her and another resident and they were doing an emergency discharge. The guardian stated she was half asleep and not clearly thinking as they told her they were taking him to Hospital #2. The guardian stated she questioned why Hospital #2 when there was a local hospital #1 and she was not provided a clear explanation. The guardian was asked whether the facility explained what an emergency discharge was and the appeals process should she disagree. The guardian stated that was never discussed and she was never provided any form to sign. The guardian stated her father is still in Hospital #2 and she has visited a couple times, but the distance is a problem. In an interview on [DATE]. 2025 at 9:00 a.m. The Social Worker at Hospital #2, stated Resident #1 was admitted on Sept. 17, 2025 following a verbal altercation at a facility. Resident #1 was found not to meet criteria for psychiatric admission. Hospital #2 reached out to the facility to try and have him return and the facility refused to take him back. Hospital #2 have now been forced to try and find placement for him. Hospital #2's social worker stated she thought Resident #1 was doing fine with no known reports of behavioral issues.In an interview on 9/30/25 at 3:46 p.m. Resident #5's sister, stated she received a call about 1:30 a.m. on Sept. 17, 2025 from Hospital #1 stating that her brother was in the emergency room (ER). That he had been in an altercation with another resident and the facility brought him there to be evaluated and now will not take him back. Resident #5's sister stated she called her father and together they went to the ER and picked him up. Resident #5's sister stated her brother has an apartment and his father took him there. The next morning her father went to the facility with Resident #5 to get his clothes. The facility refused to allow him into the facility and brought his clothes out to him. His father then took him to the grocery store and picked up some food. Resident #5's sister stated she thought her brother tried calling several people to arrange in home services, but noted her dad is pretty attentive. Resident #5's sister stated her dad is Resident #5's payee, but notes he can pay his bills. Resident #5 did not know about his medications and stated her brother probably mostly needs help with bathing, activities of daily living (ADL's), cleaning and cooking. Resident #5's sister stated she thought he was doing fine.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, and staff interview, the facility failed to implement a restorative nursing program per guidance from therapy for 1 of 1 resident (Resident #25) reviewed for positioning and mobility. The facility reported a census of 53 residents. Findings include:
Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored 15 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated intact cognition. Per this assessment, the resident had no impairment to upper extremities, and had impairment to one side of lower extremities.
During an interview on 7/29/25 at 9:33 AM, Resident #25 stated she had done restorative exercises one time.
Review of the Care Plan last revised 7/18/25 revealed a Focus area to address Restorative Programming required to maintain current level of functional mobility (Ax2 with walker and gait belt for stand pivot transfers), to preserve joint integrity, preserve strength/ROM, and to prevent decline and/or falls. An Intervention, dated 8/10/18 included See Restorative Manual for specific program.
Review of a document titled Restorative Care Program sheet, effective date 6/18/25 revealed: The Patient is discharged from: PT (physical therapy). Goals for Restorative Program: Maintain CLOF (current level of functioning) 3-5x/week. Approach/recommendations for implementation of above Yes/No (Circle one) [neither circled]. [Name brand seated bike redacted] l2-L4 10-15 min. Sit to Stand activities at grab bars or FWW (four wheeled walker). Seated B (bilateral) LE (lower extremity) strengthening 2-4 lbs. (pounds) ankle weights – hamstring curl, LAQ (long arc quad, an exercise of seated knee extension), hip abduction, hip adduction, marching. Seated B LE stretching – hamstrings gastric/calf (muscle area in calf). Precautions or comments to this program: Requires encouragement to push herself. May need assistance for sit to stand.
During an interview on 7/31/25 at 8:57 AM, Staff A, Restorative, CMA/CNA (Certified Medication Aide and Certified Nursing Assistant) explained Resident #25 is in the rotation for Restorative programming. Staff A stated sometimes she is pulled from Restorative programming for resident care. She stated today she was pulled to do showers. When queried how she did restorative programming if worked the floor, Staff A stated she is unable to explain. Staff A stated activities of daily living could be restorative, and if completed a shower could count as restorative. Staff A stated there were no other staff who were officially assigned do Restorative programming. She stated there was another staff who would sometimes assist.
Staff A stated she followed therapies recommendations, and Staff B, Central Supply was the Restorative Nurse.
On 7/31/25 at 9:10 AM, Staff B queried about their involvement in Restorative programming, and she stated she helped Staff A put stuff in the computer. She explained, Staff A would come to her with any issues with any of the residents, and Staff A did the weekly charting. Staff B denied doing any Restorative programming with residents. Staff B stated if Staff A was not available sometimes another CNA covered.
On 7/31/25 at 10:30 AM, the Regional Nurse Consultant (RNC) explained she had talked to Staff B about what to do with restorative, writing, signing off, and checking. Per the RNC, the facility didn't have what considered a technical restorative program, so what they did was follow the recommendations three to five days week as allowed.
On 7/31/25 at 5:09 PM, the Director of Nursing (DON) explained they would expect the nurse to fill in if Staff A was gone, or to assign someone else.
Review of the facility policy, titled Restorative Nursing Services dated 7/2022 revealed:
a. Restorative nursing care consists of nursing interventions that may or may not be accompanied by formalized rehabilitative services (e.g., physical, occupational or speech therapies).
b. Residents may be started on a restorative nursing program upon admission, during the course of stay or when discharged from rehabilitative care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, facility policy review, and resident and staff interviews, the facility failed to follow speech therapy recommendations for eating assistance for 1 of 18 residents reviewed for following provider orders (Resident #11). The facility reported a census of 53 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #11 scored a 5 out of 15 on the Brief Interview for Mental Status (BIMS) exam, which indicated cognition severely impaired. The MDS indicated the resident required supervision or touching assistance with eating. The MDS revealed medical diagnoses for stroke, aphasia following cerebral infarction. The MDS indicated resident not had a weight loss of 5% in one month or 10% in 6 months and not on a therapeutic diet. Review of the Care Plan revealed a Focus area revised on 6/25/25 for difficulty swallowing and pocketing food status post cerebral vascular accident. The Intervention revised on 7/16/25 indicated distant supervision; Resident #11 will pocket solids and liquids, he is able to clear when allowed. Please do not instruct Resident #11 to swallow or prevent him from taking the next bite or sip, if Resident #11 holds his food or liquid for a really long time, you many ask him to put his chin down, this triggered a swallow. The Interventions revised on 7/30/25 indicated regular diet with thin liquids with mechanical soft texture. Review of the EHR (Electronic Health Record) revealed an order for PT/OT/SP (physical therapy/occupational therapy/speech therapy) to evaluate and treat as indicated. Revision Date 7/7/25. The Speech Therapist recommendations dated 4/25/25 revealed the following for Resident #11: Feeding/Dietary: Recommend continued mech (mechanical soft diet) soft solids and nectar liquids. Please do not cue patient to swallow or touch him. He will pocket food but he is able to clear on his own. It is okay to ask him to tuck his chin, this will elicit a swallow. He has swallowing apraxia- so the more you say to him the worse it gets. Per [name redacted]. Distant supervision. The Speech Therapist recommendations dated 5/5/25 revealed the following for Resident #11: Feeding/Dietary: Recommend regular solids with the exception of raw vegetables. Recommend thin liquids, distant supervision. He can be occasionally cued to put his chin down and swallow if needed. He will pocket his food but he will clear it. Please do not cue him. The Speech Therapist recommendations dated 7/9/25 revealed the following for Resident #11: Feeding/Dietary: Recommend continued regular solids and thin liquids. Distant supervision. [NAME] will pocket solids and liquids- he is able t clear when allowed. Please do not instruct him to swallow or prevent him from taking the next bit or sip. If he shows holding food or liquid for a really long time- you may ask him to put his chin down- this will trigger a swallow.During an interview on 7/29/25 at 11:03 AM, the Speech Therapist stated if Resident #11 had to stop and think about the process, Resident #11 would stop eating. The Speech Therapist stated if she gave quiet cues, he did good. The Speech Therapist stated she completed education with the staff on how to help Resident #11 with eating and written multiple recommendations. During an interview on 7/30/25 at 9:18 AM, Resident #11 stated multiple people told him to chew and swallow. Resident #11 stated the staff took his plate away. Resident #11 stated they rubbed his cheek and told him to chew.During an interview on 7/31/25 at 2:26 PM, Staff G, CNA (Certified Nurse Aide) queried on what type of assistance Resident #11 required and Staff G stated they watched Resident #11 eat in the dining room. Staff G stated Resident #11 pocketed his food and Staff G would slid his plate away from him sometimes when his mouth was too full. Staff G stated the speech therapist told Staff G to hold back from cueing but the pocket gets to chew. Staff G queried on what direction Staff G was given for assistance with Resident #11 and Staff G stated a mix of things. Staff G stated the nurses told her not to let Resident #11 put more food in his mouth, but the speech therapist said it was alright for the resident to put more food in his mouth.During an interview on 8/4/25 at 11:09 AM, the Physical Therapist (PT) queried if she had any concerns with staff interactions with Resident #11 eating and PT stated she witnessed staff get frustrated with Resident #11. PT stated the therapy staff told Resident #11 to tuck his chin. PT stated she heard staff tell Resident #11 to chew and swallow and Resident #11 can't have anymore food until he swallowed.During an interview on 8/4/25 at 11:09 AM, Physical Therapist (PT) queried if their recommendations were orders and PT stated they get an order to treat from the provider and the therapy department assessed and gave recommendations, and since they had the order to treat, the recommendations were orders. The PT stated the nursing staff could downgrade the order when a resident struggled, but could not upgrade orders, therapy could only do that.During an observation on 8/4/25 at 12:31 PM, staff in the dining room next to Resident #11. Staff asked Resident #11 if he was going to save his food like a chipmunk and asked him to swallow his food. During an interview on 8/4/25 at 4:15 PM, Staff J, CNA queried on the type of assistance Resident #11 required for eating, and she stated it depended on the day. Staff J stated sometimes he took more cueing to make sure he swallowed between bits. Staff J stated if Resident #11 not swallowing, she moved his plate away from him and gave him something to drink. Staff J stated she gave Resident #11 drinks between bites because that is what she was told to do. Staff J, CNA stated she told him to tuck his chin to help him swallow. During an interview on 8/4/25 at 4:35 PM, Staff K, CNA asked what kind of eating assistance Resident #11 needed and Staff K stated she watched Resident #11 eat and if Resident #11 pocketed his food, she gave him a drink or told him to spit it out. Staff K queried on the directives Staff K given for Resident #11 eating assistance and Staff K stated to watch Resident #11 and when he pocked his food, try to get Resident #11 to swallow or spit it out. During an interview on 8/6/25 at 9:43 AM, the Director of Nursing (DON) stated Resident #11 didn't want to swallow and telling Resident #11 to swallow was a trigger word. The DON stated the staff instruct to tell Resident #11 to tuck his chin. The DON stated the more you told Resident #11 to do something, the more he would do the opposite and telling him to swallow didn't help. The Facility Medication and Treatment Order Practice dated 7/2022 revealed the following: a. Following Orders: 1. Physician Orders shall be followed, if unable to follow physician order, notify Director of Nursing Services/designee and physician as appropriate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, facility policy review, and resident and staff interviews, the facility failed to provide an intervention in a timely manner for a resident who complained of a rash and associated discomfort for 1 of 18 residents (Resident #21) reviewed for assessment and intervention. The facility reported a census of 53 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #21 scored a 15 out of 15 on the Brief Interview for Mental Status exam, which indicated cognition intact. The MDS indicated resident required partial/moderate assistance with upper body dressing; and substantial/maximal assistance with shower/bathing self. Review of the Care Plan revealed a Focus area revised on 7/29/25 for increased risk for impairment of skin integrity and potential pressure ulcer development related to fragile skin, history of pressure wounds and mobility impairment.The interventions dated 7/21/25 revealed avoid scratching and keep hands and body parts from excessive moisture. During an interview on 7/28/25 at 3:44 PM, Resident #21 stated she was told she would see the doctor last Thursday and she didn't. Resident #21 stated she wanted them to get ahold of her personal doctor so Resident #21 could get her standing prescriptions. Resident #21 stated it is red under her breasts and she told the nurses. Resident #21 lifted her shirt and under her left breast was reddened. Review of the EHR (electronic health record) revealed a N Adv-Skin Check note entered on 7/30/25 at 9:34 AM revealed seven different skin issues assessed. The reddened area under Resident #21 left breast not an assessed area. During an interview on 7/31/2025 at 12:40 PM, Resident #21 stated she just saw the doctor and she had to chase her down all morning. Resident #21 stated she shown the doctor and Central Records. Resident #21 stated her chest was seeping now and under both breasts. Review of a Nurse's Notes entered on 8/2/25 at 3:15 AM, revealed Pt (patient) called asking for Tylenol she was in pain due to her rash and her buttocks. Pt has a rash that extends from both breast down the middle of chest and onto abdomen. Pt rash is red and raised from skin. No odor noted. Pt bumps looks wet/moist like fluid but not like sweat in the folds of skin. Pt states it hurts. Pt state that it itches sometimes PCP (primary care provider) faxed for follow up and [end of note] Review of a N ADV Skilled Evaluation note, entered on 8/2/25 at 3:18 AM, revealed #006: New skin Issue. Location: Chest - generalized. Laterality / Orientation: Circumferential. Issue type: Other skin issue. Other skin issue description: Redden raised bumps with fluid Wound acquired in-house. Painful: Yes. Wound pain (Frequency): Continuous. Pain description: Sharp. The N ADV Skilled Evaluations continued to document the new skin issue on the resident's chest until 8/5/25. During an interview on 8/5/25 at 10:54 AM, Resident #21 stated her breast area was improved. Resident #21 stated in the shower, the old skin came off and new skin present. Resident #21 stated she took care of it herself and put a cream on it. Resident #21 stated she knew she was not supposed to be doing that. Review of the EHR revealed a Nurse's Note entered on 8/6/25 at 11:32 AM revealed - PCP (primary care provider) notified that res (resident) cont (continued) to have red raised rash on torso with complaints of occasional itching. New verbal orders received: 1. Mometasone 0.1% daily to rash until resolved and then DC (discontinue). Res (resident) is aware unable to reach family at this time. Review of Physician Orders revealed an order for Mometasone Furoate External Cream 0.1 % (Mometasone Furoate)- apply to rash topically every day shift for wound care DC when resolved- ordered 8/6/25. During an interview on 8/6/25 at 10:07 AM, the Assistant Director of Nursing (ADON) stated Staff L, Registered Nurse (RN) said something to the ADON on Saturday, but the ADON did not see the rash. The ADON reviewed the progress notes and stated the communication noted, but not the documentation for a response. The ADON stated the doctors usually respond quickly. During an interview on 8/5/25 at 2:22 PM, Staff L, RN stated she took care of Resident #21 last weekend and put a note in for the provider. Staff L stated she didn't know what came of it because Staff L went on vacation. Staff L stated she heard about Resident #21 rash from Staff Q, Licensed Practical Nurse (LPN) and Staff Q stated he put a cream on it and Staff L stated Staff L needed an order to put cream on Resident #21. Staff L stated the rash was circumferential and getting worse. During an interview on 8/5/25 at 3:02 PM, Staff Q, LPN stated he saw Resident #21 and used stock medication of petroleum jelly on Resident #21 rash on her chest and sent a note to the provider for Nystatin. Staff Q stated he was not sure if Resident #21 got an order for the cream or not. During an interview on 8/6/25 at 12:32 PM, Central Records stated Resident #21 was not on the list to see the provider on Thursday, but Resident #21 came into Central Records office and lifted her shirt and showed Central Records and the provider her chest. The Nurse Practitioner (NP) asked Resident #21 if it itched and Resident #21 stated sometimes. Central Records stated the NP told her if the rash got worse for Resident #21 to order a cream. Central Records stated Resident #21 continued to complain so they ordered her a cream today. During an interview on 8/6/25 at 12:44 PM, Central Records stated she informed the nurse about Resident #21 rash and if the rash got worse to notify the NP. Central Records stated she was not aware if the nurse passed it on, but if the rash was itching, they should of called and got an order. During an interview on 8/6/25 at 3:10 PM, the Regional Nurse Consultant stated she spoke with the nurse who was with the provider on Thursday and the Regional Nurse Consultant confirmed the cream should have been ordered on Thursday. During an interview on 8/6/25 at 3:12 PM, the ADON stated Resident #21 saw the provider on Thursday and the cream should have been ordered and then the nurses would not have had to send a note to the provider this weekend. Review of the facility policy titled, Verbal Order Policy dated February 2014 revealed: a. Only authorized, licensed practitioners, or individuals authorized to take verbal orders from practitioners, shall be allowed to write orders in the medical record. Review of the facility policy titled, Acute Condition Changes- Clinical Protocol dated March 2018 revealed:a. Direct care staff, including nursing assistants will be trained in recognizing subtle but significant changes in the resident (for example, a decrease in food intake, increased agitation, changes in skin color or condition) and how to communicate these changes to the Nurse.b. The attending physician (or a practitioner providing backup coverage) will respond in a timely manner to notification of problems or changes in condition and status. 1. The nursing staff will contact the medical director for additional guidance and consultation if they do not receive a timely or appropriate response.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a medication error rate of less than five percent when three medication errors were observed from twenty-seven opportunities for 3 of 6 residents reviewed for medication administration (Resident #28, Resident #33, Resident #36). This deficient practice resulted in facility medication error rate of 11.11%. The facility reported a census of 53 residents. Findings include:
1.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored 15 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated intact cognition. Per this assessment, the resident took insulin for four of the last seven days.
The Physician Order dated 7/1/25 revealed, Insulin Lispro Inject as per sliding scale: if 0 - 60 = 0 Units Follow Hypoglycemia Protocol; 61 - 140 = 0 Units; 141 - 180 = 1 Unit; 181 - 240 = 2 Units; 241 - 300 = 3 Units; 301 - 350 = 4 Units; 351 - 400 = 5 Units; 401+ = 0 Units Notify Physician for Instructions, subcutaneously before meals and at bedtime for Diabetes.
On 7/30/25 at 12:14 PM, Staff B, Licensed Practical Nurse (LPN) prepared supplies to check the resident's blood sugar. Resident #36 observed at a table in the dining room, and already had foods consumed off of his plate at the table. Staff B took the resident's blood sugar resulting in reading of 200. Staff B then administered 2 units of the resident's Lispro Kwikpen 100 Unit/ml (milliliter).
2. Review of the MDS assessment for Resident #33 dated 4/24/25 revealed the resident scored 14 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated intact cognition. Per this assessment, the resident was always incontinent of bowel and bladder.
Review of the Physician Order dated 8/22/24 revealed the resident ordered Ferrous Sulfate Oral Tablet 325 MG with directions to take one tablet by mouth two times a day for anemia.
On 7/31/25 at 8:13 AM, Staff H, Certified Medication Aide (CMA) administered Resident #33 one tablet of Ferrous Sulfate 324 mg (milligram) EC (enteric coated).
3. Review of the MDS assessment for Resident #36 dated 5/22/25 revealed the resident scored 15 out of 15 on a BIMS exam, which indicated intact cognition.
Review of the Physician Order dated 12/6/24 revealed, Polyethylene Glycol Powder (Polyethylene Glycol 1450) with directions to give 17 grams by mouth one time a day for constipation (Mix in 408 oz (ounces) fluid of choice).
On 7/31/25 at 8:08 AM, Staff H, Certified Medication Aide (CMA) administered Clearlax 3350 to the resident instead of Polyethylene Glycol 1450.
On 7/31/25 at 5:05 PM, the facility's Director of Nursing (DON) queried as to process if difference in order versus what in the cart, the DON responded to call for clarification.
Review of the Facility Policy titled Administering Medications dated 2001, revised 4/2019, reveled the following: Medications are administered in a safe and timely manner, and as prescribed.
The Facility Administering Medications Policy dated 6/2022 revealed:
a. Medications are administered in accordance with prescriber orders, including any required time frame.
b. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure Warfarin and Apixaban, anticoagulant medications, sliding scale insulin, and narcotic pain medication were administered per physician order for four of four residents reviewed for significant medication errors (Resident #20, Resident #36, Resident #55 and #62). The facility reported a census of 53 residents. Findings include: 1. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #20 scored 15 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated intact cognition. Per this assessment, the resident took anticoagulant medication.
Review of Resident #20's Physician Order dated 6/13/25, discontinued on 6/17/25, revealed the following: Warfarin, also known as Coumadin) Sodium Oral Tablet 4 mg (milligram) with directions to give 1 tablet by mouth one time a day every Monday, Tuesday, Wednesday, Friday, and Saturday for anticoagulant therapy.
Review of the resident's Medication Error Form dated 6/17/25 at 4:30 PM revealed, Nurse reported to this nurse manager that she had started med pass prior to med aide arriving and had given res (resident) afternoon medications and was unable to sign out the Coumadin when med aide arrived and on the cart she took over and noted it wasn't given and gave it again. Res was to receive 4mg (milligram) and was administered a total of 8mg.
Review of Resident #20's Medication Administration Record (MAR) dated June 2025 revealed Warfarin Sodium 4mg was signed out on 6/17/25 at 4:42 PM by Staff E, Certified Medication Aide (CMA).
Review of the Late Entry Nurses Note dated 6/17/25 at 11:03 PM revealed, gave resident 4 mg of coumadin, MAR was yellow however did not have a way to mark off that i gave the medication, another resident returned to hospital and got him in his room, when leaving room saw med aide giving medication to resident. dr (doctor) and new orders obtained by [name redacted] LPN (Licensed Practical Nurse). hold on 6-18-25 and recheck INR (International Normalized Ratio-lab used for blood clotting) on 6-19-25.
On 7/30/25 at 4:51 PM, Staff D, Registered Nurse (RN) queried what it meant if a medication was yellow in system, and she responded meant was something to give them (resident).
On 7/31/25 at 5:16 PM, the Director of Nursing (DON) explained the following about the situation: the second shift nurse had come on duty, nurse had a fall and an admit at that time, and were having med aides come in to help or med aide came in from another hall to help. She gave the coumadin, didn't mark on the EMAR (electronic medication administratration record), and when med aide came she then gave the meds which included the coumadin. Per the DON, resident got an extra dose that night.
2. Review of the MDS assessment dated [DATE] revealed Resident #36 scored 15 out of 15 on a BIMS exam, which indicated intact cognition. The MDS list of diagnoses for Resident #36 included diabetes mellitus. Per this assessment, the resident took insulin for four of the last seven days.
The Physician Order dated 7/1/25 revealed, Insulin Lispro Inject as per sliding scale: if 0 - 60 = 0 Units Follow Hypoglycemia Protocol; 61 - 140 = 0 Units; 141 - 180 = 1 Unit; 181 - 240 = 2 Units; 241 - 300 = 3 Units; 301 - 350 = 4 Units; 351 - 400 = 5 Units; 401+ = 0 Units Notify Physician for Instructions, subcutaneously before meals and at bedtime for Diabetes.
On 7/30/25 at 12:14 PM, Staff B, Licensed Practical Nurse (LPN) prepared supplies to check the resident's blood sugar. Resident #36 observed at a table in the dining room, and already had foods consumed off of his plate at the table. Staff B took the resident's blood sugar resulting in reading of 200. Staff B then administered 2 units of the resident's Lispro Kwikpen 100 Unit/ml (milliliter).
Review of the resident's Blood Sugar Summary revealed an entry on 7/30/25 at 12:19 PM for resident blood sugar 200.0 mg/dL (milligram/deciliter). Per Resident #36's Treatment Administration Record (TAR) dated July 2025, 2 units of insulin were administered to the resident on 7/30/25, scheduled per the Treatment Administration Record (TAR) at 11:30 AM.
On 7/31/5 at 5:04 PM, the facility's Director of Nursing (DON) explained usually 30 minutes before meal would try to start the sliding scale.
2. The MDS assessment dated [DATE] revealed Resident #55 scored a 15 out of 15 on the BIMS exam, which indicated cognition intact. The MDS revealed the resident received scheduled and as needed medication. The MDS indicated Resident #55 received an opioid medication.
