Azria Health Great Bend

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 61 residents. The sample included 17 residents, with five reviewed for unnecessary medications. Based on observations, interviews, and record review, the facility failed to ensure a 14-day stop date or a specified duration with a rationale for Resident (R) 61's ongoing as-needed (PRN) antianxiety (class of medications that calm and relax people) medication. This placed R61 at risk for unintended effects related to psychotropic (alters mood or thought) drug medications.Findings included:- R61's Electronic Health Record (EHR) revealed diagnoses of cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), and dysphagia (swallowing difficulty).R61's Quarterly Minimum Data Set (MDS) dated [DATE] recorded R61 had severely impaired cognition. The MDS recorded he required extensive assistance from two staff with bed mobility and transfers. The MDS documented R61 received an antianxiety medication during the observation period.R61's Care Plan, dated 04/02/25, recorded R61 required extensive staff assistance with his activities of daily living (ADL) care. R61's Care Plan documented the resident received Ativan (an antianxiety medication) for end-of-life restlessness.R61's Physician's Order, dated 01/30/25, directed the staff to administer lorazepam (Ativan) 1.0 milligram (mg), one tablet as needed for agitation. The order lacked a stop date.R61's EHR lacked evidence of a specified duration, which included a physician's rationale for the extended use of the PRN lorazepam.On 07/28/25 at 07:40 AM, R61 sat in a broad chair at the dining room table. Certified Medication Aide (CMA) R administered the resident's medication, which included lorazepam 1 mg. On 07/27/25 at 11:00 PM, Administrative Nurse D verified R61 received lorazepam PRN, with a physician order date of 01/30/25. Administrative Nurse D verified that the facility failed to obtain the 14-day stop date or a reason for the continued use with the appropriate rationale. The facility's Antipsychotic Medication Use policy, dated July 2022, recorded the residents would not receive medications that were not clinically indicated to treat specific conditions. Diagnosis of a specific condition for which antipsychotic medications was necessary to treat would be based on comprehensive assessment of the resident. Antipsychotic medications would be prescribed at the lowest possible dosage for the shortest period of time and are subject to gradual dose reduction and re-view. Residents would not receive PRN doses of psychotropic medications unless that medication is necessary to treat a specific that is documented in the clinical record. PRN orders for antipsychotic medications would not be renewed beyond 14 days unless the healthcare practitioner has evaluated the resident for the appropriateness of that medication and document the rationale for continued use. The duration of the PRN order would be indicated in the order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 61 residents. The sample included 17 residents. Based on observation, interview, and record review, the facility failed to ensure staff used Enhanced Barrier Precautions (EBP- infection control interventions designed to reduce transmission of resistant organisms which employs targeted gown and glove use during high contact cares) when providing care with close contact to residents with an open wound or an indwelling device and failed to properly disinfect a blood glucose meter used for more than one resident. This deficient practice placed all residents at risk for infection.Findings included:- On 07/27/25 at 12:28 PM, Licensed Nurse (LN) G obtained a blood sugar (BS) reading with a facility glucometer for Resident (R) 31. LN G did not clean or disinfect the glucometer before putting it away in the drawer on top of the other glucometer.
On 07/28/25 at 09:05 AM, observation revealed a sign on R11's door directing staff to use EBP during cares.
On 07/28/25 at 09:05 AM, Certified Nurse Aide (CNA) M and CNA N used a total mechanical lift to transfer R11 from her wheelchair to her bed. The CNAs did not don EBP gowns before providing incontinence cares. R11 had a dressing with drainage on her right buttock. At 09:20 AM, LN H performed wound care for R11 and did not don an EBP gown. R11's right buttock had an irregular shaped open wound and another open wound to her coccyx area.
On 07/28/25 at 09:20 AM, LN H stated EBP was used when R11 had a foot wound before amputation. She stated that staff no longer used the EBP for this resident.
On 07/28/25 at 09:54 AM, Administrative Nurse E stated EBP should be worn during cares for any resident with an open wound.
On 07/28/25 at 12:50 PM, Administrative Nurse E verified staff were to disinfect the glucometer after each use. The facility had two glucometers used for seven residents on the north halls.
The Assure Prism BG monitoring system (blood glucose meter) instruction manual stated the meter should be cleaned and disinfected after use on each patient. The BG system may only be used for testing multiple patients when standard precautions and the manufacturer's disinfection procedures were followed. The manufacturer validated Clorox Healthcare Bleach Germicidal wipes, Dispatch Hospital Cleaner Disinfectant Towels with Bleach, CaviWipes 1, and PDI Super Sani Cloth Germicidal disposable wipes used for disinfecting the Assure Prism multi-meter. Allow the disinfectant to stay wet for 1-2 minutes.
The facility's Cleaning and Disinfection of Resident Care Items policy, dated 10/2023, stated resident care equipment, including reusable items and durable medical equipment, would be cleaned and disinfected between residents per current Centers for Disease Control (CDC) recommendations for disinfection.
The facility's Enhanced Barrier Precautions policy, dated 04/2024, stated EBP refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high-contact resident care. Examples of high contact resident care requiring the use of a gown and gloves for EBP included dressing, bathing, transferring, providing hygiene, changing linens, changing briefs, or assisting with toileting, device care, and wound care for pressure ulcers, diabetic ulcers, surgical wounds, and venous stasis ulcers.
- R2's Electronic Medical Record (EMR) documented that R2 had a diagnoses of acquired absence of kidney (one of a pair of organs in the abdomen), chronic kidney disease (a condition where the kidneys are damaged and can't filter blood effectively, leading to a buildup of waste and other problems), and benign prostatic hyperplasia (BPH- non-cancerous enlargement of the prostate which can lead to interference with urine flow, urinary frequency, and urinary tract infections).
R2's Medicare Five Day Minimum Data Set (MDS), dated [DATE], documented that R2 had a Brief Interview of Mental Status (BIMS) of 13, which indicated intact cognition. The MDS documented R2 had a urinary catheter (a tube inserted into the bladder to drain the urine into a collection bag).
R2's Care Plan, revised 05/20/25, documented R2 dependent on staff assistance with toileting. The plan instructed staff to provide R2 catheter care every shift, monitor and document intake and output as per facility policy. The plan documented R2 was on EBP related to his urinary catheter and instructed staff to use appropriate personal protective equipment (PPE).
On 07/27/25 at 03:37 PM, R2 sat in a recliner in his room with the door open. Certified Nurse Aide (CNA) Q entered the room, went into R2's bathroom, retrieved a graduated cylinder, then, without gloves or gown, emptied R2's urine from his catheter into the graduated cylinder. CNA Q took the urine-filled graduated cylinder to the bathroom and emptied it into the toilet, rinsed it out using water from the sink, and poured the water into the toilet. When CNA Q was asked what the EBP sign posted beside R2's room entrance door, she stated that staff have to place gloves and a gown on when providing catheter care. CNA Q verified she had not applied gloves or a gown when emptying R2's urinary catheter bag and stated she should have.
On 07/29/25 at 09:57 AM, Administrative Nurse D stated if a resident is on EBP, staff should place a gown and gloves on before providing any catheter care.
The facility's EBP policy, dated 04/2024, documented EBPs are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident are activities that provide opportunities for transfer of Multidrug-Resistant Organism (MDRO- standard medications used to treat infections caused by these organisms are ineffective, making infections difficult to treat.)to staff hands and clothing. Gloves and a gown are applied before performing the high-contact resident care activity (as opposed to before entering the room). PPE is changed before caring for another resident. Face protection may be used if there is also a risk of splash or spray. Examples of high contact resident care activities requiring the use of a gown and gloves for EBP's include dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs, or assisting with toileting, or device care of use (urinary catheter, etc.). Wound care (wounds generally include chronic wounds, not shorter-lasting wounds, such as skin tears or skin grafts covered with an adhesive bandage or similar dressing. Examples of chronic wounds include, but are not limited to, pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and venous stasis ulcers.

The facility had a census of 61 residents. The sample included 17 residents. Based on record review and interview, the facility failed to submit complete and accurate staffing information through the Payroll-Based Journal (PBJ) as required. This deficient practice placed the residents a risk for inadequate staffing.Findings included:- The PBJ report provided by the Centers for Medicare & Medicaid Services (CMS) for fiscal Year (FY) 2025, Quarter (Q) 1 and FY 2025 Q 2 indicated excessively low weekend staffing.Review of the facility's Nursing staffing schedule for the above quarter revealed adequate staff on duty was provided.On 07/28/25 at 01:39 PM, Administrative Nurse D stated that the daily schedule sheets with updates are sent to the regional office. If there were any changes to the schedule, they would also be sent with the updates to the regional office.The facility's Reporting Direct Care Staffing Information (Payroll-Based Journal) policy, dated 08/22, documented that direct staffing information was reported to CMS electronically through the payroll-based journal system. Complete and accurate direct care information was reported in a uniform format specified by CMS. The staffing information was collected daily and reported for each fiscal quarter no later than 45 days after the end of the reporting quarter. The data was submitted only by designated personnel with training on the PBJ user interface.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 61 residents. The sample included 17 residents, with one reviewed for hospice (a type of health care that focused on the terminally ill patient's pain and symptoms and attending to their emotional and spiritual needs at the end of life) services. Based on observation, record review, and interview, the facility failed to ensure coordinated care and services provided by the facility with the care and services provided by hospice for Resident (R) 6. This placed the residents at risk for inadequate end-of-life cares. Findings included:- R6's Electronic Health Record (EHR) revealed diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), chronic kidney disease (longstanding disease of the kidneys leading to renal failure) with behavioral disturbance, encephalopathy (inflammatory condition of the brain), acute bronchitis (inflammation of the lining of bronchial tubes which carry air to and from the lungs), and congestive heart failure (CHF- a condition with low heart output and the body becomes congested with fluid).R6's Quarterly Minimum Data Set (MDS), dated [DATE], recorded R6 had severe cognitive impairment (problems with thinking, learning, remembering, and using judgment). The MDS recorded she required staff assistance with transfers and activities of daily living (ADL). The MDS documented the resident had occasional incontinence and ambulated with a wheelchair. The MDS did not document the resident received hospice service due to the fact it was ordered on 07/16/25.The Activities of Daily Living (ADL) Care Area Assessment (CAA), dated 09/27/24, recorded R6 required staff assistance with ADLs due to impaired functional ability. The CAA documented the resident had incontinence of urine with a diagnosis of chronic kidney disease and required assistance with toileting, transfers, and hygiene. R6s Care Plan, dated 04/23/25, recorded R6 required staff assistance with most ADL care. R6's Care Plan documented the resident required staff assistance with incontinent cares and assistance. The care plan documented staff were to allow the resident privacy when using the restroom; however, stay near the bathroom and ready to provide assistance when R6 required it. The care plan documented R6 had the potential for falls related to needing assistance with ADL's and staff would encourage her to call for assistance when needed. The Nurse's Notes, dated 07/14/25 at 11:14 AM, documented the facility received orders from the primary care physician to consult hospice care and discontinue skilled therapy. R6's Physician Order dated 07/16/25, documented the resident would receive hospice services. Review of R6's clinical record revealed the resident was admitted to hospice care on 07/14/25 with a diagnosis of congestive heart failure, chronic kidney disease Stage 3, and Alzheimer's. The facility had a care plan provided by hospice in the electronic health records. On 07/27/25 at 11:50 AM, R6 was dressed in street clothes in a wheelchair at the dining room table with oxygen on per nasal cannula, eating lunch.On 07/27/25 at 12:25 PM, Administrative Nurse D verified the facility lacked a facility care plan that indicated R6 was on hospice services.The facility's Care Plans, Comprehensive policy, dated March 2022, documented a comprehensive person-centered care plan that included measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. The comprehensive, person-centered care plan included measurable objectives and timeframes, describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being which included services that would otherwise be provided but are not provided due t the resident exercising his or her rights, including the right to refuse treatment.=, any specialized services to be provided as a result of the PASARR recommendations, which professional services are responsible for each element of care. This included the resident's stated goals upon admission and desired outcomes, building on strengths and reflecting on currently recognized standards of practice for problem areas and conditions. Assessments were outgoing, and care plans were revised as information about the residents in the resident conditions changed. The ID team reviewed and updated the care plan when there has been a significant change in the resident's condition, when the desired outcome was not met, when the resident has been admitted /readmitted to the facility from a hospital stay, and at least quarterly, and in conjunction with the required quarterly assessment.

The facility had a census of 62 residents. The sample included 17 residents. Based on observation, record review, and interview, the facility failed to provide the services of a full-time certified dietary manager for the 61 residents who resided in the facility and received their meals from the kitchen. This placed the residents at risk for inadequate nutrition.Findings included:- On 07/27/25 at 08:45 AM, observation revealed that dietary staff in the kitchen prepared the breakfast meal. On 07/27/25 at 12:00 PM, Dietary Staff BB verified she was not a certified dietary manager. Dietary Staff BB stated the facility had three residents with a pureed diet and 15 with a mechanical soft diet. On 07/29/25 at 09:15 AM, Administrative Nurse D verified Dietary Staff BB was not certified.Upon request, the facility lacked a Certified Dietary Manager policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 61 residents. The sample included 17 residents. Based on observation, interview, and record review, the facility failed to label Resident (R)5 and R69s' insulin (a hormone that lowers the level of glucose in the blood) flex pens when initially opened for use and when expired. This deficient practice placed the affected residents at risk for ineffective medications. The facility failed to ensure medications were only accessible to licensed staff when the treatment cart was left unlocked without licensed staff supervision. Findings included: - On [DATE] at 11:38 AM, the Northeast Hall nurse treatment cart was found in the hall, unlocked with insulin and other medication accessible to anyone. At that time, no staff were in sight of the treatment cart. Licensed Nurse (LN) G was located in a resident room, out of sight of the cart. When LN G came out of the resident's room, she verified that she should have locked the cart.