Review of the Care Plan revealed a Focus area dated 5/14/23 to address Resident has increased risks for alteration in comfort due to aging and decreased mobility. The Interventions dated 5/14/23 included, in part: Provide me my pain medication as ordered, document and evaluate the effectiveness of my pain medication. Coordinate with NP (Nurse Practitioner) to manage pain medication for optimum pain control.
Review of the electronic health record (EHR) revealed a Physician Order for oxyCODONE HCl oral tablet 5 mg…give 5 mg by mouth every 8 hours for chronic pain. Start date: 12/16/24.
Review of an Incident Report #1296 for Medication Error dated 6/25/25 at 9:30 PM revealed the following: Incident Description section: a. Nursing Description: Licensed Practical Nurse (LPN) [name redacted] called this DON stating that a medication error had been made. LPN gave 5 mg Oxy (oxycodone) and CMA (Certified Nurse Aide) went to cart to assist LPN with Med Pass and another 5 mg oxy was given. Immediate Action Taken section: a. Description: LPN notified PCP (primary care provider) and order received to monitor vitals for 24 hours. No adverse side effects noted.
Review of a Nurse's Note entered at 6/25/25 at 9:48 PM, revealed med error occurred. Resident was given 2 5 mg oxycodones. PCP notified about med error told to get vs (vitals) q (every) 15 min for 2 hrs (hours), q 30min for 1 hour and q 4hrs for 24 hours. VSS (vitals signs stable) when checked.
During an interview on 8/5/25 at 11:36 AM, Staff Q, LPN stated he went and gave Resident #55 his medications and then a resident’s bed deflated and he went and helped them. Staff Q stated he forgot to click off the medications given to Resident #55 before Staff M, QMA (Qualified Medication Aide) came over to his hall to help Staff Q with the remaining medication pass. Staff M and Staff Q counted narcotics and Staff Q handed Staff M the keys to the cart. Staff Q stated when he found out Staff M gave Resident #55 another dose of oxycodone he immediately called the DON and the provider and they started vitals on Resident #55.
During an interview on 8/6/25 at 11:10 AM, Staff M, QMA stated she remembered the medication error with Resident #55. Staff M stated she went over to help Staff Q because he was drowning and logged him out of the computer and then she logged into the medication cart computer. Staff M stated when she clicked on the medication administration record (MAR), Resident #55 still needed clicked off so Staff Q took Resident #55 his medications. Staff M stated she freaked out when Staff Q asked her if she gave Resident #55 a dose of oxycodone because Staff M never made a medication error before. Staff M stated Staff Q took blame and stated Staff Q should of clicked the medication off the MAR. Staff M stated Staff Q signed the narcotic out in the narcotic book, just not off the MAR.
During an interview on 8/6/25 at 3:02 PM, the DON stated Staff Q, LPN had an admission and a fall that night and gave Resident #55 his medications and walked away without clicking them off. The DON stated they did competencies after that and told Staff Q to not leave the cart again without clicking off his medications.
3. Review of the MDS assessment dated [DATE] revealed Resident # 62 scored 15 out of 15 on a BIMS exam, which indicated intact cognition. Per this assessment, the resident is prescribed an anticoagulant medication.
Review of the hospital discharge progress notes dated 4/29/25 for Resident #62 revealed the resident is diagnosed with severe pulmonary hypertension. Continue Eliquis (Apixaban) 10 mg twice daily for 6 more doses. Needs lifelong anticoagulation Eliquis 5 mg BID (two times per day).
Review of Resident # 62 Hospital Discharge Medication List. Active Medication Orders Prior to Transfer: Apixaban-Take 2 tabs twice daily for 6 more doses then followed by 1, 5 mg tab twice daily thereafter for maintenance.
The Physician Order dated 4/30/25 entered by the facility revealed the order was incorrectly entered as Eliquis 5 MG tablet. Take 1 tablet by mouth twice daily. Start date of 5/1/25 and end of 5/3/25.
Review of the May 2025 MAR revealed Apixaban Oral Tablet 5 MG. (Apixaban) Give 2 tablet by mouth two times a day for Venous Insufficiency for 2 days Order Date 4/30/25. The MAR reflected Resident #62 was given 2 doses of Apixaban on both 5/1/25 and 5/2/25.
During an interview on 8/4/25 at 2:10 PM, the DON queried regarding Resident #62’s medication and in particular anticoagulant Apixaban (Eliquis) 5 mg tab which was listed on the resident’s active Medication Orders Prior to Transfer. The DON stated she had just started at the facility at that time and the hospital discharge order was entered by the Assistant Director of Nursing and the Regional Director of nursing. The facility became aware of the medication error after the resident was discharged .
During an interview on 8/5/25 at 1:51 PM, the Regional Director of Nursing (RDN) stated that both she and the Assistant Director of Nursing (ADON) entered and reviewed the order. She believes there was a transcription error from when the order was entered. The RDN stated she printed off the packet used for admission. There were five directions for Apixaban from the active medication list from the hospital when the resident was discharged . The physician’s order that should have been entered was entered incorrectly. The RDN explained they did not realize the error until after the resident was discharged . The resident’s primary provider contacted the facility and wanted to know about the medications and this is how the error was discovered.
During an interview on 08/05/2025 2:02 PM, the ADON queried about the medication and advised the order had been entered incorrectly, and she stated the facility had problems in the past regarding discharge paperwork from this medical center. The ADON explained in the past they have contacted this medical center for clarification on physician orders and they have had difficulty getting any information or resolution. In this instance the discharging medical center was not contacted for clarification.
During an interview on 8/6/25 at 10:40 AM, the facility if the information entered doesn’t match the order from the hospital that is an error on the facility. If there is some discrepancy or something is not clear it is her expectation that the facility nurse entering the order follow up with the hospital or the medical group for clarification.
Review of the facility policy titled Administering Medications dated 2001, revised 4/2019, revealed a Policy heading which declared: Medications are administered in a safe and timely manner, and as prescribed.
The Policy Interpretation and Implementation section of the policy directed, in part:
4. Medications are administered in accordance with prescriber orders, including any required time frame.
7. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders).
10. The individual administering the medication checks the label to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication.

Based on observation, facility policy review, and staff interviews, the facility failed to store, prepare and handle food in a sanitary manner in an effort to prevent cross contamination and food borne illness during 2 of 2 kitchen observations. The facility reported a census of 53 residents. Findings include: During the initial tour of the kitchen on 7/28/25 at 1:15 PM, a metal basin observed to contain raw hamburger thawed on an upper shelf of rack. Meal trays with lidded plates rested on the shelf underneath. During an observation on 7/30/25 at 10:03 AM, bags of frozen chicken breasts in a stainless steel basin were placed on the second shelf of the refrigerator. Fruits in the plastic containers with plastic lids sat under the meat on the bottom shelf. Staff N, [NAME] noticed the meat on the second shelf and moved it to the bottom shelf. During an interview on 7/30/25 at 10:04 AM, Staff N, [NAME] stated she kept telling staff to put the meat on the bottom shelf so it didn't drip everywhere. During a continuous observation during the lunch meal service on 7/30/25 at 12:06 PM, Staff N used tongs to take a bun out of the package and then used her gloved hands to open the bun. Staff N did not change her gloves. At 12:07 PM, Staff N took another bun out of the package and opened with gloved hands and then proceeded to move the meal tickets down the line and picked up utensils. At 12:23 PM, Staff N removed the bun from the package using tongs, used the tongs and her gloved hands to open the bun. Staff N didn't remove or change gloves. At 12:24 PM used her gloved hand to put the top of the bun on the hamburger patty on the plate, then moved the hamburger bun to the side of the plate to fit a bowl of cream of mushroom soup on it, and did not remove gloves. At 12:33 PM, Staff O, Dietary Aide scooped ice from an ice container on a cart and left the scoop in the container. The scoop handle continued to laid in the container and then Staff O picked up the handle with her gloved hands, Staff O did not remove gloves and continued to use the scoop. Staff O did not try to keep the handle of the ice scoop out of the ice container. At 12:39 PM, Staff O scooped ice from container, let the ice scoop handle fall into the container. At 12:45 PM the ice scoop remained in the ice container. During an interview on 7/30/25 at 1:09 PM, Staff O, Dietary Aid queried if the ice scoop could stay in the container, and she stated the scoop could stay in the ice container but the handle should not go into the basin because she touched other things with her hands. Staff O asked what she did when gloves were contaminated and she stated take them off and wash your hands and put new gloves on. During an interview 7/30/2025 at 1:21 PM, Staff N, [NAME] queried who took the meat out of the freezer, and she stated the night cook did and confirmed the meat needed thawed on the bottom shelf. Staff N asked about the ice scoop and Staff N stated the handle should not fall in the ice container because of cross contamination. Staff N asked about touching the hamburger buns with her gloved hands and Staff N acknowledged she touched the buns and stated she should of changed her gloves due to cross contamination. During an interview on 7/30/25 at 1:32 PM, Staff P, [NAME] queried where meat needed placed when thawing in the refrigerator, and she stated on the very bottom shelf. Staff P stated she witnessed other people putting it on different shelves. Staff P stated she put the chicken on the very bottom shelf. Staff P stated nothing should be under raw meat. During an interview on 7/30/25 at 3:23 PM, the Administrator confirmed meat needed thawed on the bottom shelf and the handle of the ice scoop should never touch ice. The Administrator stated the cook should had used tongs and if she used her gloved hands, the cook should of changed her gloves.Review of the facility policy titled, Food Preparation and Service Policy dated April 2019 revealed: a. Appropriate measures are used to prevent cross contamination. These include: 1. storing raw meat separately and in drip-proof containers, and in a manner that prevents cross-contamination from other foods in the refrigeratorb. Food preparation staff adhere to proper hygiene and sanitary practices to prevent the spread of foodborne illness.c. Bare hand contact with food is prohibited. Gloves are worn when handling food directly and changed between tasks. Disposable gloves are single-use items and are discarded after each use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff and residents interviews, record review, and the facility policy, the facility failed to treat residents in a dignified manner for 3 of 3 residents (Resident #11, Resident #21, and Resident #33) reviewed for dignity. The facility reported a census of 53 residents, Findings include:
1.The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #11 scored a 5 out of 15 on the Brief Interview for Mental Status (BIMS) exam, which indicated cognition severely impaired. The MDS indicated the resident required supervision or touching assistance with eating. The MDS revealed medical diagnoses for stroke, aphasia following cerebral infarction.
The Care Plan revealed a focus area revised on 6/25/25 for difficulty swallowing and pocketing food status post cerebral vascular accident. The intervention revised on 7/16/25 indicated distant supervision; Resident #11 will pocket solids and liquids, he is able to clear when allowed. Please do not instruct Resident #11 to swallow or prevent him from taking the next bite or sip, if Resident #11 holds his food or liquid for a really long time, you many ask him to put his chin down, this triggered a swallow. The interventions revised on 7/30/25 indicated regular diet with thin liquids with mechanical soft texture.
During an interview on 7/29/25 at 10:06 AM, Resident #11 stated staff told him to chew and swallow his food, but Resident #11 couldn’t remember their names.
During an interview on 7/29/25 at 11:03 AM, the Speech Therapist stated Resident #11 continued to voice that staff told him to chew and swallow. The Speech Therapist stated she witnessed staff take Resident #11 plate away from him. The Speech Therapist stated she approached the staff and staff admitted taking away the plate, and educated staff on the proper approach. The Speech Therapist stated she wrote multiple recommendations and explained to the staff member what worked better for Resident #11. The Speech Therapist stated she believed Resident #11 and had not been diagnosed with dementia and he was able to have a conversation.
During an interview on 7/30/25 at 9:18 AM, Resident #11 stated multiple people told him to chew and swallow. Resident #11 stated the staff took his plate away. Resident #11 stated staff rubbed his cheek and told him to chew. Resident #11 showed how the staff rubbed his cheek. Resident #11 stated it made him feel disgusting. Resident #11 stated staff told him to chew and swallow in a mean tone.
During an interview on 7/31/25 at 2:26 PM, Staff G, CNA (Certified Nurse Aide) queried on what type of assistance Resident #11 required and Staff G stated staff watched Resident #11 eat in the dining room. Staff G stated Resident #11 pocketed his food and Staff G would slid his plate away from him sometimes when his mouth was too full. Staff G stated the speech therapist told Staff G to hold back from cueing but the pocket got to big and Staff G was aware Resident #11 would choke. Staff G asked if she ever rubbed Resident #11 cheek when Staff G assisted him with eating and she stated yes and told Resident #11 to chew and swallow.
During an interview on 8/4/25 at 11:09 AM, the Physical Therapist (PT) queried if she had any concerns with staff interactions with Resident #11 eating and PT stated she witnessed staff get frustrated with Resident #11. PT stated therapy staff would then tell Resident #11 to tuck his chin. PT stated she heard staff tell Resident #11 to chew and swallow and Resident #11 can’t have anymore food until he swallowed. PT asked if she ever seen staff rub Resident #11 cheek and PT stated Staff G rubbed his cheek and said swallow. PT stated the verbiage sounded aggressive and PT felt anytime someone rubbed someone’s cheek it was aggressive.
During an observation on 8/4/25 at 12:31 PM, staff in the dining room next to Resident #11. Staff asked him if he was going to save his food like a chipmunk and asked him to swallow his food. Resident #11 made slow movements and then took another bite. Resident #11 ate his meal independently.
During an interview on 8/4/25 at 4:15 PM, Staff J, CNA queried on the type of assistance Resident #11 required for eating and Staff J stated it depended on the day. Staff J stated sometimes Resident #11 took more cueing to make sure he swallowed between bits. Staff J stated if Resident #11 not swallowing, she moved his plate away from him and gave him something to drink.
During an interview on 8/6/25 at 9:43 AM, the Director of Nursing (DON) stated Resident #11 didn’t want to swallow and telling Resident #11 to swallow was a trigger word. The DON stated staff needed to tell Resident #11 to tuck his chin. The DON stated when staff told Resident #11 to slow down, he filled both his cheeks with food. The DON stated it was not appropriate to rub Resident #11 cheeks and she told the aide who did, not to touch his cheek. The DON confirmed staff should not be touching Resident #11 plate either.
2. The MDS assessment dated [DATE] revealed Resident #21 scored a 15 out of 15 on the BIMS exam, which indicated cognition intact.
During an interview on 7/28/25 at 3:33 PM, Resident #21 stated one of the staff members on the third shift was on her phone the whole shift. Resident #21 stated in her opinion, the staff didn’t want to be here and it made her feel beneath them and bad for asking for help.
During an interview on 7/31/25 at 2:19 PM, Staff G, CNA asked about staff phone use and Staff G stated she witnessed staff walking down the hallway with a resident and answered a video chat. Staff G stated she told the Assistant Director of Nursing (ADON) and the DON and they discussed it in meetings.
During an interview on 8/5/25 at 8:12 AM, Social Services queried if staff used their personal phones when doing resident cares and Social Services stated yes, she walked into the rooms and the staff would hurry up and put their phones in their pockets. Social Social stated all the staff had their phones on them and the residents got very irritated about it because the residents wanted staff to talk and take care of them, not someone else.
During an interview on 8/05/2025 at 2:29 PM, Staff L, Registered Nurse (RN) stated CNAs would text and watch videos in the hallways when the residents slept, but not during cares. Staff L stated she wouldn’t allow staff to use their phones when call lights were going off.
During an interview on 8/6/25 at 9:58 AM, the ADON stated the facility had a phone policy and the ADON went over it several times with staff. The ADON stated she understood when residents requested to see family photos, but the staff should not be showing [NAME] and tik toks. The ADON stated she instructed staff to engage with the residents during cares not with each other. The ADON stated the maintenance staff would see staff with phones and tell them to put them away or he would write them up. The ADON stated phone use was not expectable even at night because they had tasks they needed to do.
During an interview on 8/6/25 at 9:58 AM, the DON stated staff should not be their phones and the same goes for all the shifts.
During an interview on 8/6/25 at 11:05 AM, Staff M, Qualified Nurse Aide (QMA) queried if staff use their phone during resident cares and Staff M stated yes and even though Staff M wasn’t in a leadership roll, she told her coworkers to wait until they were done with cares. Staff M stated some of the residents got upset. Staff M stated some staff answer personal calls and facetime calls in front of residents.
Review of the facility Cell Phone Policy dated 12/1/24 revealed the following:
a. Personal cell phones and electronic devices are only permitted in patient care areas for authorized business purposes and only in compliance with HIPAA. Using personal cell phones for calls and texting is not permitted during working hours but may be used on break and in designated break areas. All cell phones must be on silent ringer or vibrating mode. Personal cell phones and phone earpieces are not to be carried or worn during working hours. Use of cameras or audio recordings, including camera phones, are prohibited on Company property unless authorized in writing by your supervisor or Human Resources.
3. Review of the MDS assessment for Resident #33 dated 4/24/25 revealed the resident scored 14 out of 15 on a BIMS exam, which indicated intact cognition. Per this assessment, the resident was always incontinent of bowel and bladder.
Review of the resident's Care Plan did not have a focus area for incontinence.
Review of Resident #33's current task documentation revealed, B&B (bowel and bladder)- Bladder Elimination: resident incontinent wears Large briefs.
On 7/29/25 at 12:07 PM, Resident #33 observed in their room, and interview conducted. Resident #33 explained facility would run out of briefs, and no one should ever be without the size they wear. Resident #33 stated right now the facility ran out of size need, and had to borrow some until Thursday. The resident expressed he did not feel like well cared for with the briefs, and reiterated that nobody should be without the size they need, ever. Per Resident #33 they were last changed 2 to 3 hours ago, and got a couple brief borrowed before that didn't have any. Per the resident, there had been times had to wear a brief two sizes too big.
On 7/31/25 at 2:01 PM, Staff G, CNA explained the facility did not have enough supplies, and were told when run out to tell the nurse, and on call would be notified who would take care of it. Per Staff G, there was a weekend when they took the last tab brief, Staff G notified the nurse, and the nurse was going to notify on call. Per Staff G, they did not get any until Wednesday when the truck came. Staff G further explained if did not have the right size residents would go in a different size, and per Staff G would get red, raw, sores. Per Staff G, if no tab briefs put all in pull ups, and had residents so mad.
On 7/31/25 at 3:40 PM, observation of the stock room completed with Staff F, Staffing Coordinator present. Present in the stock room were large briefs, extra large, and sizes larger than extra large. When queried about running out of briefs, Staff F confirmed. Staff F believed this occurred because staff went to the room next door to get briefs which caused the facility to run out. When queried why she felt staff were going to the resident rooms next door for briefs, Staff F explained because she would come in and residents were in wrong size or briefs they had never been in, pull up versus tab brief, etc.
On 7/31/25 at 5:10 PM, the DON explained she ordered every week, and followed the formulary. Per the DON, the biggest complaint was never enough. Per the DON, the facility had a cart for depends, and were supposed to take as went and did rounds. The DON explained the facility always had the size needed, and felt not getting used like it should have been.
The Facility Resident Rights Guidelines for all Nursing Procedures Policy dated October 2010 revealed the following:
a. Prior to having direct-care responsibilities for residents, staff must have appropriate in-service training on resident rights, including:
1. resident dignity and respect.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, record review, and the facility policy, the facility failed to notify the physician of a resident's weight loss for two different occurrences for 1 of 3 residents reviewed for nutrition (Resident #7). The facility reported a census of 53 residents. Findings Include: The MDS assessment dated [DATE] revealed Resident #7 scored a 15 out of 15 on the BIMS exam, which indicated cognition intact. The MDS revealed a loss of 5% or more in the last month or loss of 10% or more in 6 months and on a therapeutic diet. The MDS revealed resident took an diuretic. The Care Plan revealed a Focus area revised on 8/6/25 for I am at nutritional risk s/p (status post) acute on chronic CHF (Congestive Heart Failure) with h/o (history) Type 2 DM (diabetes mellitus), COPD (Chronic Obstructive Pulmonary Disease), morbid obesity, gout, hypothyroidism, hyperlipidemia, pneumonia.8/1/25- significant weight loss over 6 months. The Interventions dated 1/2/24 revealed meal enrichment/planned snacks: at least 1 cup of white milk at each meal and weight at least weekly x 1 month after admit, then at least monthly or as recommended. The interventions dated 7/24/25 revealed to offer supplements as ordered. Review of the Weight Summary document as of 8/6/25 revealed on 02/06/2025, the resident weighed 228 lbs. (pounds). On 07/18/2025, the resident weighed 203.6 lbs. (pounds) which is a -10.7% Loss.The Dietary Progress Note dated 4/9/25 at 11:16 PM, revealed significant Weight LOSS: (-) 5.2 % X 1 mo. (month). Dietitian Observations/Recommendations: Wt. (weight)- 219#(4/07) [BMI(body mass index) = 41.4, 95% UBWR (Usual Body Weight Range) of 230# +/- 3# from admit to [facility name redacted] to hospitalization on 3/27. Resident s/p (status post) hospitalization for metabolic encephalopathy and was started on IV (intravenous) antibiotics then most recently treated with a Nystatin mouth wash started on 4/4 for erythema which contributed to poor meal intakes of 25- 30% and weight loss. Per Charge Nurse--this RD (Registered Dietician) talked to tonight--mouth looks much improved and RD notes meal intakes have improved to ~60 - 65% which were usual intakes. Would suggest weekly weights X 2 weeks and RD will follow. See significant weight loss Fax to clinician.The Family Practice Note dated 4/18/25 at 3:51 PM revealed weight measured of 107.3 kg (4/3/25 at 3:54 AM) and weight estimated on 3/27/25 at 2:46 AM. The Family Practice Note did not address a significant weight loss. Review of the Weight Summary documented revealed weights completed on 4/10/25, 5/29/25, 6/5/25, 7/1/25, 7/18/25, and 8/1/25. The Dietary Note dated 6/1/25 at 3:53 PM, revealed RD notes Significant Weight LOSS: (-) 5.0% X 1 mo.[actual is 49 days as reference wt. is 219#(4/10)]], (-) 8.7% X 3 mos.[actual is 109 days as reference wt. is 228#(2/09)]. Dietitian Observations/Recommendations: Wt. - 207.5#(5/29)[BMI = 39.3] Resident is on Consistent Carbohydrate Diet and diet has returned to usual at ~65-70% s/p recent death of husband. Previous significant weight loss fax was sent to clinician in April s/p hospitalization where resident was on IV ATB and developed oral candidiasis which decreased intakes. Resident is on a meal enrichment strategy and RD will follow weights as available. RD notes that yesterday resident ate 85-90% of meals. See weight change notification fax to clinician.The EHR (electronic health record) revealed the following Physician Orders: Nutritional supplement 4 ounces one time a day with a start date of 7/30/25. Per email on 8/4/25 at 10:46 PM, the Regional Nurse Consultant communicated she did not see the notification for Resident #7 weight, but she was her own person. During an interview on 8/4/2025 at 11:42 AM, Resident #7 stated she lost weight, probably around 50 pounds. Resident #7 stated she just lost her husband and the food tasted terrible. Resident #7 stated she drank a shake.During an interview on 8/6/25 at 10:18 AM, the ADON (Assistant Director of Nursing) stated she was still digging through things to find the notification to the doctor for her significant weight loss. Per email from the Regional Nurse Consultant dated 8/4/25 at 12:56 PM, the RD [name redacted] wrote out faxes that the DM faxed out with the notifications on them. The RD and the Dietary Manager that worked during April to June no longer worked at the facility. The facility failed to supply documentation the physician notified/aware of the weight losses. Review of a facility policy titled, Change in a Resident's Condition or Status dated February 2021 revealed the following:a. The nurse will notify the resident's attending physician or physician on call when there has been a(an): 1. significant change in the resident's physical/emotional/mental conditionb. A significant change of condition is a major decline or improvement in the resident's status that: 1. will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self-limiting); 2. requires interdisciplinary review and/or revision to the care plan

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility policy review and staff interviews, the facility failed to update Care Plans to reflect two residents had a significant weight loss and one resident no longer received dialysis services for 3 of 18 (Resident #7, Resident #11 and Resident #3) reviewed for Care Plans. The facility reported a census of 53 residents. Findings include:
1.The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 scored a 15 out of 15 on the Brief Interview of Mental Status (BIMS) exam, which indicated cognition intact. The MDS revealed a loss of 5% or more in the last month or loss of 10% or more in 6 months and on a therapeutic diet. The MDS indicated Resident #7 took a diuretic (often called a water pill, a medication to help the body eliminate excess salt and water).
Review of the Care Plan revealed a Focus area revised on 8/6/25 for I am at nutritional risk s/p (status post) acute on chronic CHF (Congestive Heart Failure) with h/o (history) Type 2 DM (diabetes mellitus), COPD (Chronic Obstructive Pulmonary Disease), morbid obesity, gout, hypothyroidism, hyperlipidemia, pneumonia…. 8/1/25- significant weight loss over 6 months. The Interventions dated 1/2/24 revealed meal enrichment/planned snacks: at least 1 cup of white milk at each meal and weight at least weekly x 1 month after admit, then at least monthly or as recommended. The interventions dated 7/24/25 revealed to offer supplements as ordered.
Review of the Weight Summary dated 8/6/25 revealed on 02/06/2025, the resident weighed 228 lbs.(pounds). On 07/18/2025, the resident weighed 203.6 lbs. which is a -10.7% Loss.
During an interview on 8/6/25 at 10:18 AM, the (Assistant Director of Nursing) ADON stated Resident #7 Care Plan should be updated with the significant weight loss.
2.The MDS assessment dated [DATE] revealed Resident #11 scored a 5 out of 15 on the BIMS exam, which indicated cognition severely impaired. The MDS indicated the resident required supervision or touching assistance with eating. The MDS revealed medical diagnoses for stroke, aphasia following cerebral infarction. The MDS indicated resident not had a weight loss of 5% in one month or 10% in 6 months and not on a therapeutic diet.
Review of the Care Plan revealed a Focus area revised on 5/15/25 for nutrition: Resident #11 at nutritional risk due to s/p (status post) cerebral infarction, stenosis of right carotid artery, UTI (Urinary Tract Infection), hyperlipidemia, HTN (hypertension), Vitamin D Deficiency, Hernia.
Review of the Weight Summary document dated 7/29/25 revealed on 02/21/2025, the resident weighed 161 lbs. On 07/01/2025, the resident weighed 137 lbs which is a -14.91% Loss.
During an interview on 8/6/25 at 9:08 AM, the MDS Coordinator queried on who updated the nutrition areas of the care plans, and she stated the dietician used to update it and the dietician recently left the facility. The MDS Coordinator stated she hadn’t gotten with the interim, who works remotely to review who would update the care plan. The MDS Coordinator confirmed the Focus area for risk for nutrition should be updated to significant weight loss for Resident #7 and Resident #11.
During an interview on 8/6/25 at 9:52 AM, the ADON confirmed Resident #11 care plan needed updated to reflect a significant weight loss.
3.Review of the MDS assessment for Resident #3 dated 6/26/25 revealed a BIMS score of 15 out of 15 which indicated intact cognition. Per this assessment, the resident was not on dialysis while a resident.
Review of the Care Plan, dated dated 6/14/24, revised on 6/29/25, revealed a Focus area to address I have an alteration in in my renal functioning d/t (due to) I have CKD (chronic kidney disease) stage 3 and require dialysis.
During an interview on 7/30/25 at 1:25 PM, Resident #3 explained he had been on dialysis probably six to eight weeks, and he didn't know why it had been shut off. Per Resident #3, when he went to the hospital he had been started on it. Resident #3 confirmed he was no longer on dialysis.
On 7/30/25 at 3:07 PM, the MDS Coordinator queried if Resident #3 on dialysis now, and she responded the resident is no longer on dialysis. Per the MDS Coordinator the resident had refused dialysis. When queried if the resident had been off dialysis for awhile, the MDS Coordinator responded she did not know if had been on dialysis, and further explained when the resident first admitted a little over a year or so ago dialysis had been recommended and resident said no. The MDS Coordinator explained the resident may have had treatment in the hospital, and did not believe resident had been on it since at facility.
During an interview on 7/30/25 at 3:12 PM, the MDS Coordinator explained she would go fix the resident's Care Plan.
During an interview on 7/31/25 at 5:00 PM, the facility's Regional Nurse Consultant (RNC) explained Resident #3 not on dialysis, and the Care Plan was now fixed.
Review of the facility policy titled, Care Plans, Comprehensive Person-Centered, dated 12/23, revealed the following:
a. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents’ conditions change.
b. The interdisciplinary team reviews and updates the care plan:
1. when there has been a significant change in the resident’s condition;

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and facility policy review, the facility failed to administer a pneumococcal vaccine to 1 of 5 residents reviewed for pneumococcal vaccines (Resident #8). The facility reported a census of 55 residents.
Findings include:
The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8 scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS) exam, which indicated cognition intact.
The EMR (Electronic Medical Record) revealed the resident received the Prevnar 13 vaccination on 5/16/19.
The resident's file revealed a screen shot of immunization that the ARNP (Advanced Registered Nurse Practitioner) reviewed the immunizations and noted resident received PCV 13 in 2019 and eligible for the PCV 20 dated 2/13/24.
The Progress Notes dated 2/14/24 at 12:44 PM, revealed the Immunization Record sent to PCP (primary care provider) for review and returned that the resident was able to have the PCV20 (pneumococcal 20-valent conjugate) vaccine at this time with consent. Verbal consent received from daughter with education given at the time of risks and benefits of vaccine.
During an interview on 8/29/24 at 11:33 AM, the DON (Director of Nursing) stated he wasn't familiar with the vaccines because he relied on the Infection Preventionist to take care of them. The DON stated Resident #8 pneumococcal vaccine was due in April or May of this year.
During an interview on 8/29/24 at 11:51 AM, the ADON/IP (Assistant DON/Infection Preventionist) queried about Resident #8 pneumococcal vaccine and she stated she didn't know anything about it. The ADON stated she didn't offer Resident #8 the pneumococcal vaccine. The ADON asked who screened the residents for the pneumococcal vaccines and she stated she didn't know, but it wasn't her.
During an interview on 8/29/24 at 12:39 PM, the DON queried on how takes care of the pneumococcal vaccines and he stated the IP took care of all the immunizations. The DON stated he didn't know where the disconnect was with Resident #8 not getting her pneumococcal vaccine but he would find out. The DON stated he seen the consent signed, progress note placed, the doctor notified for the order, but nothing else. The DON stated he expected follow through for the resident to receive the vaccine.
The Facility Pneumococcal Vaccine Policy dated 9/22 revealed the following:
a. Pneumococcal vaccines would be administered to residents (unless medically contraindicated), already given, or refused) per our facility's physician-approved pneumococcal vaccination protocol.
b. Administration of the pneumococcal vaccines or revaccination's would be made in accordance with current Centers for Disease Control and Prevention (CDC) recommendations at the time of the vaccination.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the clinical record review, staff interviews, and the facility policy review, the facility failed to resubmit a PASRR (Preadmission Screening and Resident Review) with new mental health diagnoses and psychotropic medications added to the plan of care for 1 of 2 residents reviewed for PASRR (Resident #20). The facility reported a census of 55 residents.
Findings include:
The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #20 scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS) exam, which indicated cognition intact. The MDS revealed diagnoses for anxiety disorder, depression, and psychotic disorder (other than schizophrenia). The MDS revealed the resident took an antipsychotic and an antidepressants. The MDS revealed the resident took antipsychotics on a routine basis.
The Notice of PASRR Level 1 Screen Outcome dated 5/24/17 revealed no Level II required unless a significant change. The PASRR revealed the diagnoses of unspecified psychiatric illness and no medications taken by the resident.
The Care Plan revealed a focus area initiated on 5/6/23 and revised on 1/22/24 for taking Depakote therapy related to mood disorder. The interventions revised on 10/19/23 revealed an alteration in mood and behaviors due to delusions about a certain resident. The resident could be verbally aggressive toward this resident and talk to other residents about her. Resident #20 thought the other resident said things about her and took her clothes. The other resident was petite small and Resident #20 wore a 4 x-large. Resident #20 didn't want the other resident in the same room or activity.
The Care Plan revealed a focus area initiated on 1/3/18 and revised on 6/12/18 for the resident took Seroquel at bedtime for my diagnosis of psychosis in the absence of
dementia. The interventions revised on 6/12/18 revealed administration of medications as ordered by the physician.
The Care Plan revealed a focus area initiated on 1/3/18 and revised on 1/22/24 for use of antidepressant medications (Cymbalta and Trazadone) daily for depression/insomnia. The interventions revised on 1/22/24 revealed the resident participated in Telehealth visits regularly.
The EMR (Electronic Medical Record) revealed the following Medical Diagnoses:
a. dated 3/28/17- anxiety disorder, unspecified
b. dated 8/20/20- major depressive disorder, recurrent, severe with psychotic symptoms
c. dated 8/20/20- delusional disorders
The EMR revealed the following Physician Orders:
a. dated 12/7/23- Depakote sprinkles oral capsule delayed release sprinkle 125 mg (milligrams)-give 2 capsule by mouth two times a day
b. dated 12/8/23- Duloxetine HCL (hydrochloride) capsule delayed release particles 30 mg- give 1 capsule by mouth one time a day for depression
c. dated 11/8/23- Seroquel oral tablet 50 mg- give 2 tablet by mouth in the morning for delusions
d. dated 8/22/23- Seroquel oral tablet 100 mg- give 2 tablet by mouth at bedtime
During an interview on 8/29/24 at 10:58 AM, Staff A, MDS coordinator stated until recently she thought a significant change would be if the resident admitted to the hospital for mental issues. Staff A stated the Administrator educated her if the a resident changed medications and medical diagnoses, a new PASRR needed completed. Staff A stated she been going through them, but hadn't caught Resident #20 yet. Staff A confirmed Resident #20 needed her PASRR resubmitted due to the diagnoses changes.
During an interview on 8/29/24 at 12:55 PM, the Administrator confirmed a new PASRR should have been completed for Resident #20.
The Facility Behavioral Assessment, Intervention, and Monitoring Policy dated 11/22 revealed the following information:
a. New onset or changes in behavior that indicate newly evident or possible serious mental disorder, intellectual disability, or a related disorder would be referred for a PASRR Level II evaluation.

Based on clinical record review, staff interviews, and facility policy review the facility failed to ensure annual Minimum Data Set (MDS) assessments completed timely for 2 of 19 residents reviewed for completion of comprehensive assessments (Resident #18, Resident #26). The facility reported a census of 55 residents.
Findings include:
1. The Annual MDS assessment for Resident #18 revealed an assessment reference date (ARD) of 7/25/24. The resident's MDS assessment was currently still in process.
2. The Annual MDS assessment for Resident #26 revealed an ARD of 5/9/24. The resident's MDS assessment completion date documented 6/3/24.
During an interview on 8/29/24 at 11:03 AM, Staff A, MDS Coordinator confirmed the MDS for Resident #18 and #26 were late and they needed to be completed within 14 days of the ARD date.
During an interview on 8/29/24 at 12:38 PM, the DON (Director of Nursing) stated he expected the MDS to be completed on time.
During an interview on 8/29/24 at 12:56 PM, the Administrator stated she expected the MDS be completed by the date they were due.
The Facility Comprehensive Assessments Policy dated 12/23 revealed the following information:
a. The Annual Assessment was a comprehensive assessment for a resident that must be completed on an annual basis (at least every 366 days) unless an SCSA (Significant Change in Status Assessment) or a SCPA (Significant Correction to Prior Comprehensive Assessment) have been completed since the most recent comprehensive assessment was completed. Its completion dates (MDS/CAA (Care Area Assessment)/Care plan) depend on the most recent comprehensive and past assessments ARD's and completion dates.

Based on clinical record review, and staff interviews, the facility failed to ensure quarterly Minimum Data Set (MDS) assessments completed timely for 5 of 19 residents reviewed for completion of comprehensive assessments (Resident #9, Resident #18, Resident #26, Resident #29, and Resident #34). The facility reported a census of 55 residents.
Findings include:
1. The Quarterly MDS assessment for Resident #18 revealed an assessment reference date (ARD) of 4/25/24. The resident's MDS assessment completion date documented 5/20/24.
2. The Quarterly MDS assessment for Resident #26 revealed an ARD of 8/9/24. The resident's MDS assessment was still in process.
3. The Quarterly MDS assessment for Resident #29 revealed an ARD of 7/11/24. The resident's MDS assessment completion date documented 8/8/24.
4. The Quarterly MDS assessment for Resident #34 revealed an ARD of 4/18/24. The resident's MDS assessment completion date documented 5/20/24. The Quarterly MDS assessment for Resident #34 revealed an ARD dated of 7/18/24. The resident's MDS assessment completion date documented 8/13/24.
5. The Quarterly MDS assessment for Resident #9 revealed an ARD date of 7/25/24. The resident's MDS assessment completion date documented 8/27/24.
During an interview on 8/29/24 at 11:03 AM, Staff A, MDS Coordinator confirmed the MDS for Resident #18 and #26 were late and they needed to be completed within 14 days of the ARD date.
During an interview on 8/29/24 at 12:38 PM, the DON (Director of Nursing) stated he expected the MDS to be completed on time.
During an interview on 8/29/24 at 12:56 PM, the Administrator stated she expected the MDS be completed by the date they were due.
The Facility Comprehensive Assessment Policy dated 12/23 did not address quarterly MDS assessments.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interviews, the facility failed to maintain a clean environment free of hazards. Observations found resident rooms poorly cleaned, leaving debris and trash under beds for multiple days and hallways cluttered with equipment and wheelchairs.
Findings include:
During an observation on 6/4/24 at 4:30 p.m. debris (rubber glove) and trash were noticed under resident bed A in room [ROOM NUMBER] and a glove on the bathroom floor.
During an observation on 6/5/24 at 11:00 a.m. and again at 2:50 p.m. the trash and glove remained under resident bed A in room [ROOM NUMBER], after housekeeping had been in the room to clean it that day.
During an observation on 6/6/24 at 9:00 a.m. the glove and trash remained on the floor under the bed of room [ROOM NUMBER].
During an observation on 6/6/24 at 9:00 a.m. a gown and a deodorant container found on the floor in room [ROOM NUMBER]. Later that morning the gown was picked up, but the deodorant container remained on the floor behind the recliner.
During an observation on 6/6/24 at 11:00 a.m. facility including mechanical lifts and standing devices, along with resident wheelchair were left in the hallways.
During an interview on 6/4/24 at 12:10 p.m. Staff A, Housekeeping and Laundry Supervisor, stated all resident rooms are to be swept, mopped, trash removed, dusted and toilets and hard surfaces cleaned and sanitized daily Monday through Fridays. Staff A stated they deep clean (remove furniture) one room on each hall daily.
According to the minimum data set (MDS) with an assessment reference date of 5/23/24, Resident #4 had a Brief Interview for Mental Status (BIMS) score of 15, indicating an intact cognitive status.
During an interview on 6/5/24 at 2:50 p.m. Resident #4 stated housekeeping does not always clean their room Monday through Friday, and often sweep and mop the front half of the room, but not under or behind the bed or recliner.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, infection control policy, clinical record review and staff interview, the facility failed to use enhanced barrier precautions and consistent hand hygiene practices between resident contact. The facility reported census was 48.
Findings include:
According to the Mnimum Data Set (MDS) assessment, dated 2/26/24, Resident #6 had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Resident #6 required moderate assistance with mobility, transfers, dressing, toilet use and personal hygiene needs. Diagnoses included congestive heart failure, atrial fibrillation, coronary artery disease, diabetes mellitus, renal insufficiency, arthritis. Resident #6 has a catheter and is on enhanced barrier precautions.
During an observation on 6/6/24 at 7:30 a.m. Staff E, Certified Nursing Assistant (CNA), and Staff F, CNA assisted Resident #6 with personal care. Neither Staff E or Staff F wore a protective gown.
In an interview on 6/6/24 at 7:35 a.m. Staff E, Certified Nurse Aide, stated she did not wear a gown while providing care to Resident #6, who is on enhanced barrier precautions.
In an interview on 6/6/24 at 7:38 a.m. Staff F, Certified Nurse Aide, stated she forgot to wear a gown while providing care to Resident #6, who is on enhanced barrier precautions.
2. The MDS, dated [DATE], assessed Resident #5 as dependent on staff for assistance with transfers, dressing, toilet use and personal hygiene. The resident has a BIMS score of 6 out of 15, indicating severely impaired cognition.
During an observation on 6/6/24 at 10:35 a.m. Resident #5 was transferred to bed with a hoyer lift and assistance of two staff (Staff G and Staff H). Resident #5 was provided incontinence care and change of brief, then transferred back into her wheelchair per hoyer lift and assistance of Staff H and Staff G. Following care, Staff G provided Resident #5 with a snack without washing or sanitizing her hands prior to assisting with opening the snack packaging.
During an observation on 6/6/24 at 11:00 a.m. thirteen sanitizer dispensers were noted on 100 and 200 halls. Three of those dispensers were empty and through random observations this surveyor has not witnessed any staff utilize a dispenser since entering on 6/4/24.
During an observation on 6/6/24 at 1:00 p.m. Resident #5 was transferred to bed with a hoyer lift and assistance of two staff (Staff H and Staff G). Resident #5 was provided incontinence care and change of brief. Resident #5 remained in bed watching TV. Staff G was observed passing Resident #5 a drink and snack while wearing a glove, but not sanitizing her hands after the earlier care or in between glove exchanges.
During an observation on 6/6/24 at 4:28 p.m. Staff J, Registered Nurse was observed assisting a resident in room [ROOM NUMBER] to the toilet, then propelling the resident in her wheelchair to the dining room, then assisting another resident without sanitizing her hands in between resident contact.
During an observation on 6/6/24 at 4:41 p.m. Staff I, Certified Nurse Aide, was observed assisting a resident into her wheelchair., then propelling the resident to the dining room. Staff I then assisted another resident without sanitizing her hands in between resident contact.
According to the facility Handwashing/Hand Hygiene policy the facility considers hand hygiene the primary means to prevent the spread of infection:
2. All personnel shall follow the hand washing/hand hygiene procedures to help prevent infections to other personnel, residents and visitors.
6. Use an alcohol based hand rub containing at least 62% alcohol or alternatively soap (antimicrobial) and water for the following situations:
b) Before and after direct contact with residents.
m) After removing gloves.
7. Hand hygiene is the final step after removing and disposing personal protective equipment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The Minimum Data Set (MDS) dated [DATE] identified Resident #7 as cognitively intact with a BIMS (Brief Interview for Mental Status) score of 15 and had the following diagnoses: Diabetes Disorder, Gastrostomy and Anxiety Disorder. It also identified Resident #7 required substantial assistance with showers/baths, dressing, putting on footwear and turning from side to side. It did not identify the resident with a feeding tube and identified she was on a therapeutic diet.
A review of the progress notes revealed the following:
7/22/23 at 1:50 AM Resident #7 complained of pain in her right upper quadrant rating it a 9 and states it feels like someone is punching her there. Also states she has been having this pain intermittently for about a week now. Bowels active X4 quadrants. Drainage tube is patent and flowing within normal limits. The physician on call was notified and new orders received to send to ER (Emergency Room) for evaluation.
7/22/23 at 2:31 AM Ambulance notified at 2:00 AM, arrived to facility at 2:20 AM. Out of facility at 2:27 AM. Report given to the hospital nurse.
7/22/23 12:35 PM Resident admitted to the hospital for acute cholecystitis (infection of the gall bladder) and will be having cholecystectomy (surgical removal of the gall bladder).
The progress notes did not include documentation of complete assessment prior to transport to the hospital or notification of family.
7/28/2023 5:24 PM Resident returned to facility by ambulance at 4:00 PM in wheelchair. Diet order: soft foods. Gastrostomy tube with a drainage bag intact and draining. Diagnosis: Emergency cholecystectomy (removal of gall bladder). Multiple bruising to left upper extremity. Edema noted in Left hand with large bruise on anterior surface. 2 areas bandaged on abdomen. Do not remove for 3 days, may get wet. Incision across abdomen with 27 staples. Complained of pain rated a 7. Scheduled medication for pain to be administered. Care plans in EMR revised.
A review of the electronic medical record revealed no documentation to show transfer form had been completed for 7/22/23
A review of the physician orders revealed the following:
5/12/23 G-Tube is to be clamped during meals and Med Pass and for 30 minutes after otherwise to vent at all times every shift for Gastric Outlet Obstruction.
5/17/23 Drain Gastric Drainage bag and record output every shift for Drain Gastric Drainage bag and record output
The care plan dated as reviewed 8/14/23 identified Resident #7 with the problem of an actual/potential alteration in elimination pattern due to history of constipation and failed to address the physician's order to leave the dressing in place for 3 days and the need to evaluate the surgical incision and evaluate for postoperative complications.
In an interview on 11/29/23 at 10:18 AM, Staff A, LPN reported before sending a resident to the hospital, she would need to document in the nurse's notes the change of condition assessment, vital signs, full assessment from lung sounds, bowel sounds, edema, anything pertinent to the change. She would also need to document she called the doctor and how the resident was transported. The nurse who sends the resident out is responsible for documentation of the assessment, sometimes the DON or ADON will assist.
In an interview on 11/29/23 at 11:33 AM, Staff B,RN, reported before sending a resident to the hospital, she would need to complete the change of condition report and transfer form under the evaluation tab, otherwise a progress note should detail actions taken and assessment of the situation, who was notified, how they were transported, vital signs.
In an interview on 11/30/23 at 1:01 PM, the Director of Nursing (DON) reported before sending a resident to the hospital he would expect the nurse to document in the nurse's notes the reason why, the condition the resident is in, report to the hospital, and that the doctor and family were notified.
A review of the facility policy titled: Facility-Initiated Transfer or discharge date d as last reviewed October 2022 had documentation of the following:
Orientation for Transfer or Discharge (Emergent or Therapeutic Leave)
1. For an emergency transfer or discharge to a hospital or other acute care institution, implement the following procedures:
aa. Call 911 if the resident meets clinical/behavioral criteria per facility policy, or assist in obtaining transportation;
bb. Notify the resident's attending physician
cc. Orient/prepare the resident for transfer and
dd. Prepare for medical record transfer.
2. Nursing notes will include documentation of appropriate orientation and preparation of the resident prior to transfer or discharge.
Documentation of a Facility-Initiated Transfer or Discharge
1. When a resident is transferred or discharged from the facility, the following information is documented in the medical record:
aa. The basis for the transfer or discharge; if the resident is being transferred or discharged because his
or her needs cannot be met at the facility, documentation will include:
aaa. The specific resident needs that cannot be met;
bbb. This facility's attempt to meet those needs; and
ccc. The receiving facility's service(s) that are available to meet those needs
2. That an appropriate notice was provided to the resident and/or legal representative;
3. The date and time of the transfer or discharge;
4. The new location of the resident;
5. The mode of transportation;
6. A summary of the resident's overall medical, physical, and mental condition
3. At the time of the survey, the admission MDS for Resident #103 had not been completed. A review of the electronic medical record (EMR) list of medical diagnoses included: cerebral infarction due to embolism, muscle weakness and multiple fractures of ribs on the left side.
Observations of the resident revealed the following:
In an observation and interview with the resident on 11/27/23 at 10:03 AM, as he sat up in the recliner in his room with feet elevated, he reported he came in with an open area to left shin which has kerlix dressing dated 11/25/23. He wore tubigrips to both legs which had with 2+ edema.
11/28/23 at 7:04 AM Resident #103 reported he was supposed to get his dressing to his left leg and the staff didn't change it yesterday. The dressing to his left leg was dated 11/25/23 and appeared to be the same dressing he had yesterday.
11/29/23 11:33 AM, during an observation of wound care, the ADON pulled up pant leg to left leg and removed Resident #103's sock. The ADON verified the date on dressing as 11/25 and should have been changed 11/27. The dressings should be changed every other day.
A review of the progress notes dated 11/22/23 at 5:10 PM revealed Resident #103 as alert and oriented to person, time and place.