On [DATE] at 09:05 AM, Administrative Nurse D verified that staff should not leave the treatment cart unlocked when out of sight of licensed staff.
The facility's Administering Medications policy, dated 06/2022, stated during the administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide. The cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to residents or others passing by.
- On [DATE] at 08:45 AM, observation of R5's Lantus (long-acting insulin) flex pen was labeled with a date opened [DATE] and an expired date of [DATE] (46 days outdated) and still in use.
Observation of R69's Mounjaro (Long-acting medication) lacked a date opened or a date expired.
On [DATE] at 08:50 AM, License Nurse G verified that the nurses should label and date the insulin flex pens with the date opened and should discard expired insulin flex pens.
On [DATE] at 09:20 AM, Administrative Nurse D verified that the nurse should label and date the insulin flex pens with the date opened and discard expired insulin flex pens.
Medlineplus.gov directs open, unrefrigerated Lantus can be used within 28 days; after that time, they must be discarded. Moujaro should be used within 30 days; after that time, it should be discarded.
The facility's Storage of Medications policy, dated [DATE], documented the facility shall store all drugs and biologicals in a safe, secure, and orderly manner. Drugs containers that have missing, incomplete, or incorrect labels are returned to the pharmacy for proper labeling before storing, discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed.

The facility had a census of 61 residents. The sample included 17 residents. Based on observation, interview, and record review, the facility failed to ensure Resident (R) 11's medication administration was free from significant errors when staff crushed one extended-release medication. This placed R11 at risk for the medication being improperly released.Fincings included:- On 07/28/25 at 08:52 AM, Certified Medication Aide (CMA) R crushed medications for R11, including metoprolol (medication used to treat chest pain (angina), heart failure, and high blood pressure) extended release (ER), 25 milligrams (mg). CMA R placed the crushed medications in applesauce and administered them to R11, even after being asked if it was okay to crush metoprolol ER. CMA R stated she would ask the nurse later. On 07/28/25 at 11:25 AM, Administrative Nurse E verified R11's metoprolol pill card stated ER Do not crush. Administrative Nurse E verified the physician order of 06/13/25 was not metoprolol ER, but the earlier 06/11/25 re-admission orders had been for ER metoprolol. Administrative Nurse E verified the 06/13/25 order was currently in effect. On 07/28/25 at 11:32 AM, LN H contacted the pharmacy regarding the order and stated she would fax the latest order to them. On 07/29/25 at 09:09 AM, Administrative Nurse D verified that nursing should have notified the pharmacy of the change in the metoprolol order in a timely manner and ensured the Medication Administration Record (MAR) was correct. The facility's Administering Medications policy, dated 06/2022, stated medications are administered in accordance with prescriber orders. The individual administering the medication would check the label to verify the right resident, right medication, right dosage, right time, and right method of administration before giving the medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 61 residents. The sample included 17 residents, with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to provide interventions for bowel management for one resident, Resident (R) 9. This placed R9 at risk for physical decline and fecal impaction (accumulation of hardened feces in the rectum that the individual was unable to move).- The Electronic Medical Record for R9 documented diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion) without behavioral disturbance, anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), hypertension (high blood pressure), and constipation (difficulty passing stool).The Quarterly Minimum Data Set (MDS), dated [DATE], documented R9 had moderately impaired cognition. R9 was independent with toileting hygiene, personal hygiene, mobility, transfers, and dressing. R9 was always continent of bladder and bowel and did not have constipation.R9's Care Plan, dated 07/23/25, initiated on 06/28/22, documented R9 had a history of constipation and directed staff to administer medications as ordered. Staff were directed to monitor medications for side effects of constipation and keep the physician informed of any problems. The care plan further directed staff to report to the physician any changes in bowel patterns and record the bowel movement pattern each day.The Standing Orders, dated 12/01/23, for R9 directed staff to administer Milk of Magnesium (MOM), 30 milliliters (ml), as needed for up to twice daily or Dulcolax suppository (inserted into the rectum), one daily, as needed for constipation. Notify the physician if no results after two doses of MOM with a full bowel assessment.The Physician's Order, dated 04/15/25, directed staff to administer DOK (docusate sodium-a stool softener), 100 milligrams (mg), two capsules, daily, for constipation.R9's Bowel Monitoring Record, dated June and July 2025, documented R9 did not have a bowel movement for the following days:06/30/25 - 07/07/25 (8 consecutive days)R9's Medication Administration Record (MAR) for June and July 2025 lacked documentation of the staff providing interventions during the lack of bowel elimination on the above dates.The EMR lacked documentation that a bowel assessment was completed for the dates of 06/30/25 to 07/07/25.On 07/28/25 at 12:15 PM, R9 left the dining room table in his wheelchair to go to the bathroom.On 07/29/25 at 09:00 AM, Licensed Nurse (LN) H stated night shift received a report for the residents who had not had a bowel movement for three days, and notified Administrative Nurse D of any resident who had not had a bowel movement in three days, and standing orders were started.On 07/29/25 at 09:18 AM, Certified Nurse Aide (CNA) N stated R9 told the staff when he had a bowel movement and to document it in the computer.On 07/29/25 at 09:53 AM, Administrative Nurse D stated that there are standing orders for residents who have not had a bowel movement after three days, and bowel sounds are assessed.The facility's Bowel (Lower Gastrointestinal (GI) Tract) Disorders policy, dated 09/17, documented that as part of the initial assessment, the staff and physician would help identify individuals with previously identified lower GI tract conditions and symptoms. The staff and physician would identify risk factors related to bowel dysfunction. The staff would check for diffuse or localized tenderness and listen for bowel sounds. The physician would identify and order pertinent cause-specific and symptomatic interventions to institute a regimen to prevent constipation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 61 residents. The sample included 17 residents, with nine reviewed for accidents. Based on observation, record review, and interview, the facility failed to ensure staff provided adequate supervision to prevent the elopement of Cognitively Impaired Resident (R) 37, who was at risk for wandering/elopement, falls, and used a walker for mobility. The facility also failed to conduct a complete investigation when R48 obtained skin tears of unknown origin. This placed the resident at risk for abuse.On 07/15/25 at approximately 07:35 PM, facility staff could not find R37 in the building and reported seeing R37 in the lobby approximately 5-10 minutes prior. The staff found R37's walker in the lobby, but not R37. The staff located R37 outside in the facility van, seated in the front seat, in approximately 95-degree Fahrenheit (F) weather. The facility did not know how R37 got outside without staff knowledge. The failure to prevent a cognitively impaired resident from exiting the facility without staff supervision or knowledge and entering an unsafe location placed R37 in immediate jeopardy and other wandering residents at risk.Findings included:- R37 Electronic Medical Record (EMR) documented R37 had diagnoses, which included: a history of falling and dementia (a progressive mental disorder characterized by failing memory and confusion).