A review of the physician orders revealed the following:
11/22/23 Mix equal parts of Clotrimazole, Triamcinilone and Silvasorb. Apply to left lower leg including wound bed. Cover any open ulcerations with Telfa, secure with rolled gauze and tape cover with tubigrip Size F every day shift every other day for wound treatment.
A review of the November 2023 Treatment Administration Record revealed documentation the treatment signed out as completed on 11/27/23.
The only problem addressed on the care plan on 11/23/23 was urinary tract infection. It did not address the open area to his left lower leg.
In an interview on 11/29/23 at 10:18 AM, Staff A, LPN reported she was not sure of a process for ensuring all treatment orders were being carried out daily.
In an interview on 11/30/23 at 11:03 AM, the ADON reported nurses are supposed to sign off treatments on the Medication Administration Records after the treatments have been completed.
When asked why the dressings still had 11/25 dated on 11/29, she reported the dressings should have been done on 11/27. She could not explain why the treatment would be signed out on 11/27 when it had not been completed.
In an interview on 11/29/23 at 11:33 AM, Staff B,RN, reported Resident #103 should have had his dressings changed every other day. She was not sure if there was someone to double check MARs to ensure all treatments had been completed at the end of the day.
In an interview on 11/30/23 at 1:01 PM, the Director of Nursing (DON) reported the nurse who signed off the MAR on 11/27 reported after she put the new dressing on, she dated it 11/25. There were no initials on the dressing and he had instructed staff they need to start writing their initials on the dressing.
Based on observation, interview, and record review the facility failed to ensure through assessment prior to a resident's hospitalization, failed to ensure throrough assessment post a documented episode of choking, and failed to ensure the dressing to a non-pressure skin wound changed as ordered for three of four residents reviewed for assessment/intervention (Resident #7, Resident #14, Resident #103). The facility reported a census of 48 residents.
Findings include:
1. The Minimum Data Set (MDS) assessment for Resident #14 dated 8/25/23 revealed the resident scored 3 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated severe cognitive impairment.
The Health Status Note dated 10/17/23 at 8:59 AM documented, Resident AM BG (blood glucose) very low (57). He was assisted OOB (out of bed) and into dining room and given honey thickened chocolate milk and orange juice. Recheck 1 hour later was 135. While eating breakfast, resident choked on biscuits and gravy. Resident cyanotic but coughing. Resident coughed up pieces of breakfast and was verbal. PRN (as needed) hyosyne given per MAR (Medication Administration Record). Message left for hospice nurse requesting a lookback at morning BGM's (blood glucose monitor) as well as a possible texture change to pureed for resident's diet.
The Health Status Note lacked documentation of oxgyen saturation or assessment of lung sounds following the resident's documented episode of choking.
Review of oxygen saturation docuementation per the weights/vitals tab in the resident's electronic health record lacked documentation of oxygen saturation on 10/17/23.
The Health Status Note dated 10/17/23 at 10:01 AM documented, PRN (as needed) breathing treatment administered following coughing episode and res is now currently sitting up in wc (wheelchair) in room to prevent further coughing episodes. No coughing noted at this time with SpO2 (oxygen saturation) at 96% on room air Lungs are diminished but clear at this time Hospice has been notified and aware of this episode Hospice nurse to be in today to assess resident would
On 11/30/23 at 10:50 AM when queried as to what would be charted and what assessment would entail, Staff A, Licensed Practical Nurse (LPN) explained if the resident had an episode at a meal or what have you, lung sounds assessed, doctor notified, family notified. Staff A acknowledged vitals would be taken, and would be put in the vitals tab and in the progress note. Per Staff A, the lung sound assessment would be in the progress note.
On 11/30/23 at 11:48, Staff B, Registered Nurse (RN) explained the following would be charted for a choking episode: What led up to it, causative factors, the outcome of the episode and if able to clear the airway, measures taken, notification to family, physician, and administration, measures in place to prevent a reoccurrence. When queried if vital signs would be charted, Staff B acknowledged yes, under the vitals section and possibly in the note. When queried if an assessment of lung sounds would be completed, Staff B responded yes, and further explained they would typically be done for a few days after as well so make sure no residual effect. Staff B acknowledged the documentation would be in the progress notes.
On 12/4/23 at 10:08 AM when queried about assessment for a documented choking episode, the Director of Nursing responded a swallow study, determination why the resident choking, clearing the airway, full set of vitals, and to send the resident out. The DON acknowledged a respiratory assessment would be done, acknowledged it would be charted in evaluations, and in the progress note as well. The DON acknowledged need for notification to the family and doctor.
Review of the evaluations tab in the resident's electronic health record revealed the only assessment per the evaluations tab dated 10/17/23 was a skin assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a resident was able to access appropriate and timely vision care by an outside provider. The resident's vision had declined over the last nine months. (Resident #23) The facility reported a census of 48 residents.
Findings include:
The Quarterly Minimum Data Set (MDS) assessment for Resident # 23 dated 10/05/23 documented the resident scored 15 out of 15 on a Brief Interview for Mental Status (BIMS) exam which indicated the resident was cognitively intact.
Care Plan for Resident #23 dated 04/06/2020 and revised on 07/19/2020 with a Target date of 01/10/2024 documented the following focus area, goals and interventions:
Focus area: My visual ability needs and preferences are: I wear eyeglasses. Date Initiated: 04/06/2020 Revision on: 04/06/2020
Goal: I will use appropriate visual devices to promote participation in ADLs and other activities. Date Initiated: 4/06/2020 Revision on: 07/19/2022 Target Date: 01/10/2024
Interventions:
a. I am able to manage my own donning and caring of my eye glasses. If I need help I will ask for assist. Date Initiated: 04/06/2020
b. I have eye drops that will need staff to administer per my Healthcare Practitioner's order. Date Initiated: 04/06/2020
Revision on: 04/06/2020
c. I will need assistance to arrange consultation with my eye care practitioner as needed. Date Initiated: 04/06/2020 Revision on: 04/06/2020
d. Monitor/document/report PRN if I have any s/sx of acute eye problems: Change in ability to perform ADLs, Decline in mobility, Sudden visual loss, Pupils dilated, gray or milky, c/o halos around lights, double vision, tunnel vision, blurred or hazy vision. Date Initiated: 04/06/2020
11/29/23 01:31 PM Resident # 23 advised she has missed six eye doctor appointments in the last 9 months due to the facilty cancelling or not getting her to her appointments. Resident #23 reported she has difficulty seeing out of both of her eyes but her right eye is worse than her left eye. The resident advised staff member M, LPN does all of the scheduling and she had canceled several of her vision appointments.
11/30/23 09:50 AM Staff member M was gueried about Resident #23 and canceled appointments. Staff M advised the resident was being seen for cataracts. She is not aware of the resident having a change or decline in her vision. Staff M indicated she was not aware that the resident needs or has ever gotten shots in her eyes. Staff M reported the resident had missed vision appointments for several reasons:
a. Resident #23 missed one appoinment due to an issue with the van and the facility did not have alternate transportation available. That appointment had been resceduled.
2. On 08/04/2023 the resident missed an appointment due to not being able to transfer to the chair in the exam room and staff had not been available to attend the appointment.
3. The family made an appointment the facility was not notified about and the appointment was missed.
4. The facility took Resident # 23 to her vision appointment on 10/06/2023 and the resident did not like that doctor. Another appointment had been made for the resident on 12/20/2023.
Staff M shared if a resident needed vision care they are seen by an outside Optometrist. Staff M was not aware of a facility contract with an Optometrist.
11/30/23 10:15 AM The facility Administrator was queried and indicated she would find out if the facility had a contract with an Optometrist.
11/30/23 10:24 AM Staff A, LPN, advised Resident #23 had not expressed concern with her vision. Staff A reported there had been an issue with the facility van and the resident could not attend her appointment. Staff A advised there had been a couple times the resident's appointment were rescheduled. Staff A shared she would not have documented information about any appointment changes or cancellations in progress notes.
11/30/23 11:03 AM The Director of Nursing (DON), advised the facility does not have a contract with an optometrist and an optometrist does not come to the facility. A resident would have to use their previous eye doctor. If not, they would try to find a local provider that would accept the resident's insurance.
11/30/23 11:15 AM Staff member C, RN reported Resident #23 has not expressed concerns with her vision. Staff C advised the resident missed one appointment as the family had planned to take her but they were not able to drive her. On occasion, the facility has used the van to take another resident to the hospital or other unexpected situation and other facility transportation would not be available so the facility would have to cancel the scheduled appointment.
The Progress Notes dated 03/01/2023 at 15:48 revealed the Optometrist office called to ask which doctor the resident wanted to see for eye sx. Discussed this with resident and she advised which doctor she requested to see and staff made resident aware that this doctor was not be able to do pre op testing on that date so appointment would need to be rescheduled. Resident voiced understanding. Called office to notify - left voicemail requesting to return call and speak with scheduler to reschedule appt.
The Progress Notes dated 08/04/2023 at 08:45 documented this nurse attempted to notify family on 8-3-23 to see if they could meet resident at an appointment on 8-4-23 for a cataract referral and was unable to contact any family This nurse called the doctor's office stating that res will need assist to transfer into their chair for appointment and the office doesn't offer transfer help, and Dr [NAME] office asked for this nurse to reschedule the appointment. I spoke with res this am and she is upset regarding this. I attempted to explain to res that I have to have someone to go with her and res didn't feel that she would need that help and I again told her that the office would not help her. I will cont to attempt to contact family to meet at next appointment.
On 12/04/2023 The facility advised they do not have a policy regarding vision appointments or outside medical appointments.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The Minimum Data Set (MDS) dated [DATE] identified Resident #30 as cognitively intact with a BIMS (Brief Interview for Mental Status) of 15 and had the following diagnoses: Heart Failure, Renal Insufficiency (Kidney Failure) and Diabetes Mellitus. The MDS also identified Resident #30 required substantial staff assistance with lower body dressing, putting on footwear.
In an observation on 11/27/23 at 12:00 PM, Staff D, RN pushed Resident #30 in the wheelchair without foot pedals.
In an observation on 11/28/23 at 11:19 AM, Staff E, Restorative CNA pulled Resident #30 in her wheelchair out of the bathroom without foot pedals on with Resident #30's feet skimming the floor from the bathroom to outside in the hallway. Resident #30 then was able to self-propel to the main dining room.
On 9/14/20, the care plan identified Resident #30 with the problem of being at risk for falls, however, failed to address the need to place foot pedals on the wheelchair prior to transporting the resident in the wheelchair.
In an interview on 11/29/23 at 10:18 AM, Staff A, LPN reported before pushing a resident in the wheelchair, should make sure the foot pedals are on the wheelchair and put their feet on the foot pedals. This should be addressed on the care plan which any nurse can update.
In an interview on 11/29/23 at 11:33 AM, Staff B,RN, reported before pushing a resident in the wheelchair, should make sure the foot pedals are on the wheelchair and put their feet on the foot pedals. This should be addressed on the care plan
In an interview on 11/30/23 at 1:01 PM, the Director of Nursing (DON) reported before pushing a resident in the wheelchair, should make sure the foot pedals are on the wheelchair and put their feet on the foot pedals. Resident #30 has a bag on the back of her wheelchair where the foot pedals are stored. He did not feel this should be addressed on the care plan as it is common sense. He also reported the facility did utilize many CNAs from different agencies. The DON also reported it was a team effort and that all nurses could update the care plan.
Based on observation, interview, and record review, the facility failed to thoroughly investigate falls, determine root cause analysis, and ensure pre-existing interventions were implemented for fall prevention, and failed to ensure foot pedals utilized when a resident pushed in their wheelchair for two of five residents reviewed for accidents (Resident #11, Resident #30). The facility reported a census of 48 residents.
Findings include:
1. The Minimum Data Set (MDS) assessment for Resident #11 dated 8/19/23 revealed the resident scored 6 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated severe cognitive impairment. Per the assessment, Resident #11 did not have any falls since admission, entry, reentry, or the prior assessment.
The Care Plan dated 7/8/21, revised 7/13/21, documented, the resident is at risk for falls related to generalized weakness, impaired cognition, and impulsivity.
The Intervention dated 3/2/23 documented, Resident to have gripper socks on at bedtime. The Intervention dated 10/1/23 documented, Gripper socks at bedtime. The Intervention also dated 10/1/23 documented, scoop mattress to bed.
The Health Status Note dated 10/1/23 at 9:19 PM documented, Resident had unwitnessed fall at 2100 (9:00 PM). Resident observed on floor of her room sitting on her bottom with both legs out in front of her. Resident crying out Help Me Help me. Daughter [Name Redacted] notified of unwitnessed fall and protocol of neuros started. Resident takes eliquis. Resident states she did not hit her head. States her knees are hurting her. Resident unable to describe how she ended up on the floor. Not sure if she was asleep and fell out or what. Daughter states she is a wiggle worm in bed. Resident did not have gripper socks on at time of incident. Replaced her soft slipper socks with gripper socks at this time. Notified PCP (Primary Care Physician) [Name Redacted] of incident by Fax.
Review of the Incident Report dated 10/1/23 at 9:28 PM for an unwitnessed event documented, CNA notified this nurse at 2100 that resident was on the floor in her room. When this nurse entered resident's room resident was sitting on the floor upright on her buttocks with both legs in front of her next to her bed. No injuries noted after assessment. Resident was asked if she hit her head and she stated no. The Resident Description section documented, Resident was not sure how she fell.
The Incident Report and Progress Notes did not reveal a root cause analysis for the resident's fall.
The Health Status Note dated 10/7/23 at 11:35 PM documented, in part, This nurse was called into residents' room by CNA, found on floor sitting up against bed, bp (blood pressure) 154/72, p (pulse) 71, o2 (oxygen) 95%, r (respiration)16, (temperature) 97.2, no s/s (signs/symptoms) of injury, denies pain, states she was trying to go to the bathroom, this nurse reminded her to use call light, resident transferred with assist x2 et gaitbelt off floor et onto bed, CNA assisted resident to bathroom.
The Intervention dated 10/26/21, revised 12/1/21, documented, Offer toileting after meals. The Intervention dated 11/25/21 documented, Offer toileting at shift change. The Intervention dated 10/11/23 documented, Frequently offer to help me to the restroom.
The Incident Report dated 10/8/23 at 12:47 AM for the resident's fall did not address the last time the resident was assisted to the restroom prior to the fall, when the resident was last seen/by whom, and whether or not the resident had gripper socks applied at the time of the fall.
On 11/30/23 at 10:52 AM, Staff A, LPN explained the following about the initial intervention: Per Staff A, she input it following discussion with nurse and the Director of Nursing (DON), and if she saw the intervention already present she may go to the DON and ask other people.
The Facility Policy titled [Facility] Falls-Clinical Protocol revised 3/18 documented, in part, the following: 1. For an individual who has fallen, the staff and practitioner will begin to try to identify possible causes within 24 hours of the fall. The Policy also documented, Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling .If underlying causes cannot be readily identified or corrected, staff will try various relevant interventions, based on assessment of the nature or category of falling, until falling reduces or stops or until a reason is
identified for its continuation (for example, if the individual continues to try to get up and walk without
waiting for assistance).

Based on observation, interview, and record review, the facility failed to ensure consistent completion of assessments prior to dialysis for one of one resident reviewed for dialysis (Resident #37). The facility reported a census of 48 residents.
Findings include:
Review of the Minimum Data Set (MDS) assessment for Resident #37 revealed the resident scored 15 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated intact cognition. Per the assessment, the resident received dialysis while a resident.
The Care Plan dated 8/3/22 documented, I have alteration of my renal function and require DIALYSIS d/t (due to) End Stage Renal
Disease. I refuse to be weighed at the facility.
The Intervention dated 8/3/22 documented, The facility will assist me, as needed, to coordinate services and care with my
dialysis clinic. Communication with the dialysis center will be done pre/post each visit using a communication sheet or via phone and documented.
Review of the resident's COMS-Pre/Post Dialysis Evaluation revealed only one evaluation had been completed for the resident on the following dates: 11/6/23, 11/8/23, and 11/20/23.
On 11/29/23 at 10:59AM when queried about dialysis assessments pre and post, the Director of Nursing (DON) acknowledged staff were supposed to do pre and post dialysis assessments. The above dates were provided to the DON related to lack of pre dialysis assessments.
On 11/30/23 at 8:18 AM when queried about the pre-dialysis assessments, the DON acknowledged they were not completed, and explained the facility had set up triggers to pop up on the Medication Adminsitration Record (MAR) for the need to do it every dialysis day.
On 11/30/23 at 10:54 AM, Staff A, Licensed Practical Nurse (LPN) acknowledged an evaluation for pre and post dialysis in the evaluation tab.
On 11/30/23 at 11:50 AM, Staff B, Registered Nurse (RN) acknowledged if a resident on dialysis pre and post assessment supposed to be done. Per Staff B, Resident #37 refused it should be charted in the nurses note, explained the resident refused weight on occasion, and refused a full set of vitals at times.
The Facility Policy titled [Facility] Hemodialysis Access Care dated September 2010 did not address the area of concern.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The Minimum Data Set (MDS) dated [DATE] identified Resident #7 as cognitively intact with a BIMS (Brief Interview for Mental Status) score of 15 and had the following diagnoses: Diabetes Disorder, Gastrostomy and Anxiety Disorder. It also identified Resident #7 required substantial assistance with showers/baths, dressing, putting on footwear and turning from side to side. It did not identify the resident with a feeding tube and identified she was on a therapeutic diet.
Observations of the resident during the survey from 11/27/23 through 11/30/23 revealed the resident's bed with two 1/4 side rails up.
In an interview on 11/29/23 at 10:19 AM, Resident #7 reported she purchased her own bed as it had an air mattress and the side rails came with it, but none of the staff had provided any kind of education on safety issues on it.
In an interview on 11/29/23 at 10:45 AM, the Director of Nursing reviewed the resident's Electronic Medical Record and verified there was no documentation of side rail evaluation, education, etc in Resident #7's record.
A review of the care plan with the last revision date of 11/6/23 revealed the care plan did not address the use of side rails, the need for evaluation and education.
A review of the facility policy titled: Bed Safety dated as last revised August 2022 had documentation of the following:
1. The use of bed rails or side rails (including temporarily raising the side rails for episodic use during care) is prohibited unless the criteria for use of bed rails have been met, including attempts to use alternatives, interdisciplinary evaluation, resident assessment, and informed consent.
2. Prior to the installation or use of a side or bed rail, alternatives to the use of side or bed rails are attempted. Alternatives may include:
a. roll guards;
b. foam bumpers;
c. lowering the bed; and/or
d. use of concave mattresses to reduce rolling off the bed.
e. If attempted alternatives do not adequately meet the resident's needs the resident may be evaluated for the use of bed rails. This interdisciplinary evaluation includes:
a. an evaluation of the alternatives to bed rails that were attempted and how these alternatives failed to meet the resident's needs;
b. the resident's risk associated with the use of bed rails;
c. input from the resident and/or representative; and
d. consultation with the attending physician.
3. The resident assessment to determine risk of entrapment includes, but is not limited to:
a. medical diagnosis, conditions, symptoms, and/or behavioral symptoms;
b. size and weight;
c. sleep habits;
d. medication(s);
e. acute medical or surgical interventions;
f. underlying medical conditions;
g. existence of delirium;
h. ability to toilet self safely;
i. cognition;
j. communication;
k. mobility (in and out of bed); and
l. risk of falling.
2. The resident assessment also determines potential risks to the resident associated with the use of bed rails, including the following:
a. Accident hazards:
1. The resident could attempt to climb over, around, between, or through the rails, or over the foot board; and/or
2. A resident or part of his/her body could be caught between rails, the openings of the rails, or between the bed rails and mattress.
b. Restricted mobility:
1. Hinders residents from independently getting out of bed thereby confining them to their beds;
2. Creates a barrier to performing routine activities such as going to the bathroom or retrieving items in his/her room, eating, hydration and/or walking;
3. Decline in resident function, such as muscle functioning/balance; and/or
4. Skin integrity issues.
c. Psychosocial outcomes:
1. Creates an undignified self-image and alters the resident's self-esteem;
2. Contributes to feelings of isolation; and/or
3. Induces agitation or anxiety.
3. Before using bed rails for any reason, the staff shall inform the resident or representative about the benefits and potential hazards associated with bed rails and obtain informed consent. The following information will be included in the consent:
a. The assessed medical needs that will be addressed with the use of bed rails;
b. The resident's risks from the use of bed rails and how these will be mitigated;
c. The alternatives that were attempted but failed to meet the resident's needs; and
d. The alternatives that were considered but not attempted and the reasons.
4. The staff shall report to the director of nursing and administrator any accidents or incidents associated with a bed or related equipment including the bed frame, side or bed rails, and mattresses. The administrator shall ensure that reports are made to the Food and Drug Administration or other appropriate agencies, in accordance with pertinent laws and regulations including the Safe Medical Devices Act.
Based on observation, interview, and record review, the facility failed to ensure informed consent completed for use of side rails and ensure assessments completed for use of side rails for two of two residents reviewed for side rails (Resident #7, Resident #11). The facility reported a census of 48 residents.
Findings include:
1. The Minimum Data Set (MDS) assessment for Resident #11 dated 11/9/23 revealed the resident scored 6 out of 15 on a Brief Interview for Mental Status (BIMS) exam which indicated severely impaired cognition. Per the assessment, a bed rail was not used in bed for the resident.
The Care Plan did not address use of bed rails for the resident.
The Physician Order dated 6/11/21 documented, Halo/grab barsx2 for bed mobility and positioning. No directions specified for order.
On 11/29/23 at 8:35 AM, observation of Resident #11 revealed the resident in her wheelchair in her room. Resident #11's bed observed to have partial rails bilaterally on the resident's bed, with one rail up and one rail down.
On 11/30/23 at 8:34 AM, the Administrator and DON explained they had done a sweep about bedrails, contacted Power of Attorney and family, and care planned them. Per the Administrator, the residents had admission education and there had been a paper form of consent on admission. During the conversation with the DON and Administrator, it was acknowledged side rail evaluations had not occurred.
The facility provided an evaluation for bed rails as well as consent dated 11/29/23 for Resident #11.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident and staff interviews, the facility failed to serve food that was warm and palatable for three of twenty four residents reviewed (Resident #23, Resident #30, Resident #103). The facility reported a census of 48 residents.
Findings included:
1. The Minimum Data Set (MDS) dated [DATE] identified Resident #30 as cognitively intact with a BIMS (Brief Interview for Mental Status) of 15 and had the following diagnoses: Heart Failure, Renal Insufficiency (Kidney Failure) and Diabetes Mellitus. The MDS also identified Resident #30 required substantial staff assistance with lower body dressing, putting on footwear.
In an interview on 11/29/23 at 8:30 AM sitting up in wheelchair in her room, Resident #30 complained that the food is horrible. The pasta is always overcooked and food has no taste. Breakfast is always cold, especially the eggs. She reported she had spoken to many people about it, even the dietitian.
On 8/31/20, the care plan identified Resident #30 with the problem of being at nutritional risk and directed staff to offer an alternate if she dislikes food or fluids given.
A review of the dietitian progress notes revealed the following:
12/7/22 10:00 PM Some weight variation likely due to fluid fluctuations. Resident does have many food preferences and staff accommodates, if feasible. Would continue current care plan.
2/28/23 7:58 PM Resident does have many food preferences and staff accommodates, if feasible. Would continue current care plan. Intake meets estimated needs.
10/6/23 12:05 PM RD (Registered Dietitian) talked to resident on Tuesday and decision made was to 'start with' small portions of potatoes when on the menu and No dessert except pie as resident stated 'do not take my pie away from me'.
2. At the time of the survey, the admission MDS for Resident #103 had not been completed. A review of the electronic medical record (EMR) list of medical diagnoses included: cerebral infarction due to embolism, muscle weakness and multiple fractures of ribs on the left side.
A review of the progress notes dated 11/22/23 at 5:10 PM revealed Resident #103 as alert and oriented to person, time and place.
In an interview on 11/27/23 at 10:03 AM, Resident #103 reported the food does not always taste so good.