R37's admission Minimum Data Assessment (MDS), dated [DATE], documented R37 had a Brief Interview of Mental Status (BIMS) score of three, which indicated severe cognitive impairment. The MDS documented R37 used a walker for mobility and required staff supervision with ambulation. The MDS documented R37 had a fall in the last two to six months.
R37's Care Area Assessment(CAA), dated 11/07/24, documented the CAA triggered due to R37 was at risk for falls. R37's risk for falls included: generalized weakness, decreased safety awareness, a history of falls before admission, and psychotropic (alters mood or thought) medications. The CAA documented R37 had a BIMS of three and a diagnosis of dementia.
R37's Quarterly MDS, dated 05/28/25, documented R37 had a BIMS score of five, which indicated severe cognitive impairment. R37 used a walker for mobility and required supervision with ambulation. The MDS documented R37 had no falls since the prior assessment.
R37's Care Plan, revised 05/31/25, documented R37 had limited physical mobility and instructed staff to provide R37 with one staff assistance, using a walker for ambulation. The plan lacked interventions regarding R37's elopement risk. The plan documented R37 had impaired cognitive function related to dementia and instructed staff to cue, reorient, and supervise her as needed. The plan documented R37 as at risk for falls, instructed staff to anticipate and meet the resident's needs, and offer and assist R37 with ambulation.
The Elopement Evaluation dated 11/05/24 documented R37 with a history of elopement or attempted elopement while at home and wandering behavior.
The Elopement Evaluation dated 05/31/25 lacked documentation regarding whether R37 had a history of elopement.
On 07/15/25 at approximately 07:35 PM, facility staff could not find R37 in the building and reported seeing R37 in the lobby approximately 5-10 minutes prior. The staff found R37's walker in the lobby, but not R37, and reported that the door alarm did not activate. The staff located R37 outside of the building, in the facility van, and seated in the front seat in approximately 95 degrees Fahrenheit (F) weather. The facility did not know how R37 got outside without their knowledge.
The National Weather Service table titled Temperature Inside a Vehicle noted an ambient temperature outside of 93 degrees F, the temperature inside a vehicle can rise up to 130 degrees F within 60 minutes.
According to Weather Underground, the weather outside at the time R37 left the building, unsupervised, was approximately 95 degrees Fahrenheit and sunny.
The staff found R37 in the front seat of the facility van.
Observation revealed the facility is located near a highway, with speed limits of 40 miles per hour (mph), approximately 100 feet from the building. Cognitively impaired R37 is at a fall risk and did not have her walker with her.
During a phone interview on 07/27/25 at 09:42 AM, Certified Nurse Aide (CNA) O stated she was working on 07/15/25 when R37 left the building without staff supervision. CNA O stated prior to the elopement, R37 sat in the lobby on the couch by the entrance door. CNA O went down the southwest hall of the facility to answer a couple of call lights, and when she came back, R37 was not on the couch, but her walker was beside it. CNA O started looking for R37 because R37 was known to wander. CNA O stated CNA P went outside looking for R37 and noted the front entrance door was not alarming.
On 07/28/25 at 09:06 AM, Administrative Nurse D stated on 07/16/25, the night of R37's elopement, the door alarm was not sounding when staff noticed R37 was missing from inside the facility. Administrative Nurse D stated she did not know how R37 exited the building without staff supervision, but thought R37 might have followed a family member out the door.
The facility's Wandering and Elopement Policy, revised 06/17/20, documented if a resident was determined to be at risk for wandering and elopement, educational materials would be available concerning the risk for eloping. Specific intervention(s) would be provided to the resident and family and would be documented in the resident's record. A wandering /elopement risk evaluation, too, would be completed by a licensed member of the clinical staff for each resident to identify the level of risk which may lead to elopement upon admission or readmission, quarterly, upon a change in status or condition as it related to unsafe wandering, post-elopement or elopement attempts, and as required by state regulation.
On 07/28/25 at 12:33 PM, Administrative Staff A and Administrative Nurse D were provided the IJ template and notified that the facility's failure to provide safe, adequate supervision for cognitively impaired R37 to prevent the elopement placed the resident in immediate jeopardy.
The facility's corrective measures, completed on 07/25/25, included the following:
In-service on elopement policy.
Checked all door alarms
Conducted elopement drill, and four drills will be held annually at each community:
One drill will be held each shift, including one weekend day.
An elopement evaluation tool was completed by a licensed member of the clinical staff for each resident identified as a risk for elopement.
In-service for transportation driver regarding the facility van would be locked at all times.
The surveyor verified the implemented corrective actions while on site; the deficient practice was deemed past non-compliance and remained at a J scope and severity.
- R48's Electronic Medical Record documented diagnoses of a stable burst fracture of two vertebra (bone of the spinal column), chronic respiratory failure, chronic lymphocytic leukemia (a cancer that develops in the bone marrow, where blood cells are produced) in remission, pain, osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain), and dorsalgia (back pain).
R48's admission Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of nine, indicating moderate impairment. The MDS documented R48 was dependent on staff for transfers and had no falls since admission.
R48's Fall Care Area Assessment (CAA), dated 07/14/25, stated contributing factors include weakness, reliant on staff for Activities of daily living (ADL), and mobility.
R48's Care Plan, dated 07/11/25, directed staff to be sure the resident's call light was within reach and encourage the resident to use it for assistance as needed. The care plan laid out staff direction for transfers and mobility. The 07/16/25 update stated two skin tears on the left lower leg, with a treatment plan and monitoring plan, initiated 07/18/25.
The Progress Note, dated 07/16/25 at 05:00 PM, documented Certified Nurse Aides (CNA) were getting R48 up for supper and noted two bruised areas that were bleeding on her left lower leg. The bruised areas with one 2 centimeters (cm) skin tear and one 3 cm skin tear. Staff cleansed the area with wound cleanser, patted dry, and applied steri-strips and a dry dressing. R48 said her leg bumped something during the transfer.
The Incident Report, dated 07/16/25, did not include a dated witness statement even though the resident claimed it happened during a transfer.
On 07/28/25 at 10:23 AM, R48 laid in bed with the head of the bed elevated and blue pressure relief booties on her feet. R48 stated the pain in her back was better today.
On 07/28/25 at 03:28 PM, Administrative Nurse D stated the interdisciplinary team (IDT) reviewed the incident. She provided an undated witness statement from the CNA who found the skin tears, but no witness statement documenting what happened.
On 07/29/25 at 09:05 AM, Administrative Nurse D stated she thought the CNA wrote a statement that she was transferring the resident when her leg bumped the wheelchair but did not provide that witness statement.
The facility's Abuse, Neglect, Exploitation policy, dated 10/2023, stated all reports of resident abuse (including injuries of unknown origin), neglect, and exploitation were to be reported to local, state, and federal agencies and thoroughly investigated by facility management. The findings of all investigations would be documented and reported. All allegations would be thoroughly investigated. the administrator initiated investigations. Upon conclusion of the investigation, the investigator records the findings on approved documentation forms.

The facility had a census of 61 residents. The sample included 17 residents, with one reviewed for range of motion (ROM). Based on observation, interview, and record review, the facility failed to provide ROM services to improve or maintain Resident (R) 56's ROM in his partially contracted (abnormal permanent fixation of a joint or muscle) right hand.Findings included:- R56's Electronic Medical Record documented a diagnosis of hemiplegia and hemiparesis (weakness and paralysis on one side of the body) following cerebral infarction (stroke) affecting his right dominant side.R56's Minimum Data Set (MDS), dated 05/26/25, documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS documented R56 required moderate staff assistance for mobility and dressing, and did not receive splint or brace therapy or restorative services.R56's Activities of Daily Living (ADL) Care Area Assessment (CAA), dated 02/27/25, documented he required assistance with ADL's due to hemiplegia and generalized weakness. R56's Care Plan, dated 05/19/25, lacked interventions related to the prevention of contractures. The care plan stated R56 had limited physical mobility related to hemiplegia from a cerebral vascular accident affecting his right dominant side. Staff were to monitor, document, and report any signs of immobility, such as contractures forming or worsening, initiated 03/11/25. The care plan stated R56 would receive appropriate specialized services to attain or maintain his highest practicable psychological, physical, functional, and psychosocial well-being, initiated 03/16/24. The Physician Order, dated 02/28/24, directed staff to perform brace skin care, check skin covered by the brace every shift, and report any changes to the physician.On 07/27/25 at 09:32 AM, R56 sat in his recliner in his room. R56 stated he had a stroke with right sided paralysis. R56's hand was in a fist without a splint (it was on his bed, out of reach). He stated he required assistance to place the splint. R56 stated staff did not provide ROM for his right hand or any other restorative exercises. On 07/28/25 at 09:45 AM, Licensed Nurse (LN) H stated the facility did not have restorative aides. She stated they used to, but the aides were usually busy doing regular aide work. She did not know if R56 was supposed to have the hand splint on. LN H entered his room and asked him if he wanted to wear the splint and offered to put it on if he put it out every morning. LN H then placed one of the two braces he had in his room on his right hand/wrist. On 07/28/25 at 10:00 AM, Administrative Nurse E stated the facility had not had a restorative program for the past few years. She verified that the care plan did not include interventions to prevent contractures.On 07/28/25 at 10:06 AM, Therapy Consultant GG stated R56's right hand did not open to full extension. He was admitted with a splint, and the facility got him a softer splint after he complained about the original one. Therapy Consultant GG stated he was educated on donning/doffing a splint and said he could do it himself. He was to use it for two to five hours as tolerated.On 07/29/25 at 09:00 AM, Administrative Nurse D verified that the facility should provide restorative services to maintain or improve residents' range of motion. The facility's Restorative Nursing Services policy, dated 07/2022, stated residents would receive restorative nursing care as needed to help promote optimal safety and independence. Residents may be started on a restorative nursing program upon admission, during the course of their stay, or when discharged from rehabilitative care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 61 residents. The sample included 17 residents, with three reviewed for bathing. Based on observation, record review, and interview, the facility failed to provide consistent bathing services for two residents, Resident (R) 27 and R42. This placed the residents at risk for complications related to poor hygiene.Findings included:- The Electronic Medical Record (EMR) for R27 documented diagnoses of Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of his fingers, masklike faces, shuffling gait, muscle rigidity, and weakness), hypertension (high blood pressure), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest).The Annual Minimum Data Set (MDS), dated [DATE], documented R27 had intact cognition. R27 was independent with eating, toileting hygiene, dressing, personal hygiene, mobility, and transfers. R27 required supervision with ambulation and bathing.R27's Care Plan, dated 05/19/25, initiated on 04/18/24, documented R27 preferred three baths per week and required staff assistance.The May 2025 Bathing Sheets documented R27 had not received a bath or shower during the following days:05/05/25 - 05/17/25 (13 days)05/19/25 - 05/29/25 (11 days)The EMR documented R27 refused bathing on 05/07/25, 05/08/25, 05/11/25, and 05/14/25.The June 2025 Bathing Sheets documented R27 had not received a bath or shower during the following days:06/01/25 - 06/19/25 (19 days)06/21/25 - 06/30/25 (10 days)The EMR documented R27 refused bathing on 06/01/25, 06/06/25, 06/08/25, 06/11/25, 06/22/25, 06/25/25, and 06/29/25.The July 2025 Bathing Sheets documented R27 had not received a bath or shower during the following days:07/21/25 - 07/28/25 (8 days)The EMR documented R27 refused her bathing on 07/23/25.On 07/28/25 at 12:30 PM, R27 sat at the dining room table, hair uncombed. When R27 was asked any questions, she would not respond.On 07/29/25 at 09:10 AM, Licensed Nurse H stated R27 refused bathing. Staff offered alternative days and times, but R27 would continue to refuse.On 09/29/25 at 09:20 AM, Certified Nurse Aide (CNA) N stated R27 usually took her showers if she was working but would often refuse other staff. If a resident refused, they would tell the nurse, and the nurse would talk with the resident. CNA N further stated res are offered alternative bathing dates or times.On 07/29/25 at 09:53 AM, Administrative Nurse D stated residents who refused bathing were offered a different option, such as bed baths or provided with a wash rag. The CNA would chart on the bath sheet that the resident refused, and then the nurse was notified so the nurse could talk with the resident.The facility Shower/Tub Bath policy, dated 10/10, documented that the facility promoted cleanliness and provided comfort to the resident. Staff were to observe the condition of the resident's skin and notify the supervisor if the resident refused the shower or bath. The physician was notified if the resident had any areas that may need to be treated. Staff are to report other information according to facility policy and professional standards of practice.- The Electronic Medical Record (EMR) for R42 documented diagnoses of displaced fracture of the base of the neck of the left femur (a break in the left thigh bone), Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure, hypertension (high blood pressure), and diabetes mellitus (DM- when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the inulin) type two.The admission Minimum Data Set (MDS), dated [DATE], documented R42 had moderately impaired cognition. R42 was independent with toileting hygiene, dressing, personal hygiene, mobility, transfers, and ambulation. R42 received partial assistance with bathing.The Quarterly/Five Day Medicare MDS, dated 06/27/25, documented R42 had an intact condition. R42 required substantial staff assistance for transfers and showers. R42 required partial staff assistance for dressing, personal hygiene, and mobility.R42's Care Plan, dated 06/29/25, initiated on 04/11/25, documented R42 required partial to moderate assistance with bathing. R42 required cueing and reminders to complete self-care and hygiene tasks.The May, June, and July 2025 Bathing Sheets documented R42 had not received a shower on the following days:05/06/25 - 06/08/24 (34 days)06/10/25 - 06/19/25 (10 days)R42 was hospitalized from [DATE] - 06/25/2506/25/25 - 07/13/25 (19 days)07/15/25 -07/28/25 (14 days)The