On 11/28/23, the care plan identified the resident to be at nutritional risk due to recent stroke and history of mild dementia and directed staff to offer an alternate if he dislikes food/fluids given on the menu.
On 11/28/23 at 12:47 PM, the dietary manager delivered a test tray and took the temperatures of the food that was delivered on a plate warmer with a hard plastic dome cover. She took the temperatures as follows:
Goulash at 178 degrees Fahrenheit
Green beans at 120 degrees Fahrenheit
Lettuce salad - 53.8 degrees Fahrenheit
The Surveyor tasted goulash which was very bland, the green beans were lukewarm. The lettuce salad tasted slightly warm.
A review of the facility policy titled: Food Prep and dated as last revised April 2019 had documentation of the following:
Food Preparation, Cooking and Holding Time/Temperatures
1. The danger zone for food temperatures is between 41 degrees Fahrenheit and 135 degrees Fahrenheit.
2. Potentially hazardous foods include meats, poultry, seafood, cut melon, eggs, milk, yogurt and cottage cheese.
3. The longer foods remain in the danger zone the greater the risk for growth of harmful pathogens. Therefore PHF (Potentially Hazardous Food) must be maintained below 41 degrees Fahrenheit or above 135 degrees Fahrenheit.
3. During an interview on 11/28/23 at 11:48 AM, Staff N, [NAME] stated the tossed salads never temp. She stated they always make them prior to the service and put them on ice but they still don't temp.
On 11/28/23 at 11:55 AM, temperature checks done prior to the lunch service completed with Staff N revealed the following temperatures:
a. tossed salad- 49.3 degrees- Staff N took the temperature of the toss salads in the refrigerator and stated they weren't much different.
b. green beans 211.1 degrees
On 11/28/23 at 12:45 PM, the post temperatures completed at the end of the lunch meal completed and revealed the following temperatures:
a. tossed salad 51.3 degrees
b. green beans 174.9 degrees
During an interview on 11/28/23 at 1:52 PM, Staff O, RDN (Registered Dietician Nutritionist) queried if she got a test tray and she stated yes she requested a test tray at the end of the month and completed a kitchen check. Staff O asked if she checked the temperatures and she stated the temperatures were low and the green beans temped at 120 degrees.
During an interview on 11/28/23 at 2:10 PM, Staff O stated the strawberries on her test tray temped at 50.5 degrees. She stated she spoke to the residents after the meal and asked them about the temperatures of the food. Staff O stated she didn't temp the tossed salad.
During an interview on 11/28/23 at 2:12 PM, Staff N stated they did the strawberries right after breakfast and then kept in the refrigerator until they started service. Staff N stated she felt they did everything they could do, they kept everything in the refrigerator and didn't take out until before service. Staff N stated she agreed the lettuce didn't temp at the appropriate temperature before or after the meal. Staff N asked if the green beans and strawberries temped at the appropriate temperature on the test tray and she stated no, they didn't. Staff N asked about the goulash and how they add flavoring or if able to and she stated they follow the recipe and don't add anything. Staff N asked if resident can add their own flavoring and she stated yes, the residents had salt and pepper on the tables and the family could provide seasonings for them.
During an interview on 11/28/23 at 2:26 PM, Staff O queried if she tried the goulash and she stated yes and she ate it all. She stated she felt it could of had a little more flavoring. She stated she thought it needed a little more sodium and she didn't use a lot of salt in her cooking. Staff O asked if she thought the temperatures were appropriate and she stated the green beans could of been hotter but had good flavor and the strawberries were cold to her and the lettuce was fine.
During an interview on 12/4/23 at 12:54 PM, the Administrator queried on the expectation of the food temperature and she stated she expected them to be up to the regulations and up to a safe temperature. The Administrator asked about her expectations for the taste of the food and she stated they follow the recipes and make sure the tables had salt and pepper on them.
4. On 11/28/2023 at 10:40 AM Resident # 23 was interviewed regarding any concerns she had. Resident advised the food here is terrible. It is nasty. I'm done eating it.Resident # 23 goes to the dining room but leaves most of the food on plate. It has no taste or flavor. Everything is starch or sugar.
On 11/28/23 1:47 PM The food today was fairly good. The State should be here all the time. The lettuce was good and it wasn't just wilted lettuce. It had tomatoes and onions in it. It usually doesn't. She liked the goulash and thought it had good flavor. It was hot enough for her. Corporate can leave though. They are walking around like they care but they really don't. They are not fooling anyone.
On 11/30/2023 at 11:45 AM Staff member B, RN was queried and reported she had a lot of complaints about the taste of the food. Residents are given an alternative choice.
On 12/04/2023 at approximately 2:30 PM Resident #23 advised the food had been bad again recently especially over the weekend. I didn't eat it. The meals served today had nothing but starch and sugar. That's all we get here starch and sugar.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. At the time of the survey, the admission MDS for Resident #103 had not been completed. A review of the electronic medical record (EMR) list of medical diagnoses included: cerebral infarction due to embolism, muscle weakness and multiple fractures of ribs on the left side.
A review of the progress notes dated 11/22/23 at 5:10 PM revealed Resident #103 as alert and oriented to person, time and place.
Observations of the resident revealed the following:
In an observation and interview with the resident on 11/27/23 at 10:03 AM, as he sat up in the recliner in his room with feet elevated, he reported he came in with an open area to left shin which has kerlix dressing dated 11/25/23. He wore tubigrips to both legs which had with 2+ edema.
11/28/23 at 7:04 AM Resident #103 reported he was supposed to get his dressing to his left leg and the staff didn't change it yesterday. The dressing to his left leg was dated 11/25/23 and appeared to be the same dressing he had yesterday.
11/29/23 11:33 AM, during an observation of wound care, the ADON pulled up pant leg to left leg and removed Resident #103's sock. The ADON verified the date on dressing as 11/25 and should have been changed 11/27. The dressings should be changed every other day.
A review of the physician orders revealed the following:
11/22/23 Mix equal parts of Clotrimazole, Triamcinilone and Silvasorb. Apply to left lower leg including wound bed. Cover any open ulcerations with Telfa, secure with rolled gauze and tape cover with tubigrip Size F every day shift every other day for wound treatment.
A review of the November 2023 Treatment Administration Record revealed documentation the treatment signed out as completed on 11/27/23.
The only problem addressed on the care plan on 11/23/23 was urinary tract infection. It did not address the open area to his left lower leg.
In an interview on 11/29/23 at 10:18 AM, Staff A, LPN reported she was not sure of a process for ensuring all treatment orders were being carried out daily.
In an interview on 11/30/23 at 11:03 AM, the ADON reported nurses are supposed to sign off treatments on the Medication Administration Records after the treatments have been completed.
When asked why the dressings still had 11/25 dated on 11/29, she reported the dressings should have been done on 11/27. She could not explain why the treatment would be signed out on 11/27 when it had not been completed.
In an interview on 11/29/23 at 11:33 AM, Staff B,RN, reported Resident #103 should have had his dressings changed every other day. She was not sure if there was someone to double check MARs to ensure all treatments had been completed at the end of the day.
In an interview on 11/30/23 at 1:01 PM, the Director of Nursing (DON) reported the nurse who signed off the MAR on 11/27 reported after she put the new dressing on, she dated it 11/25. There were no initials on the dressing and he had instructed staff they need to start writing their initials on the dressing.
Based on observation, interview, and record review the facility failed to accurately document receipt of hospice services and completion of a wound treatment for two of two residents reviewed for records (Resident #18, Resident #103). The facility reported a census of 48 residents.
Findings include:
1. The Minimum Data Set (MDS) for Resident #18 dated 9/16/23, completed 9/22/23, revealed the resident scored 15 out of 15 on a Brief Interview for Mental Status (BIMS) exam. Per the assessment, Resident #18 did not receive hospice care while a resident.
The Care Plan revised 11/16/23 documented, I am at nutritional risk due to h/o (history of) ETOH (alcohol) dependence, cardiomyopathy, cirrhosis and weight loss hx (history). I have been admitted to Hospice in October 2022 and Decertified in [DATE]. Resident to be certified for Hospice Care end of June/Early July 2023. As of October 2023 resident remains decertified from Hospice.
The Health Status Note dated 9/18/23 at 8:22 AM documented, Resident discharged from hospice on 9.17.2023. No change in condition. Resident and POA (Power of Attorney) aware.
The Health Status Note dated 9/24/23 at 9:39 PM documented, Hospice cares continue-No change in condition.
The Health Status Note 9/25/23 at 11:42 AM documented, Night nurse passed along to please have hospice fill resident's morphine sulfate order. Resident has not been on hospice services for awhile now per [Name Redacted], RN (Registered Nurse). Resident low on morphine sulfate, Back up/ partial bottle located in medication room at this time. Nurse on duty to call primary [Name Redacted], NP (Nurse Practitioner) office for request of medication refill when resident is running low at a later time to alot time for processing of medication request.
The Health Status Note dated 9/26/23 at 3:51 AM documented, Resident continues on Hospice level of care. No changes noted this shift.
The Restorative Weekly Note dated 9/29/23 at 2:28 PM documented, Res has recently been discharged from Hospice care All RT program activities at this time are being re evaluated by in house PT (physical therapy).
On 11/30/23 at 8:16 AM when queried about hospice documentation, the Director of Nursing (DON) explained he was told the resident went back and forth on whether or not the resident wanted to be on hospice or did not. Per the DON, the nurses documented based on the resident's preference, and explained the nurse was not going to call to restart and stop which was why the documentation went back and forth.
On 11/30/23 at 10:54 AM, Staff A, Licensed Practical Nurse (LPN) explained the resident would say he did not want to be on hospice, the doctor would be contacted and it would be discontinued. Staff A explained usually when the resident had upper respiratory concerns or did not want to go to the the hospital, the resident wanted to go back on hospice.
On 12/4/23 at 2:04 PM, the facility explained there was not a policy to address complete and accurate records.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident and staff interview, the facility failed to ensure proper infection control techniques for one of three residents observed during medication pass (Resident #6), during the drainage of a GT (gastric tube) drainage bag for one of one residents observed with a GT drainage bag (Resident #7) and during wound care for one of one residents observed (Resident #103). The facility reported a census of 48 residents.
Findings included:
1. The Minimum Data Set (MDS) dated [DATE] identified Resident #6 as cognitively intact with a BIMS (Brief Interview for Mental Status) score of 15 and had the following diagnoses: Atrial Fibrillation (an abnormal heart rhythm), Coronary Artery Disease, Parkinson's Disease and Anxiety Disorder. The MDS also identified Resident #6 as independent with most activities of daily living.
During observation of med pass for Resident #6 on 11/28/23 at 6:35 AM, Staff B, RN removed one tablet of Alprazolam 1 mg from blisterpack, the pill fell out on top of med cart. Staff B picked up the pill with her bare hand, placed it in the medication cup and administered it to the resident.
A review of the physician orders and November 2023 Medication Administration Record revealed an order dated 11/30/18 Alprazolam 1 miligram one tablet give by mouth two times a day for anxiety disorder.
In an interview on 11/29/23 at 10:18 AM, Staff A, LPN reported if she removed pills from a blisterpack and it fell out on top of the medication cart, she would have to dispose of it.
In an interview on 11/29/23 at 11:33 AM, Staff B,RN, reported if she removed pills from a blisterpack and it fell out on top of the medication cart, she would have to waste it. She admitted she got flustered as the surveyor was observing her.
In an interview on 11/30/23 at 1:01 PM, the Director of Nursing (DON) reported if a nurse removed pills from a blisterpack and it fell out on top of the medication cart, she would expect the nurse to waste the pill.
2. The Minimum Data Set (MDS) dated [DATE] identified Resident #7 as cognitively intact with a BIMS (Brief Interview for Mental Status) score of 15 and had the following diagnoses: Diabetes Disorder, Gastrostomy and Anxiety Disorder. It also identified Resident #7 required substantial assistance with showers/baths, dressing, putting on footwear and turning from side to side. It did not identify the resident with a feeding tube and identified she was on a therapeutic diet.
In an observation on 11/28/23 at 11:17 AM, Staff B, RN entered room and washed hands, donned gloves, a placed paper towel on the floor and placed graduate on top of paper towel. Staff B used the correct technique to drain the GT drainage bag. The GT drainage bag was not placed in a dignity bag. Staff B placed both the tubing and bag on the floor underneath the resident's wheelchair.
On 5/18/23, the care plan identified Resident #7 with a gastric drainage bag and did not direct staff to place the bag in a dignity bag and keep both bag and tubing off the floor.
In an interview on 11/29/23 at 10:18 AM, Staff A, LPN reported when emptying out Resident #7's GT drainage bag she would keep both bag and tubing off the floor.
In an interview on 11/29/23 at 11:33 AM, Staff B,RN, reported when emptying out Resident #7's GT drainage bag she would make sure it's secure and covered and off the floor.
In an interview on 11/30/23 at 1:01 PM, the Director of Nursing (DON) reported when emptying out Resident #7's GT drainage bag, he would expect the nurse to make sure both bag and tubing are kept off the floor.
3. At the time of the survey, the admission MDS for Resident #103 had not been completed. A review of the electronic medical record (EMR) list of medical diagnoses included: cerebral infarction due to embolism, muscle weakness and multiple fractures of ribs on the left side.
A review of the progress notes dated 11/22/23 at 5:10 PM revealed Resident #103 as alert and oriented to person, time and place.
During an observation of wound care which began on 11/29/23 at 11:17 AM, Staff C, RN did not use alcohol hand sanitizer to sanitize hands before she pulled out the 3 tubes of ointment out of the treatment cart. She squirted a small amount of Triamcinalone 0.025%, Clotrimazole 1% cream and Silvasorb and mixed together into a medication coup. She did not wear gloves to handle the tubes of ointment then returned to ziplock bag which she then returned to treatment cart. Staff C then found a bottle mixed by pharmacy with all 3 ointments and did not wear gloves when she used a cotton tipped applicator to remove from the bottle and added to med cup which she had mixed.
11/29/23 at 11:22 AM When asked what type of wound Resident #103 had, Staff C could not recall if the wound was arterial or venous. She stated she needed more supplies and took the medication cup of ointment with her and locked up treatment cart.
11/29/23 at 11:24 AM Staff C returned to unlock treatment cart and removed telfa dressings then said I need rolled gauze locked tx cart and left to get rolled gauze
11/29/23 at 11:30 AM Staff C returned to Resident #103's room with supplies and placed on paper towels on top of resident's bed.
11/29/23 at 11:33 AM Staff C washed her hands and donned gloves, removed Resident #103's sock. She verified the date on dressing was written as 11/25 and the dressing should have been changed 11/27.
11/29/23 at 11:35 AM Staff C removed a pair of scissors from her pocket and did not disinfect them prior to cutting the dressings from Resident #103's left leg.
11/29/23 at 11:37 AM Staff C washed her hands and donned new gloves. She squirted skin wound cleanser onto 4x4 gauze dressings and dabbed the wound from the top to the bottom, rather than inward out. She used same dressings to cleanse all areas (using a washboard motion) of the leg without changing surface.
11/29/23 at 11:39 AM Staff C removed her gloves, did not use sanitize her hands and donned new gloves. She used a cotton tipped applicator to apply the ointment mixture onto telfa dressing and used same dressing to spread ointment mixture all over shin area and back of leg using washboard motion back and forth.
11/29/23 at 11:41 AM Staff C removed her gloves, used Alcohol Hand Sanitizer and donned new gloves. Staff C applied dressings to the wound, did not disinfect the scissors before she cut the new dressing.
In an interview on 11/29/23 at 10:18 AM, Staff A, LPN reported when cleansing a wound, she would clean from the middle of the wound and outward and should disinfect the scissors before and after each use.
In an interview on 11/29/23 at 11:33 AM, Staff B,RN, reported when cleansing a wound, she would clean from the from the least dirty part of the wound which would be the outside of the wound before she would clean the actual wound. She would disinfect her scissors before and after each use.
In an interview on 11/30/23 at 1:01 PM, the Director of Nursing (DON) reported when cleansing a wound, he would expect the nurse to clean from the high part of the wound to the lowest. He would also expect the nurse to disinfect the scissors before and after each use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Immunization Registry Information System (IRIS) review, staff interview, and facility policy review, the facility failed to ensure pneumococcal vaccines offered timely for two of five residents reviewed for immunizations (Resident #4, Resident #11). The facility reported a census of 48 residents.
Findings include:
1. The Minimum Data Set (MDS) assessment for Resident #4 dated 10/5/23 revealed the resident scored 13 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated intact cognition.
Review of Resident #4's electronic health record revealed the resident was born in 1932.
Review of IRIS documentation for the resident revealed the resident received PCV-13 (Pnuemococcal Polysacharide) on 11/17/16. IRIS documentation of immunizations lacked additional pneumococcal vaccination administration.
Review of a paper Vaccination History document provided by the facility revealed the resident last had PPSV-23 (Pneumococcal Polysaccharide) on 10/24/02.
The webpage https://www.cdc.gov/vaccines/vpd/pneumo/hcp/who-when-to-vaccinate.html#adults-19-64 revealed the following per the Received PCV13 at Any Age and PPSV23 After age [AGE] Years heading: Use shared clinical decision-making to decide whether to administer PCV20. f so, the dose of PCV20 should be administered at least 5 years after the last pneumococcal vaccine.
Review of the resident's Immunization Consent/Declination Form dated 10/16/23 lacked acceptance or declination about PCV-20.
2. The Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident #11 scored 6 out of 15 on a Brief Interview for Mental Status (BIMS) exam which indicated severely impaired cognition.
Review of Resident #4's electronic health record revealed the resident was born in 1934.
Review of IRIS documentation for Resident #11 revealed the resident received PCV-23 on 10/25/13. Per the resident's electronic health record, the resident received PCV-13 on 11/1/17.
On 12/4/23 at 4:38 PM, the Administrator explained via email the facility did not have any further information about PVC-20 for the above residents.
The Facility Policy titled [Facility] Pneumococcal Vaccine revised 9/22 documented, Prior to or upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, will be offered the vaccine series within thirty (30) days of admission to the facility unless medically contraindicated or the resident has already been vaccinated.

Based on Information Registry Information System (IRIS) review, staff interview, and facility policy review, the facility failed to ensure a resident was offered COVID-19 vaccination(s) timely for one of five residents reviewed for immunizations (Resident #18). The facility reported a census of 48 residents.
Findings include:
Review of census information for Resident #18 revealed the resident admitted to the facility 8/17/22. Review of IRIS documentation for the resident revealed the resident received one dose of a two dose series for COVID-19 vaccination on 8/17/22. The resident had another COVID-19 vaccine which could be given 9/7/22 per the earliest date per IRIS, 9/7/22 per the recommended IRIS information, and considered past due 9/28/22 per IRIS.
Review of the resident's Vaccination History per a paper form provided by the facility revealed dose 1 of a 2 dose series given 8/17/22.
Review of the Immunization Consent/Declination Form revealed consent for COVID-19 dated 11/15/23.
On 12/4/23 at 4:38 PM, the Administrator explained via email the facility did not have further information about the resident's second COVID vaccination.
The Facility Policy titled [Facility] Coronavirus Disease (COVID-19) -Vaccination of Residents, revised 12/21, documented, Each resident is offered the COVID-19 vaccine unless is medically contraindicated, or the resident has already been immunized.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interviews, clinical record review, the facility failed to ensure the dignity of two of three reviewed (Residents #3 and #7). The facility reported a census of 47 residents.
Findings included:
1. The admission Minimum Data Set (MDS) dated [DATE] identified Resident #3 as cognitively intact with a Brief Interview for Mental Status (BIMS) of 13. The MDS documented the resident had the following diagnoses; Atrial Fibrillation (an abnormal heart rhythm), Pneumonia and Arthritis. The MDS also identified Resident #3 required substantial assistance with oral hygiene, upper body dressing and totally dependent on staff for toileting, showering, lower body dressing, putting on foot wear and repositioning. The MDS also documented that Resident #3 had an indwelling catheter.
Observations of Resident #3 revealed the urinary drainage bag was not placed in a dignity bag on 11/27/23 at the following times:
At 10:35 AM observed the resident as follows; she sat up in her wheelchair in her room with urinary drainage bag which had not been placed in a dignity bag under wheelchair seat.
At 11:00 AM observation of Resident unchanged.
At 11:30 AM observation of Resident unchanged.
At 12:05 PM observed the resident as follows; she sat up in her wheelchair in the main dining room. The urinary drainage bag which had not been placed in a dignity bag was visible underneath the wheelchair seat. She sat at the table directly in front of the entrance to the kitchen where multiple staff members had walked past her to enter the kitchen.
At 12:22 PM observed resident as follows; she remained in the main dining room eating lunch with the urinary drainage bag still not placed in a dignity bag.
At 1:30 PM observed resident as follows; she sat up in her wheelchair in her room with the urinary drainage bag without a dignity bag and highly visible to anyone walking past the room in the hallway.
At 2:00 PM observation of resident unchanged.
At 3:00 PM observation of resident unchanged.
At 3:30 PM observation of resident unchanged.
The Care Plan for Resident#3 documented a focus area with initiated date of 11-2-23 as follows; impaired urinary elimination pattern due to urinary retention resultant with the need for a catheter. The Care Plan failed to direct staff to place the drainage bag in a dignity bag for privacy.
2. The Minimum Data Set (MDS) dated [DATE] identified Resident #7 as cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 and had the following diagnoses: Diabetes Disorder, Gastrostomy and Anxiety Disorder. It also identified Resident #7 required substantial assistance with showers/baths, dressing, putting on footwear and turning from side to side. It did not identify the resident with a Gastrostomy Tube (GT), but identified that she was on a therapeutic diet.
Observations of the resident revealed the resident did not have the Gastrostomy Tube (GT) (a tube inserted through the belly that beings nutrition directly to the stomach) drainage bag placed in a dignity bag on the following dates and times;
Observation on 11/27/23 at 11:01 AM the resident was asleep in bed with the GT drainage bag which had not been placed in a dignity bag and visible from the hallway.
At 12:08 PM observation unchanged.
On 11/27/23 at 12:30 PM as she sat up in her wheelchair in her room, the GT drainage bag remained without a dignity bag and visible from the hallway.
At 12:45 PM observation unchanged.
At 1:28 PM observation unchanged.
At 2:06 PM observation unchanged.
On 11/27/23 from 2:15 PM to 2:26 PM during an observation of a transfer with a mechanical lift, Staff G, Certified Nurses Aide (CNA) and Staff H, CNA entered the room. Neither CNA had placed the GT drainage bag in a dignity bag prior to leaving the room.
On 11/28/23 at 6:22 AM the resident was asleep in bed with the GT drainage bag which had not been placed in a dignity bag and visible from the hallway.
On 11/28/23 at 7:54 AM as she sat up in bed, with the GT drainage bag which had not been placed in a dignity bag was visible from the hallway.
On 11/28/23 at 10:36 AM the resident was asleep in bed with the GT drainage bag which had not been placed in a dignity bag was visible from the hallway.
On 11/28/23 at 11:16 AM as she sat up in her wheelchair in her room with the GT drainage bag which had not been placed in a dignity bag and visible from the hallway.
On 11/28/23 at 11:17 AM after Staff B, Registered Nurse (RN) entered room and drained the GT drainage bag, she did not place it in a dignity bag before she left the room.
On 11/29/23 at 7:30 AM the resident was asleep in bed with the GT drainage bag which had not been placed in a dignity bag however, on the left side of the bed and not visible from the hallway.
On 11/29/23 at 8:40 AM the resident sat up in her wheelchair in her room with the GT drainage bag which had not been placed in a dignity bag and visible from the hallway.
In an interview on 11/29/23 at 10:19 AM, Resident #7 reported she used to have a cover for her bag (GT bag), but one of the aides had thrown it in the laundry and she never saw it after that, it had been a few years ago.
On 5/18/23, the Care Plan identified Resident #7 with the problem of an actual alteration in her Gastrointestinal Tract related to gastroparesis/gastric outlet obstruction which required a GT placement for decompression and failed to direct staff to place the tube feeding bag in a dignity bag for privacy.
In an interview on 11/29/23 at 10:18 AM, Staff A, Licensed Practical Nurse (LPN) reported a resident that has a urinary drainage bag or bag for GT drainage should always have the bag placed in a dignity bag. The bag and tubing should never be placed on the floor.
On 11/29/23 at 11:33 AM, Staff B,RN, reported a resident that has a urinary drainage bag or bag for GT drainage should always have the bag placed in a dignity bag. The bag and tubing should never be placed on the floor.
In an interview on 11/30/23 at 12:30 PM, Staff E, CNA reported a resident that has a urinary drainage bag or bag for GT drainage should always have the bag placed in a dignity bag. The bag and tubing should never be placed on the floor.
On 11/30/23 at 12:47 PM, Staff F, CNA reported a resident that has a urinary drainage bag or bag for GT drainage should always have the bag placed in a dignity bag. The bag and tubing should never be placed on the floor.
In an interview on 11/30/23 at 1:01 PM, the Director of Nursing (DON) reported a resident that has a urinary drainage bag or bag for GT drainage should always have the bag placed in a dignity bag. The bag and tubing should never be placed on the floor.
A review of the facility policy titled: Urinary Catheter Care dated as last revised September 2014 did not address the need to place the drainage bag in a dignity bag,

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, record review, and the facility policy, the facility failed to have the call light within reach for a resident while in bed for 1 of 1 residents reviewed for call lights (Resident #35). The facility reported a census of 48.
Findings include:
The Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #35 scored a 11 out of 15 on the Brief Interview Mental Status (BIMS) which indicated moderately impaired cognition. The MDS documented impairment on both sides of his lower extremities and the resident used a wheelchair. The MDS documented the medical diagnosis of Parkinsons, unspecified.
The Care Plan revealed a focus area dated 11/18/21 of increased risk for actual/potential limitations in my ability to perform my ADL (Activities of Daily Living) related to generalized weakness and cognitive deficits. The interventions dated 1/24/22 directed staff to encourage the resident to use the bell to call for assistance.
The Care Plan revealed a focus area initiated on 11/18/21 and revised on 8/15/23 of risk for falls related to impaired mobility and decreased safety awareness. The interventions dated 5/29/22 directed staff to be sure the resident's call light is within reach and encouraged the resident to use it for assistance as needed.
During an observation on 11/27/23 at 11:19 AM, Resident #35 laid in bed, call light was against the wall on the floor by the bed, not within reach of the resident.
During an observation on 11/28/23 at 8:21 AM, Resident #35 laid in bed, call light on the floor against the wall by the resident's bed, not within reach of the resident.
During an observation on 11/29/23 at 8:26 AM, Resident #35 laid in bed, call light on the floor next to the wall and not within reach of the resident.
During an interview on 11/30/23 at 10:46 AM, Staff A, LPN (Licensed Practical Nurse) queried on where call lights needed to be located and she stated within reach of the resident. Staff A asked if she considered a call light on the floor by the wall within reach and she stated no.
During an interview on 11/30/23 at 11:09 AM, Staff C, Assistant Director of Nursing (ADON) asked where call lights needed to be located and she stated near the resident, within reach. Staff C asked if she considered a call light within reach if the call light laid on the floor next to the wall and she stated no, not unless the resident was independent.
During an interview on 11/30/23 at 12:41 PM, Staff E, Certified Nurse Assistant queried if a call light needed to be within reach of the resident and she stated yes. Staff E asked what she considered within reach and she stated if the resident in the recliner she pinned it to the chair, and if the resident in bed she pinned it on the bed where the resident could reach it. Staff E asked if the call light laid on the floor if she considered it within reach of the resident and she stated no.
During an interview on 12/4/23 at 9:42 AM, the Director of Nursing (DON) queried on where the call light needed to be located and he stated within the resident's reach. The DON asked if the call light laid on the floor next to the wall if he considered that within reach and he stated no. He stated the staff supposed to make sure the call light within reach as per standards of care.
The Answering the Call Light Policy dated 10/22 revealed the following information:
a. Ensure that the call light is accessible to the resident when in bed, from the toilet, from the shower or bathing facility and from the floor.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 00. The Minimum Data Set (MDS) dated [DATE] identified Resident #7 as cognitively intact with a BIMS (Brief Interview for Mental Status) score of 15 and had the following diagnoses: Diabetes Disorder, Gastrostomy and Anxiety Disorder. It also identified Resident #7 required substantial assistance with showers/baths, dressing, putting on footwear and turning from side to side. It did not identify the resident with a feeding tube and identified she was on a therapeutic diet.
Observations of the resident during the survey from 11/27/23 through 11/30/23 revealed the resident's bed with two ¼ side rails up.
In an interview on 11/29/23 at 10:19 AM, Resident #7 reported she purchased her own bed as it had an air mattress and the side rails came with it, but none of the staff had provided any kind of education on safety issues on it.
In an interview on 11/29/23 at 10:45 AM, the Director of Nursing reviewed the resident's Electronic Medical Record and verified there was no documentation of side rail evaluation, education, etc in Resident #7's record.
A review of the care plan with the last revision date of 11/6/23 revealed the care plan did not address the use of side rails, the need for evaluation and education.
00. The Minimum Data Set (MDS) dated [DATE] identified Resident #30 as cognitively intact with a BIMS (Brief Interview for Mental Status) of 15 and had the following diagnoses: Heart Failure, Renal Insufficiency (Kidney Failure) and Diabetes Mellitus. The MDS also identified Resident #30 required substantial staff assistance with lower body dressing, putting on footwear.
In an observation on 11/27/23 at 12:00 PM, Staff D, RN pushed Resident #30 in the wheelchair without foot pedals.
In an observation on 11/28/23 at 11:19 AM, Staff E, Restorative CNA pulled Resident #30 in her wheelchair out of the bathroom without foot pedals on with Resident #30's feet skimming the floor from the bathroom to outside in the hallway. Resident #30 then was able to self-propel to the main dining room.
On 9/14/20, the care plan identified Resident #30 with the problem of being at risk for falls, however, failed to address the need to place foot pedals on the wheelchair prior to transporting the resident in the wheelchair.
In an interview on 11/29/23 at 10:18 AM, Staff A, LPN reported before pushing a resident in the wheelchair, should make sure the foot pedals are on the wheelchair and put their feet on the foot pedals. This should be addressed on the care plan which any nurse can update.
In an interview on 11/29/23 at 11:33 AM, Staff B,RN, reported before pushing a resident in the wheelchair, should make sure the foot pedals are on the wheelchair and put their feet on the foot pedals. This should be addressed on the care plan
In an interview on 11/30/23 at 1:01 PM, the Director of Nursing (DON) reported before pushing a resident in the wheelchair, should make sure the foot pedals are on the wheelchair and put their feet on the foot pedals. Resident #30 has a bag on the back of her wheelchair where the foot pedals are stored. He did not feel this should be addressed on the care plan as it is common sense. He also reported the facility did utilize many CNAs from different agencies. The DON also reported it was a team effort and that all nurses could update the care plan.
A review of the facility care plan titled: Comprehensive Person Centered Care Plans dated as last revised December 2016 had documentation of the following:
1. The comprehensive person -entered care plan will:
a. Include measurable objectives and time frames;
b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being;
c. Describe services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment;
d. Describe any specialized services to be provided as a result of PASARR recommendations;
e. Include the resident's stated goals upon admission and desired outcomes;
f. Include the resident's stated preference and potential for future discharge, including his or her desire to return to the community and any referrals made to local agencies or other entities to support such a desire;
g. Incorporate identified problem areas;
h. Incorporate risk factors associated with identified problems;
i. Build on the resident's strengths;
j. Reflect the resident's expressed wishes regarding care and treatment goals;
k. Reflect treatment goals, timetables and objectives in measurable outcomes;
l. Identify the professional services that are responsible for each element of care;
m. Aid in preventing or reducing decline in the resident's functional status and/or functional levels;
n. Enhance the optimal functioning of the resident by focusing on a rehabilitative program; and
o. Reflect currently recognized standards of practice for problem areas and conditions.
2. The comprehensive person-centered care plan is developed within seven (7) days of the completion of the required comprehensive assessment (MDS)
3. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' condition change.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, and facility policy the facility failed to document the resident's Advance Directives for two of two residents reviewed (Residents #103 and #203). The facility reported a census of 48 residents.
Findings included:
1. At the time of the survey, the admission MDS for Resident #103 had not been completed. A review of the Electronic Medical Record (EMR) list of medical diagnoses included: cerebral infarction due to embolism, muscle weakness and multiple fractures of ribs on the left side.
The admission Progress Note dated [DATE] at 5:10 PM revealed Resident #103 as alert and oriented to person, time and place. The admission Progress Note documented the resident had diagnoses which included weakness with falls, and would be on skilled level of care for therapy after discharge from a hospital.
On [DATE], a review of the EMR revealed no documentation to address Resident #103's preference for Advance Directives (legal documents that provide instructions for medical care and only go into effect if you cannot communicate your own wishes).
On [DATE], a review of the facility notebook for Iowa Physician Orders for Scope and Treatment which communicates the resident's preferences for key life-sustaining treatments such as Cardiopulmonary Resuscitation (CPR) (IPOST's) lacked documentation to address Resident #103's preferences for Advance Directives.
On [DATE] at 7:00 AM, a review of the EMR revealed no documentation on the Face Sheet, the Physician Orders, the Medication Administration Record or Care Plan to address the Advance Directives.
On [DATE] at 10:30 AM, the facility provided a copy of the IPOST signed by the resident on [DATE].
In an interview on [DATE] at 7:04 AM, when asked about Advance Directives, Resident #103 reported in the event his heart stopped, he chose not to have CPR done.
In an interview on [DATE] at 10:18 AM, Staff A, Licensed Practical Nurse (LPN) reported the following;
a. Staff would find information on the resident's code status in a 3 ring binder behind the nurse's station on the shelf, alphabetized and IPOSTs and advance directives
b. If the staff could not find any information on the resident regarding code status, the staff would have to do CPR
c. If there wasn't an order on admission, the social worker has been responsible for notifying the doctor to obtain an order.
d. When a resident is first admitted , orders for Advance Directives should be obtained within 24 hours.
In an interview on [DATE] at 11:33 AM, Staff B, Registered Nurse (RN), reported the following;
a. Staff would find information on the resident's code status in a binder at the nurse's station which has all the current IPOST, advance directives.
b. If the staff could not find any information on the resident regarding code status, the staff would have to do CPR
c. If there wasn't an order on admission, the social worker has been responsible for notifying the doctor to obtain an order.
d. When a resident is first admitted , orders for Advance Directives should be obtained within 24 hours.
In an interview on [DATE] at 12:30 PM, Staff E, Certified Nurses Aide (CNA) reported the following;
a. If she did not know what the resident's code status was and it was not in the computer, she would ask the nurse and thought there was a book at the nurse's station to address it.
b. If the staff could not find any information on the resident regarding code status, if the resident coded, she would check with the nurse to see what the code status is.
In an interview on [DATE] at 12:47 PM, Staff F, CNA reported the following;
a. If she did not know what the resident's code status was and it was not in the computer, she would ask the DON and find someone that knew.
b. If the staff could not find any information on the resident regarding code status, if the resident coded, she would start CPR.
In an interview on [DATE] at 1:01 PM, the Director of Nursing (DON) reported the following;
a. Staff would find information on the resident's code status in a notebook at the nurse's station which has all the IPOSTS in it.
b. If the staff could not find any information on the resident regarding code status, the staff would have to start CPR
c. If there wasn't an order on admission, the nurse on duty or the social worker is responsible for notifying the doctor to obtain an order.
d. When a resident is first admitted , he would expect the order for Advance Directives to be obtained as soon as possible.
A review of the facility policy titled: Advance Directives dated as last revised [DATE] had directed staff as follows;
Determining Existence of Advance Directive
a. Prior to or upon admission of a resident, the social services director or designee inquires of the resident, his/her family members and/or his or her legal representative, above the existence of any written advance directives.
b. The resident or representative is provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so.
2. Resident #203 admitted to facility on [DATE].
The admission Progress Note dated [DATE] at 1:19 PM documented as follows: facility nurse received report from nurse at the hospital. The resident was described as a [AGE] year old male, with altered mental status, hallucinations, shoulder pain and increased falls with a persistent hacking cough, with the Advanced Directive status of Do not resuscitate/Do not intubate (DNR/DNI).
The Baseline Care Plan dated [DATE] at 10:05 section Advanced Directives/Code Status was left blank.
Record Review completed on [DATE] at 9:41 AM revealed the residents EHR lacked documentation of Physician Orders for advanced directives.
During an interview on [DATE] at 3:09 PM, Staff I, Social Services stated the facility always did their own advanced directives unless the resident already filled out an Iowa Physician Orders for Scope of Treatment (IPOST) or had a living will. She stated the resident was a full code status until the advanced directives were signed by the doctor. She stated she reviewed the advanced directives with Resident #203 wife today. Staff I asked when advanced directives needed completed and she stated normally on the day of admission and usually done in a couple of days after admission.
The IPOST completed on [DATE] and signed by the doctor. (4 days after admission and resident/resident representative requested DNR)
During an interview on [DATE] at 9:43 AM, the DON queried on when advanced directives needed completed and he stated they should be attempted on admission. The DON stated advanced directives and the IPOST were voluntary and when not completed the resident is considered a full code. The DON asked in what time frame he expected the advanced directives be completed and he stated it depended on why they were not completed and they might be waiting on the Power of Attorney (POA).

Based on observation, interview, and record review, the facility failed to ensure physician notification occurred for heart rate per parameters included the resident's Care Plan for one of one residents reviewed for physician notification (Resident #4). The facility reported a census of 48 residents.
Findings include:
The Minimum Data Set (MDS) assessment for Resident #4 dated 10/5/23 revealed the resident scored 13 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated intact cognition.
The Care Plan dated 7/14/21 documented, The resident is on Digoxin Therapy r/t (related to) atrial fibrillation. The Intervention dated 7/14/21 documented, Report to physician if pulse falls below 60 or rises above 110 or if you detect skipped beats or other changes in rhythm.
Review of documentation of the resident's pulse for October 2023 and November 2023 revealed the following dates, times, and documentation of heart rate less than 60.
Documentation of the resident's heart rate on 10/1/23 and 10/2/23 revealed the following instances of heart rate less than 60:
a. 10/1/23 at 2:35 PM: 37 bpm (beats per minute)
b. 10/1/23 at 3:20 PM: 45 bpm
b. 10/1/23 at 3:35 PM: 53 bpm
c. 10/1/23 at 4:05 PM: 44 bpm
d. 10/1/23 at 4:35 PM: 48 bpm
e. 10/1/23 at 5:35 PM: 47 bpm
f. 10/1/23 at 6:12 PM: 48 bpm
g. 10/1/23 at 6:35 PM: 52 bpm
h. 10/1/23 at 7:35 PM: 50 bpm
i. 10/1/23 at 8:35 PM: 48 bpm
j. 10/2/23 at 5:25 AM: 55 bpm
Documentation of the resident's heart rate during the time period of 10/4/23 through 10/8/23 revealed the following instances of heart rate less than 60:
a. 10/4/23 at 10:04 AM: 53 bpm
b. 10/4/23 at 1:36 PM: 53 bpm
c. 10/5/23 at 9:53 AM: 56 bpm
d. 10/6/23 at 8:18 AM: 55 bpm
e. 10/7/23 at 10:03 AM: 55 bpm
f. 10/8/23 at 8:39 AM: 57 bpm
The Progress Notes dated 10/01/23 to 10/8/23 lacked notification to the residents physician of the heart rate less than 60 bpm.
On 11/30/23 at 10:48 AM, Staff A, Licensed Practical Nurse (LPN) explained if she notified the physician, it would be charted in the progress note and transfer form.
On 11/30/23 at 11:47 AM, Staff B, Registered Nurse (RN) acknowledged contact to the physician would be in the progress note.
On 12/4/23 at 10:02 AM, the Director of Nursing (DON) explained physician notification documentation would be in the progress note.
The Facility Policy titled [Facility] Change in a Resident's Condition or Status revised 2/21 documented, Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and facility policy review, the facility failed to provide a homelike environment by cleaning and removing stains and dried food on a resident's recliner for 1 of 2 residents reviewed for cleanliness of the building (Resident #22). The facility reported a census of 48.
Findings include:
The Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #22 scored a 15 out of 15 on the Brief Interview for Mental Status which indicated cognition intact. The MDS revealed medical diagnoses of stroke and hemiplegia following cerebral infarction affecting the right dominant side.
During an observation on 11/27/23 at 10:58 AM, Resident #22 right side seat cushion on the recliner dirty with dried food and stains on it. Incontinent pad on the recliner had a brown mark smeared on the end of it by the stains on the seat.
During an interview on 11/27/23 at 10:58 AM, Resident #22 stated the staff spend about 10 minutes in his room to clean. He stated he ate in his chair and could have spilled something.
During an observation on 11/28/23 at 8:54 AM, Resident #22 recliner chair had dried food and stains on the left and right armrests. The left side of the recliner left arm of his recliner chair had white chunks of food dried on it. The seat on the recliner had a dried food and on it.
During an observation on 11/29/23 at 8:33 AM, Resident #22 sat in his recliner and the arms of his recliner had dried food/stains on them and the left side of his recliner had white dried food on it.
During an observation on 11/30/23 at 10:57 AM, Resident #22 recliner had an incontinent pad on the seat cushion and the arms of the recliner chair had dried food/stains and white thick food stuck to the left side of the chair.
During an interview on 11/30/23 at 12:22 PM, Staff J, Housekeeping queried who responsibility it was to clean the furniture and she stated she cleaned the furniture when they had stains on them. She stated Resident #22 sat in his chair often when she cleaned his room. She stated the maintenance staff will tell her if she needed to clean a recliner and her boss also told her and showed her things that needed done.
During an interview on 11/30/23 at 12:30 PM, Staff K, Housekeeping Manager, stated she was responsible for cleaning the furniture and the resident's chair would be cleaned by the end of the day.
During an interview on 11/30/23 at 12:38 PM, Staff K, stated she looked at the chair and they were cleaning it now. She stated the chair looked dingy, and she would ask if they could get him a different one.
During an interview on 12/4/23 at 12:54 PM, the Administrator queried on her expectation of the resident's furniture being cleaned and she stated she expected it to be clean. She stated they removed the resident's recliner, cleaned it, and replaced it with a different one. The Administrator asked if she saw the recliner and she stated yes. The Administrator asked her thoughts on the recliner and she stated it did not live up to our expectations.
The Daily Patient Room Cleaning Policy dated 10/7/16 did not address cleaning the furniture.
The Deep Clean Checkoff List Policy dated 9/5/17 revealed the following information:
a. Make sure to inform resident(s) you ' re deep cleaning their room. Let resident(s) know we will be in their room for 30 minutes and if they could leave for that time it would be greatly appreciated. You
must move the bed, dresser, and any large objects so you can clean behind it. This room must be sanitized, dusted, and dirt free when you are done.
1. Clean and wipe down all chairs (legs and backs not just where you sit).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, record review, and the facility policy review, the facility failed to ensure residents free from chemical restraints when narcotics pain medication was administered for management of resident's behavior for 1 of 5 residents reviewed for unnecessary medications (Resident #15). The facility reported a census of 48.
Findings include:
The MDS Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 scored a 2 out of 15 Brief Interview of Mental Status (BIMS) exam, which indicated severely impaired cognition. The MDS documented the resident was unable to answer presence of pain. The MDS indicated the resident received scheduled pain medications, and the resident received or was offered As Needed (PRN) pain medications, and the resident didn't receive non-medication intervention for pain. The MDS documented that the resident received antipsychotics, antidepressants, anti-anxiety, and an opioid class of medications that are considered high-risk drug classes.
The Care Plan revealed a focus area dated 5/29/22 for increased risks for actual/potential limitation (s) in my ability to perform my ADL (Activities of Daily Living) related to impaired mobility and impaired cognition. The interventions dated 5/29/22 revealed resident often refused showers and must be reapproached.
The Care Plan documented a focus area initiated on 5/10/23 and revised on 10/3/23 as follows; There are days the resident may become agitated and verbally aggressive towards staff and others due to poor impulse control secondary to Dementia. The resident may also become anxious and/or tearful at times. The interventions dated 5/10/23 directed staff as follows; use analysis of key times, places, circumstances, triggers, and what de-escalated behavior and document; assess and anticipate resident's needs for food, thirst, toileting needs, comfort level, body positioning, pain etc.; assess resident's understanding of the situation and allowed time for the resident to express self and feelings towards the situation; give the resident as many choices as possible about care and activities.
The Electronic Medical Record (EMR) revealed the following diagnoses;
a. unspecified dementia, severe, with agitation
b. anxiety disorder, unspecified
c. major depressive disorder, single episode, unspecified
d. low back pain, unspecified
e. unspecified osteoarthritis, unspecified site
f. rheumatoid arthritis, unspecified
The Physician Orders revealed the following medications;
a. ordered 12/1/21- Sertraline HCl tablet 100 mg- Give 1 tablet by mouth one time a day for antidepressant
b. ordered 12/6/21: Tylenol Extra Strength tablet 500 mg (Acetaminophen)- Give 1 tablet by mouth every 4 hours as needed for pain or fever
c. ordered 2/2/23- Trazadone HCl (hydrochloride) oral tablet 50 mg- Give 50 mg by mouth at bedtime for depression
d. ordered 4/11/23: Tylenol Extra Strength oral tablet 500 mg (Acetaminophen)- Give 1 tablet by mouth every morning and at bedtime for pain
e. ordered 4/30/23- Lorazepam concentrate 2 mg/ml- Give 0.5 ml by mouth four times a day for anxiety Do not change times per provider order (benzodiazepines, used to produce a calming effect).
f. ordered 5/1/23- Aripiprazole tablet 2 mg- Give 1 tablet by mouth one time a day for dementia aggression (antipsychotic)
g. ordered 7/21/23- Morphine Sulfate (concentrate) solution 20 mg/ml (milligrams/milliliters)- Give 5 mg by mouth every 4 hours as needed for pain (opiate, narcotic used for treatment of pain)
The August MAR (Medication Administration Record) documented the following times the prescribed morphine administered to Resident #15:
a. 8/2/23 at 6:31 PM, pain level 8
b. 8/8/23 at 8:19 PM, pain level 5
c. 8/12/23 at 3:06 PM, pain level 8
d. 8/29/23 at 6:26 PM, pain level 5
e. 8/31/23 at 11:09 PM, pain level 4
The September MAR documented the following times the prescribed morphine administered to Resident #15:
a. 9/2/23 at 2:37 PM, pain level 3
b. 9/3/23 at 5:27 PM, pain level 5
c. 9/7/23 at 10:30 PM, pain level 5
d. 9/10/23 at 4:07 PM, pain level 6
e. 9/13/23 at 4:39 PM, pain level 6
f. 9/16/23 at 5:25 PM, pain level 6
g. 9/19/23 at 4:33 PM, pain level 7
h. 9/24/23 at 2:55 PM, pain level 6
i. 9/30/23 at 5:57 PM, pain level 8
The October MAR documented the following times the prescribed morphine administered to Resident #15:
a. 10/7/23 at 11:46 AM, pain level 9
b. 10/12/23 at 3:58 PM, pain level 0
c. 10/15/23 at 2:38 PM, pain level 5
d. 10/29/23 at 4:55 PM, pain level 6
The November MAR documented the following times the prescribed morphine administered to Resident #15:
a. 11/2/23 at 9:19 AM, pain level 7
b. 11/3/23 at 9:16 AM, pain level 7
c. 11/8/23 at 1:39 PM, pain level 6
d. 11/11/23 at 7:32 AM, pain level 7
e. 11/15/23 at 10:22 AM, pain level 7
f. 11/21/23 at 10:20 AM, pain level 7
g. 11/25/23 at 1:54 PM, pain level 7
The MAR's for August, September, October, and November revealed resident never received the PRN (as needed) Tylenol for pain.