EMR documented R42 refused bathing on 05/19/25, 05/27/25, 06/09,25, 06/16/25, 06/30/25, 07/07/25, and 07/21/25.On 07/28/25 at 09:23 AM, R42 sat in his chair in his room. His hair was uncombed, greasy, and he was unshaven. R42 had on yellow socks; both socks were very soiled with a dried substance all over the socks. R42 stated he did not know what was all over his socks. When R42 was asked about his bathing and if staff offered different choices, he stated, I don't know. On 07/29/25 at 09:10 AM, Licensed Nurse H stated R42 refused bathing, but he had said he would take his shower sometime today. Staff offered alternative days and times, but R2 would continue to refuse.On 09/29/25 at 09:20 AM, Certified Nurse Aide (CNA) N stated R42 refused his showers all the time, no matter how many staff talked to him. If a resident refused, they would tell the nurse, and the nurse would talk with the resident. CNA N further stated that residents were offered alternative bathing dates or times.On 07/29/25 at 09:53 AM, Administrative Nurse D stated residents who refused bathing were offered a different option, such as bed baths or provided with a wash rag. The CNA would chart on the bath sheet that the resident refused, and then the nurse was notified so the nurse could talk with the resident.The facility's Shower/Tub Bath policy, dated 10/10, documented that the facility promoted cleanliness and provided comfort to the resident. Staff were to observe the condition of the resident's skin and notify the supervisor if the resident refused the shower or bath. The physician was notified if the resident had any areas that may need to be treated. Staff are to report other information according to facility policy and professional standards of practice.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 61 residents. The sample included 17 residents, with three reviewed for hospitalization. Based on observation, record review, and interview, the facility failed to notify the Office of the Long-Term Care Ombudsman (LTCO - a public official who works to resolve resident issues in nursing facilities) for two sampled residents, Resident (R) 42 and R6. This placed the residents at risk for uninformed care choices.Findings include:- The Electronic Medical Record (EMR) for R42 documented diagnoses of displaced fracture of the base of the neck of the left femur (a break in the left thigh bone), Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), hypertension (high blood pressure), and diabetes mellitus (DM- when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the inulin) type two.
The admission Minimum Data Set (MDS), dated [DATE], documented R42 had moderately impaired cognition. R42 was independent with toileting hygiene, dressing, personal hygiene, mobility, transfers, and ambulation. The MDS further documented R42 had no functional impairment and had no falls.
The Quarterly/Five Day Medicare MDS, dated [DATE], documented R42 had intact cognition. R42 required substantial staff assistance for transfers and showers. R42 required partial staff assistance for dressing, personal hygiene, and mobility. The MDS further documented R42 had lower functional impairment on one side, a fall with a major injury, and did not ambulate.
R42's Care Plan dated [DATE], initiated on [DATE], directed staff to be sure his call light was within reach and encouraged him to use it for assistance as needed. The care plan directed staff to ensure R42 wore appropriate footwear when ambulating or mobilizing in his wheelchair.
R42's Progress Note, dated [DATE] at 02:23 PM, documented R42 was admitted to the hospital with a fracture of the left femur.
R42's clinical record lacked evidence that the Ombudsman was notified of the hospital transfer.
R42's Progress Note, dated [DATE] at 04:24 PM, documented R42 was readmitted back into the facility.
On [DATE] at 09:23 AM, R42 sat in his recliner, hair disheveled, greasy, and unshaven. R42 stated he had no pain and was independent with transfers and ambulation.
On [DATE] at 01:30 PM, Social Service X stated the Ombudsman had not been notified of the hospital transfer, R42 had been mistakenly missed when the notice to the Ombudsman was sent at the end of June.
On [DATE] at 08:53 AM, Administrative Nurse D stated the Ombudsman should be notified when a resident is transferred to the hospital.
The facility's Transfer or Discharge Notices policy, dated 03/25, documented residents or resident representatives were notified of an impending transfer or discharge in writing and a language and manner they would understand. A copy of the notice was sent to the Office of the State Long-Term Care Ombudsman.
- R6's Electronic Health Record (EHR) revealed diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), chronic kidney disease (longstanding disease of the kidneys leading to renal failure) with behavioral disturbance, encephalopathy (inflammatory condition of the brain), and acute bronchitis (inflammation of the lining of bronchial tubes which carry air to and from the lungs).
R'6s Quarterly Minimum Data Set (MDS), dated [DATE], recorded R6 had severe cognitive impairment (problems with thinking, learning, remembering, and using judgment). The MDS recorded she required staff assistance with transfers and activities of daily living (ADL). The MDS documented the resident had occasional incontinence and ambulated with a wheelchair.
The Care Area Assessment (CAA), dated [DATE], recorded R6 required staff assistance with ADLs due to impaired functional ability. The CAA documented the resident had incontinence of urine with a diagnosis of chronic kidney disease and required assistance with toileting, transfers, and hygiene.
R6's Care Plan, dated [DATE], recorded R6 required staff assistance with most ADL care. R6's Care Plan documented the resident required staff assistance with incontinent cares and assistance. The care plan documented staff were to allow the resident privacy when using the restroom; however, stay near the bathroom and ready to provide assistance when R6 required it. The care plan documented R6 had the potential for falls related to needing assistance with ADL's and staff would encourage her to call for assistance when needed.
On [DATE] at 08:56 AM, Nurse's Notes documented R6 had a wet cough, warm to the touch, and had had confusion. The note documented R6 was in bed and had been incontinent and needed more assistance with cares. The resident's vital signs were temperature 100.7 (normal 97.9to 98.6), blood pressure 134/99 (normal 120/80), pulse 101 (normal 60-100), respirations 20 (normal 12-20), and oxygen saturation was 96 percent (normal 95-100).
On [DATE] at 04:21 PM, Nurses Notes documented R6 had been shaky, with clammy skin, yellowish looking skin, and had not been making very good words with talking today. The notes documented R6 had been incontinent, weak, not eating much, with a moist wet cough, her blood sugar reading was 105 (normal 70-99), the facility called her primary care physician, and sent the res to the emergency room by ambulance to be treated and evaluated. The primary care physician ordered the resident to be sent to the hospital. The notes documented R6 left with EMS at 04:20 PM. R6's niece was contacted with the information.
On [DATE] at 04:37 AM, Nurse's Notes documented the facility received an admission history and physical from the primary care physician for R6's admission to the hospital.
On [DATE] at 04:16 PM, Nurse's Notes documented the resident was admitted back to the facility with a diagnosis of acute metabolic encephalopathy hypoxia, urinary tract infection, and rhinovirus. The resident was transported from the transport van to the facility in a wheelchair. The resident had a foley catheter and had oxygen per nasal cannula set at 2 liters continuous flow. The resident was admitted on antibiotics for lower respiratory infection for seven days and had a non-productive cough.
R6's clinical record lacked documentation staff notified the LTCO of R6's discharge from the facility.