The Behavior Note dated 8/2/23 at 5:04 PM revealed the resident tearful, appeared anxious, combative with cares and exit seeking.
The Behavior Note dated 8/12/23 at 5:57 PM revealed the resident yelled out, became combative with staff, appeared anxious and tearful, exit seeking. Gave PRN morphine.
The Behavior Note dated 8/29/23 at 9:10 PM revealed the resident tearful and appeared anxious, yelled out, and became combative at times.
The Progress Note dated 9/2/23 5:29 PM revealed the resident tearful at beginning of shift and when asked if in pain resident reported yes but unable to verbalize where. prn morphine given with good results. (The MAR documented a pain level of 3).
The Behavior Note dated 9/3/23 at 6:04 PM, the resident tearful and appears to be cried, yelled out, gave prn morphine, no other behaviors noted.
The Behavior Note dated 9/10/23 at 5:26 PM, the resident wandered the hallways, yelled out E', tearful and appeared anxious.
The Progress Note dated 9/13/23 at 5:11 PM, the resident yelled out, exit seeking, resistant to cares, tearful and appeared anxious.
The Behavior Note dated 9/16/23 at 5:20 PM, the resident tearful and appeared anxious, resistant to cares.
The Behavior Note dated 9/24/23 at 5:20 PM, the resident cried and yelled out, appeared anxious, resistant to cares and combative with staff.
The Behavior Note dated 9/30/23 at 4:37 PM, the resident yelled out, resistive to cares. resident attempted to spit out medications. resident became combative with staff.
The Behavior Note dated 10/12/23 at 8:42 PM, the resident became very anxious, wandered and become agitated with redirection. PRN Morphine utilized and appeared to be effective. Resident able to eat in MDR (Main Dining Room) without any further behaviors.
The Behavior Note dated 10/15/23 at 5:24 PM, the resident yelled out, cried, and appeared anxious.
The Behavior Note dated 10/29/23 at 4:59 PM, the resident yelled out, combative with staff during cares.
The Behavior Note dated 11/2/23 at 1:27 PM, the resident very tearful and called out this AM. PRN morphine given with relief noted. Compliant with cares and medications.
The Behavior Note dated 11/3/23 at 1:43 PM, the resident tearful this AM. PRN morphine given with relief noted. Compliant with cares and medications.
The Behavior Note dated 11/8/23 at 1:35 PM, the resident called out and restless after lunch. PRN morphine given.
The Behavior Note dated 11/11/23 at 1:30 PM, the resident tearful and yelled out this AM. PRN morphine given with relief noted. Compliant with cares and medications.
The Behavior Note dated 11/15/23 at 2:02 PM, the resident yelled, hit and kicked after being bathed this AM. Repeated yelling out and agitated behavior. PRN morphine given with relief noted.
The Behavior Note dated 11/21/23 at 1:25 PM, the resident very tearful and called out this AM. PRN morphine given with relief noted.
The Behavior Notes and Progress Notes lacked the documentation that Care Plan interventions had been used prior to giving PRN Morphine.
During an observation on 11/27/23 at 10:31 AM, Resident #15 sat in her wheelchair in the hallways. She had a lamb stuffed animal on her lap.
During an observation on 11/27/23 at 1:38 PM, the resident sat in the wheelchair in the common area and held her stuffed animal. Staff asked her if she wanted to lay down.
During an observation on 11/27/23 at 1:40 PM, the resident in her wheelchair and make sounds and self propelled herself in the common room.
During an observation on 11/28/23 at 1:46 PM, resident laid in her bed in her room and slept. Resident's head propped up on a pillow.
During an observation on 11/30/23 at 10:56 AM, resident in her wheelchair in the hallway and had a blanket over her. She is smiling and in good spirits when people walk by and talk to her.
During an interview 11/30/23 at 9:26 AM, the DON (Director of Nursing) stated Resident #15 was prescribed Morphine for low back pain because she experienced tearfulness and behaviors. He stated the doctor put her on a two week trial and it appeared effective so they kept her on it. He stated it wasn't ordered for behaviors. The DON asked why the morphine used instead of the PRN Tylenol and he stated for the severity of pain. He stated the resident was unable to give a numerical number so they used physical signs and symptoms. The DON what he considered severity of pain and he stated anything over a 5.
During an interview on 11/30/23 at 10:38 AM, Staff A, Licensed Practical Nurse (LPN) queried on Resident #15 behaviors and she stated the resident had bad sundowning and they waited to wake her up to help with her behaviors. She stated the resident didn't like her showers and became tearful for an hour or two after her showers. She stated the resident didn't like to go the bathroom. She stated they tried to fill out the resident and redirect and reapproach as needed. Staff A asked how Resident #15 displayed pain and she stated she kept repeating things and would tense up. Staff A stated she never gave her morphine and only gave her Tylenol.
During an interview on 11/30/23 at 11:13 AM, Staff C, Assistant Director of Nursing (ADON) queried on Resident #15 behaviors and she stated the resident got anxious, scared, and non-verbal most of the time and wouldn't say how she felt. She stated other times the resident perfectly happy. She stated the resident's behaviors depended on how she woke up in the morning. Staff C stated the resident didn't like to be helped or changed positions. Staff C asked about Resident #15 pain and she stated the resident pain displayed by her behaviors and physically. She stated she cried and not happy the whole day. She stated she wasn't sure if pain caused the behaviors. Staff C stated Resident #15 couldn't voice pain but the staff could tell the resident was in discomfort.
During an interview on 11/30/23 at 11:51 AM Staff B, Registered Nurse (RN) queried on Resident #15 behaviors and she typically the resident yelled out, tearful, hit, kicked, or pinched staff. Staff B asked what the cause of the resident's behaviors were and Staff B stated she was unsure if they were caused by the resident's dementia or pain. She stated the resident calmed down after the PRN Morphine but didn't know if it was from the narcotic effect or the relief of pain. Staff B asked if the staff did an other interventions prior to the administration of morphine, and she yes they did one on one time with the resident and gave her the stuffed animal, had other residents talk to her. Staff B stated she was bad at charting the other measures she took prior to administration of the Morphine. Staff B asked how the resident was in pain and she stated she tried to hold up the pain card for the resident and the resident would only say E and other times the resident showed facial grimacing.
During an interview on 12/04/23 at 9:54 AM, the DON queried on the resident order for PRN Morphine and PRN Tylenol and the expectation of use of Tylenol prior to Morphine and he stated it depended on the documentation and if the resident asked for pain medication. He stated he didn't know why the resident didn't ask for Tylenol and if not utilized the medication needed reviewed to see if needed discontinued. Discussed with the DON the progress notes and pain level when giving Morphine and the documentation revealed Morphine effective. The DON asked his expectation for use of Morphine and he stated it depended on the documentation because Morphine can potentially be a chemical restraint.
The Use of Restraints Policy dated April 2017 did not address the use of chemical restraints.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and the facility policy review, the facility failed to provide the required documentation needed for transfers to the hospital for 1 of 3 residents reviewed for hospitalizations (Resident #22). The facility reported a census of 48.
Findings include:
The MDS Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #22 scored a 15 out of 15 on the Brief Interview for Mental Status (BIMs) exam, which indicated cognition intact. The MDS revealed medical diagnosis for anxiety disorder and depression.
The Social Work Progress Note dated 4/3/23 at 1:21 PM revealed the staff reported Resident #22 make gestures with a gait belt, gestures of wrapping it around his neck and hanging himself. The Director of Nursing (DON) (put one on one in place immediately. Social Services had a conversation with Resident #22 about his gesture of hanging himself and he denied it. However with further conversation he stated that he cried all of the time and felt sad all the time. Social Services expressed to Resident #22 that they would need to send him to the hospital for evaluation, when comments like that were made the facility take them very serious. Resident #22 stated that he understood and he was willing to go to the hospital.
The Progress Note dated 4/3/23 at 5:28 PM revealed the resident sent to emergency room (ER) at 4:00 PM via facility van.
The Progress Note dated 4/3/23 at 9:03 PM revealed resident admitted to geri psych at the local hospital per (Emergency Room) ER nurse.
The Progress Note dated 10/8/23 at 2:30 PM, revealed at 2:15 PM reported resident found on the floor. On assessment resident complained pain in lower back and tailbone area. When trying to get vitals and check Range of Motion (ROM) resident became combative with a history of doing so. Resident kicking walker and and hit staff. Let him know if he would not let us assess him, the hospital needed to check him out. Resident started hitting again. Called on call doctor. New order to send to Emergency Department (ED). DON notified at 2:20 PM. Wife notified at 2:25 PM. Ambulance called at 2:27 PM.
During an interview on 11/27/23 at 11:06 AM, Resident #22 stated he went to the hospital a couple of times and the last time he went was 2 months ago when he fell.
The Review of the EMR (Electronic Medical Record) lacked documentation of the E-interact Transfer Form-V5 for Resident #22 for the dates 10/8/2023 and 4/3/2023.
During an interview on 11/30/23 at 10:43 AM, Staff A, Licensed Practical Nurse (LPN) queried what needed documented when a resident transfers and she stated the condition of the resident, notification of the doctor, the times the DON, doctor, and family notified and anyone else called, when the resident transferred out, the assessment, and the assessment forms. Staff A asked what paperwork sent with resident and she stated the Iowa Physicians Orders for Scope of Treatment (IPOST), medication sheet, and face page. She stated she also documented when the resident transferred out and called down to the ER and gave report.
During an interview on 11/30/23 at 11:20 AM, Staff C, Assistant Director of Nursing (ADON) queried on what she documented when a resident transferred and she stated vitals, reason the resident left the facility, family and doctor notified, order from doctor, and what lead up to discharging to the hospital. She stated she filled out a transfer form and let the hospital know if resident could walk and if resident oriented. Staff C asked what paperwork the facility sent with transfer and she stated the Medication Administration Record (MAR), advance directives, and transfer form. Staff C asked what documentation needed documented in the progress note and she stated the family notified, when called 911, when called the doctor, what was wrong with the patient, if the resident transferred by ambulance or with family member, the time the resident left, and when we called and gave report to the ER.
During an interview on 12/4/23 at 9:43 AM, the Director of Nursing (DON) queried on the expectations for documentation with transfers and he stated the transfer evaluation needed completed and assessments, and the doctor's notification.
The Transfer or Discharge, Facility Initiated Policy dated October 2022 revealed the following documentation:
a. When a resident transferred or discharged from the facility, the following information documented in the medical record:
1. The basis for the transfer or discharge and if the resident was transferred or discharged because his or her needs cannot be met at the facility the documentation will include:
a. the specific resident needs that cannot be met;
b. the facility's attempt to meet those needs;
c. the receiving facility's service(s) that were available to meet those needs
b. Appropriate notice provided to the resident and/or legal representative
c. The date and time of the transfer or discharge
d. The new location of the resident
e. The mode of transportation
f. A summary of the resident's overall medical, physical, and mental condition
g. Disposition of personal effects
h. Disposition of medications
i. Others as appropriate or as necessary
j. The signature of the person recording the data in the medical record

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and the facility policy, the facility failed to consistently notify the ombudsman of a resident's transfer to the hospital for 1 of 3 residents reviewed for hospitalization (Resident #22). The facility reported a census of 48.
Findings include:
The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #22 scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS) exam, which indicated cognition intact. The MDS revealed medical diagnosis for anxiety disorder and depression.
The Progress Note dated 10/8/23 at 2:30 PM, revealed at 2:15 PM reported resident found on the floor. On assessment resident complained of pain in lower back and tailbone area. When trying to get vitals and check Range of Motion (ROM) resident became combative with a history of doing so. Resident kicking walker and and hit staff. Let him know if he would not let us assess him, the hospital needed to check him out. Resident started hitting again. Called on call doctor. New order to send to Emergency Department (ED). DON notified at 2:20 PM. Wife notified at 2:25 PM. Ambulance called at 2:27 PM.
During an interview on 11/27/23 at 11:06 AM, Resident #22 stated he went to the hospital a couple of times and the last time he went was 2 months ago when he fell.
Review of Ombudsman Notification provided by the facility did not include notification for Resident #22's hospitalization described in the resident's progress notes dated 10/8/23.
During an interview on 12/4/23 at 9:26 AM, Staff I, Social Services queried on when they notified the ombudsman and she stated once a month they sent them a report on all voluntary discharges and transfers to the hospital. Staff I asked if a resident transferred to the hospital and not admitted would the ombudsman be notified and she stated yes, anybody that left the facility was on the report. She stated the facility had a new business office manager and she was in training. Staff I stated the October report documented inpatient hospital transfers but not the transfers to the hospital. Staff I stated she didn't see Resident #22 on the report.
During the interview on 12/05/23 at 9:26 AM, the Administrator queried on her expectations for notification to the Ombudsman and she stated notification need sent monthly and she set up for her to receive the report they send to the ombudsman as well. The Administrator asked what needed to be included on the report and she stated hospitalization, any discharges including non-voluntary and voluntary, anyone who left the facility.
The Transfer and Discharge, Facility Initiated dated October 2022 revealed the following information:
a. A copy of notice sent to the Office of the Long Term Care Ombudsman at the same time of the notice of the transfer or discharge provided to the resident or resident representative.
b. Notice of Transfer provided to the resident and representative as soon as practicable before the transfer and to the long-term care (LTC) ombudsman when practicable (example in monthly list of residents that include all notice content requirements). A copy of the transfer form and supporting progress note will suffice (example- copy of transfer form provided to resident and EMS (Emergency Medical Services at time of transfer, resident representative notified and requests/declines copy of transfer form at this time.)

Based on record review, staff interviews, and the facility policy the facility failed to complete the Annual Minimum Data Set (MDS) assessment within a timely manner for 3 of 15 residents reviewed for annual MDS assessments (Resident #15, #22, #35). The facility reported a census of 48.
Findings include:
Resident #35 MDS Annual assessment Assessment Reference Date (ARD)/Target Date dated 10/12/23 completed on 11/8/23 and accepted/locked on 5/22/23.
Resident #22 MDS Annual assessment ARD/Target Date dated 9/21/23 and not completed until 10/17/23 and accepted/locked on 10/17/23.
Resident #15 MDS Annual assessment ARD/Target Date dated 8/17/23 and not completed until 9/12/23 and accepted/locked on 9/12/23.
During an interview on 11/30/23 at 12:05 PM, Staff L, MDS Coordinator queried on who did the MDS assessments and she stated she did. Staff L informed the resident whose annual MDS assessments not completed timely and she stated she couldn't make excuses, it was black and white. She stated the old Director of Nursing (DON) left in the middle of September and she was pulled to the floor 7 or 8 times. She stated she knew the MDS assessments were behind. She stated the DON was good about not pulling her to the floor.
During an interview on 12/4/23 at 9:43 AM, the DON queried on when annual assessments needed completed and he stated he wasn't familiar with MDS, and would hope they get them done quickly, within the time frame.
The Resident Assessment Policy dated March 2022 revealed the following information:
a. The resident assessment coordinator was responsible for ensuring that the interdisciplinary team conducts timely and appropriate resident assessments and reviews according to the following requirements:
1. Quarterly Assessment;
b. All resident assessments completed within the previous 15 months are maintained in the resident ' s active clinical record. The results of the assessments are used to develop, review and revise the resident ' s comprehensive care plan.

Based on observation, interview, and record review the facility failed to ensure timely completion of a Significant change Minimum Data Set (MDS) assessment for one of one resident reviewed for significant change assessments (Resident #14). The facility reported a census of 48 residents.
Findings include:
The Minimum Data Set (MDS) assessment for Resident #14 revealed the assessment reference date 8/25/23. The completion date for the assessment revealed 9/20/23.
The Care Plan dated 10/13/23 documented, I am receiving Hospice Services through [Redacted] due to end stage dementia, Parkinson's disease, Chronic Obstructive Pulmonary Disease (COPD), and dysphagia.
On 11/30/23 at 12:04 PM when queried as to the timeframe to complete significant change assessments, the Minimum Data Set (MDS) Coordinator acknowledged 14 days from the date a significant change determined. The MDS Coordinator acknowledged she was behind, and was pulled to work the floor.
The Facility Policy titled [Facility] Resident Assessments dated March 2022 documented, OBRA-Required Assessments - are federally mandated, and therefore, must be performed for all residents of Medicare and/or Medicaid certified nursing homes.

4. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #4, Assessment Reference Date 10/5/23, revealed a completion date of 11/7/23.
The Facility Policy titled [Facility] Resident Assessments dated March 2022 documented, 1. The resident assessment coordinator is responsible for ensuring that the interdisciplinary team conducts timely and appropriate resident assessments and reviews according to the following requirements: a. OBRA required assessments - conducted for all residents in the facility .(2) Quarterly Assessment.
Based on record review, staff interviews, and the facility policy the facility failed to complete the quarterly Minimum Data Set (MDS) assessment in a timely manner for 4 of 15 residents reviewed for quarterly MDS assessments (Resident #4, #22, #35, #46). The facility reported a census of 48.
Findings include:
1. Resident #35 MDS quarterly assessment ARD (Assessment Reference Date)/Target Date dated 4/20/23 completed on 5/22/23 and accepted/locked on 4/11/23.
2. Resident #22 MDS quarterly assessment ARD/Target Date dated 7/1/23 and not completed until 7/16/23 and accepted/locked on 7/17/23.
3. Resident #46 MDS quarterly assessment ARD/Target Date dated 10/15/23 and not completed until 11/16/23 and accepted/locked on 11/16/23.
During an interview on 11/30/23 at 12:05 PM, Staff L, MDS coordinator queried on who did the MDS assessments and she stated she did. Staff L informed the resident whose quarterly MDS assessments not completed timely and she stated she couldn't make excuses, it was black and white. She stated the old Director of Nursing (DON) left in the middle of September and she been pulled to the floor 7 or 8 times. She stated she knew the MDS assessments were behind. She stated the DON was good about not pulling her to the floor.
During an interview on 12/4/23 at 9:43 AM, the DON queried on when quarterly assessments needed completed and he stated within 3 months. He stated he wasn't familiar with MDS, and would hope they get them done quickly, within the time frame.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The Minimum Data Set (MDS) dated [DATE] identified Resident #7 as cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 and had the following diagnoses: Diabetes Disorder, Gastrostomy and Anxiety Disorder. It also identified Resident #7 required substantial assistance with showers/baths, dressing, putting on footwear and turning from side to side. It did not identify the resident with a Gastrostomy Tube (GT) (feeding tube) and identified she was on a therapeutic diet.
A review of the physician orders revealed the following;
a. 5/12/23 GT is to be clamped during meals and Med Pass and for 30 minutes after otherwise to vent at all times every shift for Gastric Outlet Obstruction.
b. 5/17/23 Drain Gastric Drainage bag and record output every shift for Drain Gastric Drainage bag and record output
On 6/6/23, the Care Plan identified Resident #7 with the problem of an actual/potential alteration in elimination pattern due to history of constipation and directed the staff to follow these interventions:
a. Follow facility bowel protocol for bowel management.
b. Give medications as ordered for constipation.
c. Monitor/document/report PRN (as needed) signs and symptoms of complications related to constipation: Change in mental status, new onset: confusion, sleepiness, inability to maintain posture, agitation, Bradycardia (slow, low pulse), Abdominal distension, vomiting, small loose or stools, fecal smearing, Bowel sounds, Diaphoresis, Abdomen: tenderness, guarding, rigidity, fecal compaction.
d. Observe and report to my Healthcare Provider any signs and symptoms of changes of bowel patterns, pain, discomforts, skin around site or stoma.
In an interview on 11/29/23 at 10:18 AM, Staff A, LPN reported the following:
a. If a resident has a GT, this should be addressed on the MDS.
b. She could not recall when Resident #7 had her GT inserted, it had been this year for decompression, probably in April
c. There should not be any reason why the GT was not addressed on her last MDS.
d. The MDS coordinator is responsible for entering data into the MDS.
In an interview on 11/29/23 at 11:33 AM, Staff B,RN, reported the following:
a. If a resident has a GT, this should be addressed on the MDS.
b. She could not recall the exact date when Resident #7 had her GT inserted, she thought spring of 2023.
c. She could not think of any reason why the GT would not be addressed on the last MDS.
d. The MDS coordinator is responsible for entering data into the MDS
In an interview on 11/30/23 at 12:15 PM, the MDS Coordinator reported the following:
a. Resident #7 had her GT inserted 5/12/23
b. The GT should have been addressed on the MDS. She reported that Section K was filled out by the dietitian and since she is not receiving feedings through the GT, it is basically there for decompression.
c. She is reported she is behind on completing MDSs as she had been pulled to work the floor to administer medications or work as a CNA.
In an interview on 11/30/23 at 1:01 PM, the Director of Nursing (DON) reported the following:
a. If a resident has a GT, this should be addressed on the MDS.
b. When asked why the GT was not addressed on the last MDS, he reported the MDS coordinator has
been pulled away from completing MDSs and help out on the floor. There are administrative nurses that can help.
c. The MDS coordinator is responsible for entering data into the MDS.
A review of the facility policy titled: Resident Assessments and dated as last revised March 2022 had documentation of the following:
1. A comprehensive assessment of every resident's needs is made at intervals designated by ONRA and PPS requirements.
2. The resident assessment coordinator is responsible for ensuring that the interdisciplinary team conducts timely and appropriate resident assessments and reviews according to the following requirements:
a. OBRA required assessments - conducted for all residents in the facility:
1. admission Assessment (Comprehensive);
2. Quarterly Assessment;
3. Annual Assessment (Comprehensive);
4. Significant Change in Status Assessment (SCSA) (Comprehensive);
5. Significant Correction to Prior Comprehensive Assessment (SCPA) (Comprehensive);
6. Significant Correction to Prior Quarterly Assessment (SCQA); and
7. Discharge Assessment (return anticipated and return not anticipated).
3. comprehensive assessment includes:
Completion of the Minimum Data Set (MDS);
Completion of the care area assessment (CAA) process; and
Development of the comprehensive care plan
Based on observation, interview, clincial record review, and facility policy review the facility failed to ensure accurate completion of the Minimum Data Set (MDS) assessment to address use of bed rails, gastrostomy tube, and weight loss for two of fifteen residents reviewed for MDS accuracy (Resident #7, Resident #11). The facility reported a census of 48 residents.
Findings include:
1. The Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored 6 out of 15 on a Brief Interview for Mental Status (BIMS) exam which indicated severely impaired cognition. Per the assessment, Resident #11 did not have a weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months. Per the assessment, a bed rail was not used in bed.
The Dietary Progress Note dated 11/2/23 at 7:51 PM documented, WT (weight) - 97#(11/2)[BMI (body mass index)= 20.3 .RD (Registered Dietician) notes significant weight loss (-)10.2% X 3 mos using wt of 108#(8/01) as comparison weight.
On 11/29/23 at 8:35 AM, observation of Resident #11 revealed the resident in her wheelchiar in her room. Resident #11's bed observed to have partial rails bilaterally on the resident's bed, with one rail up and one rail down.
The Physician Order dated 6/11/21 documented, Halo/grab barsx2 for bed mobility and positioning. No directions specified for order.
On 11/30/23 at 12:09 PM, the Minimum Data Set (MDS) Coordinator explained Section K completed by the Registered Dietician, and further explained per her understanding bed rails would only be positive if considered a restraint. Per the MDS Coordinator, residents used the side rails/positioning bars for bed mobility/transfer assistance and none were considered a restraint. Per MDS Coordinator, staff did set up assistance with the rails.

Based on observation, record review and staff interview, the facility failed to address the problem of an open wound on the initial care plan for one of one residents admitted within the last 30 days. (Resident #103). The facility reported a census of 48 residents.
Findings included:
1. At the time of the survey, the admission Minimum Data Set (MDS) had not been completed for Resident #103. A review of the Electronic Medical Record (EMR) list of medical diagnoses included: cerebral infarction due to embolism, muscle weakness and multiple fractures of ribs on the left side.
In an observation and interview with the resident on 11/27/23 at 10:03 AM, the resident sat up in the recliner in his room with feet elevated, he reported he came in with an open area to the left shin which had kerlix dressing dated 11/25/23. He wore tubigrips to both legs which had with 2 pluse edema (swelling of tissue).