On [DATE] at 10:40 AM, Social Service X stated she would send notification of discharge to the Ombudsman regarding the resident's discharge from the facility to home, hospital, and if they had expired, once a month. Social Service X verified she failed to include R6 in the [DATE] discharges.
On [DATE] at 09:30 AM, Administrative Nurse D verified that the social service designee would send monthly reports to the Ombudsman office that included residents who were discharged , went to the hospital, and expired residents from the facility. Administrative Nurse D verified SSD X notified her she failed to include R6 in the [DATE] report to the Ombudsman office.
The facility's Transfer or Discharge Notice policy dated [DATE] documented residents or residents' representatives are notified of an impending transfer or discharge and the reason for the move in writing and in a language and manner they understand. A copy of the notice is sent to the Office of the Ombudsman. A copy is sent to the Office of the State Long Term Care Ombudsman at the same time the notice of transfer or discharge is provided to the resident and representative. The facility will send a copy of the discharge notice to the Office of the State Long Term Care Ombudsman. Notice to the Office of the State LTC Ombudsman will occur at the same time as the notice of discharge is provided to the resident and the resident's representative.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 61 residents. The sample included 17 residents, with two reviewed for abuse, neglect, or exploitation. Based on observation, interview, and record review, the facility failed to thoroughly investigate in a timely manner the injury of unknown origin to Resident (R) 48, who stated it happened when staff were transferring her.Findings included: - R48's Electronic Medical Record documented diagnoses of a stable burst fracture of two vertebra (bone of the spinal column), chronic respiratory failure, chronic lymphocytic leukemia (a cancer that develops in the bone marrow, where blood cells are produced) in remission, pain, osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain), and dorsalgia (back pain).R48's admission Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of nine, indicating moderately impaired cognition. The MDS documented R48 was dependent on staff for transfers and had no falls since admission. R48's Fall Care Area Assessment (CAA), dated 07/14/25, stated contributing factors included weakness, reliance on staff for Activities of daily living (ADL), and mobility.R48's Care Plan, dated 07/11/25, directed staff to be sure the resident's call light was within reach and encourage the resident to use it for assistance as needed. The care plan lacked staff direction for transfers and mobility. The 07/16/25 update stated two skin tears on the left lower leg, with a treatment plan and monitoring in place, initiated 07/18/25.The Progress Note, dated 07/16/25 at 05:00 PM, documented Certified Nurse Aides (CNA) were getting R48 up for supper and noted two bruised areas that were bleeding on her left lower leg. The bruised areas with one 2-centimeter (cm) skin tear and one 3 cm skin tear. Staff cleansed the area with wound cleanser, patted dry, and applied steri-strips and a dry dressing. R48 said her leg bumped something during the transfer.The Incident Report, dated 07/16/25, did not include a dated witness statement even though the resident claimed it happened during a transfer. On 07/28/25 at 10:23 AM, R48 laid in bed with the head of the bed elevated and blue pressure relief booties on her feet. R48 stated the pain in her back was better today. On 07/28/25 at 03:28 PM, Administrative Nurse D stated the interdisciplinary team (IDT) reviewed the incident and should have investigated the incident as an injury of unknown origin. She provided an undated witness statement from the CNA who found the skin tears, but no witness statement documenting what happened. On 07/29/25 at 09:05 AM, Administrative Nurse D stated she thought the CNA wrote a statement that she was transferring the resident when her leg bumped the wheelchair, but did not provide that witness statement.The facility's Abuse, Neglect, Exploitation policy, dated 10/2023, stated all reports of resident abuse (including injuries of unknown origin), neglect, and exploitation were to be reported to local, state, and federal agencies and thoroughly investigated by facility management. The findings of all investigations would be documented and reported. All allegations would be thoroughly investigated. the administrator-initiated investigations. Upon conclusion of the investigation, the investigator records the findings on approved documentation forms.

The facility identified a census of 62 residents, with three residents reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Based on record review, observation, and interview, the facility failed to provide necessary care, consistent with professional standards of practice, to prevent pressure ulcers including offloading for Resident (R) 1 who developed a facility-acquired unstageable pressure ulcer (depth of the wound is unknown due to the wound bed is covered by a thick layer of other tissue and pus) on her left heel. This deficient practice also placed R1 at risk for infection and pain.
Findings included:
- R1's Electronic Medical Record (EMR) documented R1 had diagnoses of a pubic fracture, pressure ulcers, weakness, abnormality of gait and mobility, and need for personal care.
R1's admission Minimum Data Set (MDS), dated 02/13/25, documented R1 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated moderately impaired cognition. The MDS documented R1 required substantial/maximum staff assistance with dressing, donning (putting on) footwear, and bed mobility. The MDS noted R1 was dependent on staff for all transfers. The MDS documented R1 was at risk for developing pressure ulcers; R1 was admitted with two Stage 2 (partial-thickness skin loss into but no deeper than the dermis including intact or ruptured blisters) pressure ulcers and one Stage 3 (full-thickness pressure injury extending through the skin into the tissue below) pressure ulcer. The MDS documented R1 had pressure ulcer treatments including nutrition and hydration management, pressure ulcer care, and application of ointments/medications.
The Functional Abilities Care Area Assessment (CAA), dated 02/13/25, documented R1 had an alteration in self-care and mobility function with altered elimination, a risk for falls, and a risk for skin breakdown. The CAA identified R1 admitted with a Stage 3 pressure ulcer to her coccyx (tailbone area) and a Stage 2 pressure ulcer to her right and left buttocks. The CAA noted R1 received antibiotics for positive wound cultures and infection.
The Pressure Ulcer/Injury CAA, dated 02/13/25, documented R1 entered the facility with pressure ulcers, and had contributing factors of diabetes mellitus (DM - when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), weakness, and immobility.
R1's Care Plan documented R1 required substantial to maximum assistance from one to two staff for bathing, bed mobility, and transfers; R1 was dependent on one to two staff for toileting. The care plan directed staff to follow facility policies and protocols for the prevention and treatment of skin breakdown, administer treatments as ordered, monitor for effectiveness, and provide pressure relieving/reducing devices on R1's bed and chair (02/10/25). The plan documented R1 was to wear heel protectors at all times (03/27/25). The plan directed staff to use caution during transfers and bed mobility to prevent R1 from striking her arms, legs, and hands against any sharp or hard surfaces (04/11/25). R1's Care Plan lacked interventions related to repositioning and lacked interventions related to offloading until 03/27/25.
The Braden Scale for Predicting Pressure Sore Risk, dated 02/18/25, documented R1's score as 18, which indicated R1 was at low risk for pressure ulcer development.
The Braden Scale for Predicting Pressure Sore Risk, dated 03/08/25, documented R1's score as 17, which indicated R1 was at low risk for pressure ulcer development.