A review of the Progress Note dated 11/22/23 at 5:10 PM revealed Resident #103 as alert and oriented to person, time and place.
On 11/27/23, a review of the EMR revealed the only problem addressed on the baseline care plan on 11/23/23 was urinary tract infection. It did not address the open area to his left lower leg.
A review of the progress notes revealed the following:
11/22/23 at 5:10 PM Resident arrived at facility at 12:45 PM and had a wound to the left lower extremity shin which measured 2 centimeters (cm) by 1.5 cm with treatment that had already been implemented from the hospital. Resident #103 was identified as alert and oriented to person, time and place.
In an interview on 11/29/23 at 10:18 AM, Staff A, Licensed Practical Nurse (LPN) reported when a resident is newly admitted with an open area with orders for treatments, she would expect this to be addressed on the care plan and that the MDS coordinator is responsible for developing the baseline care plan.
In an interview on 11/29/23 at 11:33 AM, Staff B, Registered Nurse (RN), reported when a resident is newly admitted with an open area with orders for treatments, she would expect this to be addressed on the care plan and she did not know who was responsible for developing the baseline care plan.
In an interview on 11/30/23 at 12:15 PM, the MDS Coordinator reported Resident #103 had an open area to his left leg when he was admitted and this should have been addressed on the baseline care plan. She also reported any of the nurses can update the care plans.
In an interview on 11/30/23 at 1:01 PM, the Director of Nursing (DON) reported when a resident is newly admitted with an open area with orders for treatments, he would expect that to be addressed on the care plan. He also reported the MDS coordinator was responsible for developing the baseline care plan.
A review of the facility care plan titled: Comprehensive Person Centered Care Plans dated as last revised December 2016 had documentation of the following:
1. The comprehensive person -entered care plan will:
a. Include measurable objectives and time frames;
b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being;
c. Describe services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment;
d. Describe any specialized services to be provided as a result of PASARR recommendations;
e. Include the resident's stated goals upon admission and desired outcomes;
f. Include the resident's stated preference and potential for future discharge, including his or her desire to return to the community and any referrals made to local agencies or other entities to support such a desire;
g. Incorporate identified problem areas;
h. Incorporate risk factors associated with identified problems;
i. Build on the resident's strengths;
j. Reflect the resident's expressed wishes regarding care and treatment goals;
k. Reflect treatment goals, timetables and objectives in measurable outcomes;
l. Identify the professional services that are responsible for each element of care;
m. Aid in preventing or reducing decline in the resident's functional status and/or functional levels;
n. Enhance the optimal functioning of the resident by focusing on a rehabilitative program; and
o. Reflect currently recognized standards of practice for problem areas and conditions.
2. The comprehensive person-centered care plan is developed within seven (7) days of the completion of the required comprehensive assessment (MDS)
3. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' condition change.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. The Minimum Data Set (MDS) dated [DATE] identified Resident #7 as cognitively intact with a BIMS score of 15 and had the following diagnoses: Diabetes Disorder, Gastrostomy and Anxiety Disorder. It also identified Resident #7 required substantial assistance with showers/baths, dressing, putting on footwear and turning from side to side. It did not identify the resident with a feeding tube and identified she was on a therapeutic diet.
Observations of the resident during the survey from 11/27/23 through 11/30/23 revealed the resident's bed with two 1/4 side rails up.
In an interview on 11/29/23 at 10:19 AM, Resident #7 reported she purchased her own bed as it had an air mattress and the side rails came with it, but none of the staff had provided any kind of education on safety issues on it.
In an interview on 11/29/23 at 10:45 AM, the Director of Nursing reviewed the resident's Electronic Medical Record and verified there was no documentation of side rail evaluation, education, etc in Resident #7's record.
A review of the care plan with the last revision date of 11/6/23 revealed the care plan did not address the use of side rails, the need for evaluation and education.
4. The MDS dated [DATE] identified Resident #30 as cognitively intact with a BIMS of 15 and had the following diagnoses: Heart Failure, Renal Insufficiency (Kidney Failure) and Diabetes Mellitus. The MDS also identified Resident #30 required substantial staff assistance with lower body dressing, putting on footwear.
In an observation on 11/27/23 at 12:00 PM, Staff D, Registered Nurse (RN) pushed Resident #30 in the wheelchair without foot pedals.
In an observation on 11/28/23 at 11:19 AM, Staff E, Restorative Certified Nurses Aide (CNA) pulled Resident #30 in her wheelchair out of the bathroom without foot pedals on with Resident #30's feet skimming the floor from the bathroom to outside in the hallway. Resident #30 then was able to self-propel to the main dining room.
On 9/14/20, the Care Plan identified Resident #30 with the problem of being at risk for falls, however, failed to address the need to place foot pedals on the wheelchair prior to transporting the resident in the wheelchair.
In an interview on 11/29/23 at 10:18 AM, Staff A, Licensed Practical Nurse (LPN) reported before pushing a resident in the wheelchair, should make sure the foot pedals are on the wheelchair and put their feet on the foot pedals. This should be addressed on the care plan which any nurse can update.
In an interview on 11/29/23 at 11:33 AM, Staff B,RN, reported before pushing a resident in the wheelchair, should make sure the foot pedals are on the wheelchair and put their feet on the foot pedals. This should be addressed on the care plan
In an interview on 11/30/23 at 1:01 PM, the Director of Nursing (DON) reported before pushing a resident in the wheelchair, should make sure the foot pedals are on the wheelchair and put their feet on the foot pedals. Resident #30 has a bag on the back of her wheelchair where the foot pedals are stored. He did not feel this should be addressed on the care plan as it is common sense. He also reported the facility did utilize many CNAs from different agencies. The DON also reported it was a team effort and that all nurses could update the care plan.
A review of the facility care plan titled: Comprehensive Person Centered Care Plans dated as last revised December 2016 had documentation of the following:
1. The comprehensive person -entered care plan will:
a. Include measurable objectives and time frames;
b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being;
c. Describe services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment;
d. Describe any specialized services to be provided as a result of PASARR recommendations;
e. Include the resident's stated goals upon admission and desired outcomes;
f. Include the resident's stated preference and potential for future discharge, including his or her desire to return to the community and any referrals made to local agencies or other entities to support such a desire;
g. Incorporate identified problem areas;
h. Incorporate risk factors associated with identified problems;
i. Build on the resident's strengths;
j. Reflect the resident's expressed wishes regarding care and treatment goals;
k. Reflect treatment goals, timetables and objectives in measurable outcomes;
l. Identify the professional services that are responsible for each element of care;
m. Aid in preventing or reducing decline in the resident's functional status and/or functional levels;
n. Enhance the optimal functioning of the resident by focusing on a rehabilitative program; and
o. Reflect currently recognized standards of practice for problem areas and conditions.
2. The comprehensive person-centered care plan is developed within seven (7) days of the completion of the required comprehensive assessment (MDS)
3. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' condition change.
Based on observation, interview, and record review, the facility failed to ensure bed rails, use of foot pedals during transport, and documentation of behaviors, anxiety, and major depressive disorder were addressed on the Care Plan for four of fifteen residents reviewed for Care Plans (Resident #7, Resident #11, Resident #22, Resident #30). The facility reported a census of 48 residents.
Findings include:
1. The Quarterly Minimum Data Set (MDS) assessment for Resident #11 dated 11/9/23 revealed the resident scored 6 out of 15 on a Brief Interview for Mental Status (BIMS) exam which indicated severely impaired cognition. Per the assessment, a bed rail was not used in bed for the resident.
The Care Plan did not address use of bed rails for the resident.
The Physician Order dated 6/11/21 documented, Halo/grab barsx2 for bed mobility and positioning. No directions specified for order.
On 11/29/23 at 8:35 AM, observation of Resident #11 revealed the resident in her wheelchair in her room. Resident #11's bed observed to have partial rails bilaterally on the resident's bed, with one rail up and one rail down.
On 11/30/23 at 8:19 AM, the Director of Nursing (DON) acknowledged he had seen issues with care planning the facility was trying to address.
On 11/30/23 at 12:09 PM the Minimum Data Set (MDS) Coordinator queried about care planning of bed rails, the MDS Coordinator explained she believed a care plan added for Resident #11 yesterday or today.
2. The MDS (Minimum Data Set) assessment dated [DATE] revealed Resident #22 scored a 15 out of 15 on the BIMS (Brief Interview for Mental Status) exam, which indicated cognition intact. The MDS revealed medical diagnosis for anxiety disorder and depression.
The EMR (Electronic Medical Record) revealed the following medical diagnosis dated 11/28/22:
a. major depressive disorder, single episode, unspecified
b. anxiety disorder, unspecified
The Physician Orders dated 11/28/22 revealed the following medications ordered:
a. sertraline HCL (hydrochloride) tablet 100 mg (milligram)- give one tablet by mouth one time a day for anxiety
b. buspirone HCL tablet 15 mg- give 1 tablet two times a day for depression
The Social Work Progress Note dated 3/9/2023 at 2:22 PM, documented Social Services reported to DON (Director of Nursing) Resident #22 stated during his PHQ-9 (Resident Mood Interview) that he had thoughts of hurting himself and stated he had a plan. When asked to share the plan he put his finger to his lips and made shh sound. Social Services explained to Resident #22 that the facility used a protocol that they had to follow when someone stated thoughts and a plan to hurt themselves. Social Services phoned Resident #22 wife and informed her of what Resident #22 stated and that he was sent to the hospital for evaluation. The wife stated that she understood and wanted to make an appointment and come in and speak to Social Services next week about Resident #22 and her inability to care for him at home.
The Care Plan lacked documentation of a focus area for the above medical diagnosis and psychiatric medications upon admission.
The Care Plan revealed a focus area for antidepressant medication (venlafazine, mirtazapine) use for diagnosis of depression,; during interview Resident #22 stated he had suicidal ideation initated on 5/4/23. The interventions dated 6/13/23 revealed resident currently took antidepressant medications. Target behaviors to monitor include behavior #1 agitation; behavior #2 sad/crying; behavior #3 making statements and/or non-verbal actions of suicidal ideations.
The Care Plan revealed a focus area for alteration in mood and behaviors as evidenced by occasional verbal outbursts and cursing at staff dated 10/3/23. The interventions dated 10/3/23 documented anticipated and meeting the resident's needs and assisted the resident to develop the most appropriate methods of coping and interacting.
During an interview on 11/30/23 at 12:09 PM, Staff L, MDS Coordinator queried on who does the care plans and she stated she did them and the DON started helping her and regional does them but only when they were in the building. Staff L asked if Resident #22 took major depressive disorder and anxiety disorder and admitted on psychiatric medications, should the care plan address the diagnosis and medications and she stated yes, the care plan needed a focus area.
During an interview on 12/04/23 at 9:43 AM, the DON (Director of Nursing) queried on the expectation of the care plan addressing Resident #22 psychiatric medications and psychiatric diagnoses on admission and the DON stated yes, if they received the medications for the medical diagnoses at that time.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident and staff interview, the facility failed to update the Care Plans for two of fifteen residents reviewed after returning from the hospital (Residents #7 and #22). The facility reported a census of 48 residents.
Findings include:
1. The Minimum Data Set (MDS) dated [DATE] identified Resident #7 as cognitively intact with a Brief Interview for Mental Status score of 15 and had the following diagnoses: Diabetes Disorder, Gastrostomy and Anxiety Disorder. It also identified Resident #7 required substantial assistance with showers/baths, dressing, putting on footwear and turning from side to side. It did not identify the resident with a feeding tube and identified she was on a therapeutic diet.
A review of the progress notes revealed the following:
a. 7/22/23 at 1:50 AM Resident #7 complained of pain in her right upper quadrant rating it a 9 and states it feels like someone is punching her there. Also states she has been having this pain intermittently for about a week now. Bowels active X 4 quadrants. Drainage tube is patent and flowing within normal limits. The physician on call was notified and new orders received to send to ER (Emergency Room) for evaluation.
b. 7/22/23 at 2:31 AM Ambulance notified at 2:00 AM, arrived to facility at 2:20 AM. Out of facility at 2:27 AM. Report given to the hospital nurse.
c. 7/22/23 12:35 PM Resident admitted to the hospital for acute cholecystitis (infection of the gall bladder) and will be having cholecystectomy (surgical removal of the gall bladder).
The progress notes did not include documentation of complete assessment prior to transport to the hospital or notification of family.
On 11/29/23 at 10:18 AM, Staff A, Licensed Practical Nurse (LPN) reported any nurse or the MDS coordinator can update the care plan which should have been updated after Resident #7 was hospitalized .
On 11/29/23 at 11:33 AM, Staff B, Registered Nurse (RN), reported the MDS Coordinator, DON or ADON had the responsibility to update care plans. Care plans should be updated after a resident has been hospitalized .
On 11/30/23 at 12:15 PM, the MDS Coordinator reported the care plan had not been updated as she had been pulled to work the floor to give medications or work as being a CNA. She also reported any nurse could have updated the care plan.
On 11/30/23 at 1:01 PM, the Director of Nursing (DON) reported any nurse can update the care plan which should have been updated after Resident #7's hospitalization.
A review of the facility care plan titled: Comprehensive Person Centered Care Plans dated as last revised December 2016 had documentation of the following:
1. The comprehensive person -entered care plan will:
a. Include measurable objectives and time frames;
b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being;
c. Describe services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment;
d. Describe any specialized services to be provided as a result of PASARR recommendations;
e. Include the resident's stated goals upon admission and desired outcomes;
f. Include the resident's stated preference and potential for future discharge, including his or her desire to return to the community and any referrals made to local agencies or other entities to support such a desire;
g. Incorporate identified problem areas;
h. Incorporate risk factors associated with identified problems;
i. Build on the resident's strengths;
j. Reflect the resident's expressed wishes regarding care and treatment goals;
k. Reflect treatment goals, timetables and objectives in measurable outcomes;
l. Identify the professional services that are responsible for each element of care;
m. Aid in preventing or reducing decline in the resident's functional status and/or functional levels;
n. Enhance the optimal functioning of the resident by focusing on a rehabilitative program; and
o. Reflect currently recognized standards of practice for problem areas and conditions.
2. The comprehensive person-centered care plan is developed within seven (7) days of the completion of the required comprehensive assessment (MDS)
3. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' condition change.
2. The MDS assessment dated [DATE] revealed Resident #22 scored a 15 out of 15 on the Brief Interview for Mental Status exam, which indicated cognition intact. The MDS revealed medical diagnosis for anxiety disorder and depression.
The Electronic Medical Record (EMR) revealed the following medical diagnoses dated 11/28/22:
a. major depressive disorder, single episode, unspecified
b. anxiety disorder, unspecified
The Social Work Progress Note dated 3/9/2023 at 2:22 PM, documented Social Services reported to Director of Nursing (DON) Resident #22 stated during his PHQ-9 (Resident Mood Interview) that he had thoughts of hurting himself and stated he had a plan. When asked to share the plan he put his finger to his lips and made shh sound. Social Services explained to Resident #22 that the facility used a protocol that they had to follow when someone stated thoughts and a plan to hurt themselves. Social Services phoned Resident #22 wife and informed her of what Resident #22 stated and that he was sent to the hospital for evaluation. The wife stated that she understood and wanted to make an appointment and come in and speak to Social Services next week about Resident #22 and her inability to care for him at home.
The Social Work Progress Note dated 4/3/23 at 1:21 PM revealed the staff reported Resident #22 make gestures with a gait belt, gestures of wrapping it around his neck and hanging himself. The DON (put one on one in place immediately. Social Services had a conversation with Resident #22 about his gesture of hanging himself and he denied it. However with further conversation he stated that he cried all of the time and felt sad all the time. Social Services expressed to Resident #22 that they would need to send him to the hospital for evaluation, when comments like that were made the facility take them very serious. Resident #22 stated that he understood and he was willing to go to the hospital.
The Care Plan revealed a focus area for antidepressant medication (Venlafazine, Mirtazapine) use for diagnosis of depression,; during interview Resident #22 stated he had suicidal ideation initated on 5/4/23. The interventions dated 6/13/23 revealed resident currently took antidepressant medications. Target behaviors to monitor include behavior #1 agitation; behavior #2 sad/crying; behavior #3 making statements and/or non-verbal actions of suicidal ideations.
The Care Plan revealed a focus area for alteration in mood and behaviors as evidenced by occasional verbal outbursts and cursing at staff dated 10/3/23. The interventions dated 10/3/23 documented anticipated and meeting the resident's needs and assisted the resident to develop the most appropriate methods of coping and interacting.
During an interview on 11/30/23 at 12:09 PM, Staff L, MDS Coordinator queried if the care plan should of been updated after the resident sent to the hospital for suicidal ideation in March and April of this year prior to May and she stated yes, it should of been sooner. Staff L asked what time frame should the care plan be updated and she stated right away, when the resident came back from the hospital was always the goal.
During an interview on 12/4/23 at 9:43 AM, the DON queried on the expectation of the care plan being updated after a resident sent out for suicidal ideation and he stated as sooner as possible. The DON asked if the resident sent out in March and April and the care plan not updated until May, what would he expected and he stated it needed to be done sooner.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident and staff interview, the facility failed to follow physician orders and administer blood pressure medications per accepted standard of practice for 3 of 15 residents reviewed (Residents #7, #11, and #30) The facility reported a census of 48 residents.
Findings include:
1. The Minimum Data Set (MDS) dated [DATE] identified Resident #7 as cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 and had the following diagnoses: Diabetes Disorder, Gastrostomy and Anxiety Disorder. It also identified Resident #7 required substantial assistance with showers/baths, dressing, putting on footwear and turning from side to side. It did not identify the resident with a feeding tube and identified she was on a therapeutic diet.
A review of the physician orders revealed the following:
a. 5/12/23 G-Tube is to be clamped during meals and Med Pass and for 30 minutes after otherwise to vent at all times every shift for Gastric Outlet Obstruction.
b. 5/17/23 Drain Gastric Drainage bag and record output every shift for Drain Gastric Drainage bag and record output
A review of the Medication Administration Records revealed an order to drain the Gastric Drainage bag and record output every shift and the order had not been followed on these dates:
AUGUST 2023
No documentation on first shift on August 2, 7, 12, 17,22, 27, 28, on second shift on [DATE]
SEPTEMBER 2023
No documentation on first shift on [DATE], 18, 19, 28, 30, on second shift on [DATE] & 29, on third shift September 19, 29, 30
OCTOBER 2023
No documentation on first shift on October 12 & 31, on third shift on [DATE]
NOVEMBER 2023
No documentation of outputs on the first shift on November 4 & 10, none on second shift on [DATE] & 6
On 5/23/23, the Care Plan identified Resident #7 with the problem of actual/potential alteration in elimination pattern due to history of constipation and failed to address the order to drain the Gastric Drainage bag and record the output every shift.
On 12/4/23 at 8:28 AM, the Director of Nursing reported the following:
a. The nurse is responsible for draining the GT drainage bag and recording the output once a shift.
b. The nurse should record it on the Electronic Medication Administration Record (EMAR)
c. When the treatment is not signed out as completed, the EMAR will mark the item as red which should alert the nurse to complete.
d. The only reasons why there wouldn't be documentation on the EMAR would be if the resident was out of the facility, the resident refused, or the resident was sleeping. And if that's the case, it should still be signed off when it was done
2. The Quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #30 as cognitively intact with a BIMS of 15 and had the following diagnoses: Heart Failure, Renal Insufficiency (Kidney Failure) and Diabetes Mellitus. The MDS also identified Resident #30 required substantial staff assistance with lower body dressing, putting on footwear.
During an observation of a medication pass on 11/28/23 at 6:25 AM, Staff A, LPN administered Aspart insulin 2 units to Resident #30.
A review of an incident report dated 11/28/23 revealed documentation of the following:
Resident #30 was administered Aspart insulin instead of Lispro as ordered.
A review of the physician orders revealed an order dated 7/25/23 for: Lispro Inject as per sliding scale: if blood sugar 150 - 200 = 2 units are to be given.
On 9/14/20, the Care Plan identified Resident #30 with the problem of being at risk for alteration in her blood sugar levels, hypoglycemia (low blood sugar) and/or hyperglycemia (high blood sugar) related to diabetes mellitus. Interventions included: Provide medication, blood sugar checks/labs as ordered.
On 11/28/23 at 12:30 PM, the Director of Nursing (DON) reported there was a medication error with Resident #30. The order was for Lispro sliding scale. The nurse pulled the wrong medication from the Emergency Kit and the nurse this morning went to give it didn't read it.
In an interview on 11/29/23 at 10:18 AM, Staff A, Licensed Practical Nurse (LPN) reported before she administers insulin, she should check the manufacturer's name. When asked about the medication error which occurred 11/28/23 she reported, she pulled the pen that said it was short acting and she gave Resident #30 Aspart when she had orders for Lispro. The nurse who worked the night before pulled the wrong insulin pen from the Emergency kit. Staff A reported she should have checked the pen against the order.
In an interview on 11/29/23 at 11:33 AM, Staff B, Registered Nurse (RN), reported before she administers insulin, she would check the pen against the MAR (Medication Administration Record) and the medication error could have been prevented if the nurse checked the pen against the MAR.
In an interview on 11/30/23 at 1:01 PM, the DON reported the medication error could have been prevented if the nurse followed the protocol for medication administration and followed the rights. The night shift nurse had pulled a pen out of the Emergency Kit and pulled out the wrong pen and put it in Resident #30's medication drawer. Staff A had pulled out the wrong insulin pen from the refrigerator.
3. The Minimum Data Set (MDS) assessment for Resident #11 dated 11/9/23 revealed the resident scored 6 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated severely impaired cognition.
The Care Plan dated 7/13/21 documented, I have coronary artery disease (CAD) and prior NSTEMI.
The Intervention dated 7/13/21 documented, Monitor blood pressure. Notify physician of any abnormal readings.
The Physician Order dated 6/12/21 documented, Amlodipine Besylate Tablet 5 MG (milligrams) with instructions to give 1 tablet by mouth one time a day for HTN (hypertension).
The Physician Order dated 9/10/21 documented, Carvedilol Tablet 6.25 MG with instructions to give 1 tablet by mouth two times a day for blood pressure (BP).
The Physician Order dated 6/16/21 documented, Isosorbide Mononitrate extended release (ER) Tablet Extended Release 24 Hour 30 MG with instructions to give 1 tablet by mouth one time a day for blood pressure DO NOT CRUSH.
Physician Orders for blood pressure medication lacked parameters for when to hold the above medications.
Review of the resident's Medication Administration Record (MAR) for October 2023 revealed the resident received all three medications every day in October 2023.
Review of documented blood pressures per the Blood Pressure Summary in the resident's electronic health record revealed, in part, the following documented blood pressures:
a. 10/2/2023 12:28 AM: 96/50
b. 10/3/23 2:25 PM: 91/50
c. 10/4/23 at 11:02 AM: 82/53
d. 10/9/23 at 10:26 AM: 98/46
e. 10/30/23 at 4:08 PM: 92/49
On 11/30/23 at 10:48 AM when queried if she noticed parameters for blood pressure medications, Staff A, Licensed Practical Nurse (LPN) said no. Staff A explained she went by nursing judgement, and if all over the place, she would contact the doctor and see what they wanted. Staff A explained she would send a list of blood pressures the resident had and would ask for parameters. Per Staff A, everybody was different. Staff A explained she would look at the history and resident's baseline, and would make a decision off of that. Per Staff A, the med aide would tell her if high or low and she would look at the norm. When queried if she had been notified by the med aide, Staff A explained she had not been notified about low blood pressures.
On 11/30/23 at 11:47 AM when queried about parameters for blood pressure medications, Staff B, Registered Nurse (RN), explained she saw parameters on occasion and not always. Staff B explained if low blood pressure, she would call the Physician if there were not parameters in place.
On 12/4/23 at 10:06 AM, the Director of Nursing explained he personally did not give blood pressure medications to people without parameters with a systolic below 100. The DON acknowledged if the medication aide gave blood pressure medications and took the blood pressure below the normal level, the nurse would be notified prior to giving medications.