The Incident Note, dated 03/15/25 at 12:44 AM, documented the nurse was called into R1's room by the Certified Nurse Aides (CNA) who reported R1 had blood by her left heel. The note documented the nurse found R1 had five centimeters (cm) by three cm Stage 3 pressure ulcer on her left heel. The staff cleansed the wound with wound cleanser and applied Xerofoam (sterile non-adhering fine mesh gauze treated with a bacteriostatic agent) and a border dressing to R1's left heel.
The Order Note, dated 03/20/25, documented a left heel dressing change. Staff were to cleanse the wound with wound cleanser, apply calcium alginate (highly absorbent dressing), cover with a bordered adhesive foam dressing and change daily and as needed.
The Wound Assessment Note, dated 03/20/25, documented R1's left heel wound measured 5 cm by 6 cm by 0.2 cm deep.
The IDT Note, dated 03/21/25, documented R1 had a new pressure ulcer on her left heel. Staff received orders to start calcium alginate to aid in the formation of granulation tissue (new tissue formed during wound healing) and to debride (medical removal of dead, damaged, or infected tissue to improve the healing potential for the remaining healthy tissue) areas of loose skin. The note documented the treated area had no signs or symptoms of infection.
The Wound Assessment Note, dated 03/26/25 documented R1's left heel wound measured 5.5 cm by 7.4 cm and was mostly necrotic (pertaining to the death of tissue in response to disease or injury).
The IDT Note, dated 03/26/25, documented R1's left heel treatment started the previous week. The peri-wound (tissue surrounding the wound) was opening up and increased in size. The wound had no signs or symptoms of infection noted to the area.
The Wound Assessment Note, dated 04/03/25, documented R1's left heel wound measured 6 cm by 8.5 cm and had progressed to an unstageable ulcer.
The IDT Note, dated 04/03/25 documented R1's left heel ulcer progressed in normal stages for pressure ulcers, the peri wound was sloughing (dead tissue, usually cream or yellow in color) off and the wound was expanding in size.
The Wound Assessment Note, dated 04/11/25, documented R1's left heel ulcer measured 5.7 cm by 8.5 cm and continued to be necrotic and unstageable.
The Wound Assessment Note, dated 04/17/25, documented R1's left heel wound measured 5.6 cm by 8.3 cm. The wound was necrotic, unstageable, and had a foul odor.
The IDT Note, documented all of R1's pressure sores showed signs of improvement except the left heel ulcer. Staff requested and received an order for a wound culture due to the wound's odor.
The EMR lacked evidence of the culture results that were ordered.
The Skin/Wound Note, dated 04/21/25, documented R1 had a large injury to her left leg. R1 obtained a laceration (cut) to her left inner calf during a transfer with a Hoyer lift (total body mechanical lift) caused by R1's leg rubbing on the back of the foot pedal. Staff called Emergency Medical Services (EMS) and sent R1 to the emergency room for suture (stitches) placement.
The Hospital Progress Note, dated 04/22/25, documented the hospital placed nine sutures on R1's left anterior shin laceration to R1's leg that grazed the back of the foot pedals on her wheelchair. The note documented the hospital had concerns about R1's left heel wound due to the malodorous smell, and an X-ray was done that showed a large soft tissue wound posterior (back) to the calcaneus (heel bone) with adjacent soft tissue swelling, osseous (hard, mineralized tissue that provides the skeletal structure of the human body) destruction of the posterior calcaneal (heel bone) cortex (outer layer of any part) adjacent to the wound consistent with acute osteomyelitis (local or generalized infection of the bone and bone marrow). R1 received vancomycin (antibiotic) and Zosyn (antibiotic) at the transferring hospital. R1 was transferred to a higher-level hospital for surgical evaluation. R1's age, multiple comorbid conditions, and lack of mobility as well as dementia, resulted in a conservative treatment plan. R1's responsible party discussed the options to discharge back to long-term care on hospice versus continuation of intravenous (IV) antibiotics for six to eight weeks and see how R1 did.
The General Progress Note, dated 04/28/25, documented R1 arrived from a higher level of care with diagnoses of failure to thrive, wounds, and frail elderly. R1 was admitted back to the facility on hospice.
The Infection Note, dated 04/30/25, documented R1 continued an antibiotic for her left heel wound. There were no signs and symptoms of infection to left heel. The staff changed the dressing, and the area was without odor.
On 05/07/25 at 11:30 AM, observation revealed R1 lay in bed sleeping. R1 had oxygen tubing pulled down below her chin. R1 had blue pressure-relieving boots on both feet. R1 lay on a low-air mattress.
On 05/07/25 at 11:30 AM, R1 stated she did not know how she got the sore on her left heel, but it hurt. R1 apologized for being sleepy, saying she had just received a pain pill, which made her sleepy.
On 05/07/25 at 01:00 PM, CNA O stated she could not remember if R1 had pressure-relieving boots prior to her obtaining the heel wound. CNA O stated she did not know if turning and repositioning was on R1's Care Plan but staff would turn and reposition anyway regardless of if it was on the care plan. CNA O stated R1 had been on an air mattress since R1's admission to the facility.
On 05/07/25 at 01:10 PM, CNA P stated she did not think R1 had pressure-relieving boots on her feet before she developed the left heel pressure ulcer. CNA P stated there was nothing that alerted or informed staff which residents needed to be turned or repositioned, but the CNA just knew and did it anyway.
On 05/07/25 at 01:20 PM, Licensed Nurse (LN) G stated she was sure R1 had been on an air mattress since admission, but she could not accurately say whether R1 had pressure-relieving boots to her feet prior to getting the pressure wound on the left heel.
On 05/07/25 at 02:30 PM, Administrative Nurse D stated she did not know why R1's Care Plan did not include pressure-relieving boots as an intervention until 03/27/25 after R1 had sustained the left heel ulcer. Administrative Nurse D stated the facility was in between MDS nurses at that time, and training new MDS nurses about care plan interventions was complicated. Administrative Nurse D stated she thought R1 had pressure-relieving boots in place from admission. Administrative Nurse D stated she knew R1 had an air mattress since her admission to the facility. Administrative Nurse D stated she thought R1 had possibly been in the dying process since her admission, and that is why she obtained the pressure ulcer. Administrative Nurse D stated she expected that residents would not develop facility-acquired pressure ulcers unless they were unavoidable.
The facility did not provide a policy on pressure ulcer prevention.

The facility identified a census of 58 residents with three residents reviewed for elopement and wandering. Based on record review, observation, and interview, the facility failed to ensure staff provided adequate supervision to prevent cognitively impaired Resident (R)1 from exiting the facility without staff knowledge and supervision. On 06/13/24 at approximately 07:55 AM R1, who was at risk for elopement, propelled his wheelchair from the dining room to the smoker's room on the south hall. R1 went into the smoker's room and said that it was his home. Housekeeping Staff U removed R1 from the smoker's room and told Certified Nurse Aide (CNA) N what R1 was doing. R1 reentered the smoker's room and CNA N went in and tried to convince R1 to leave but R1 again stated it was his home. Since R1 was not attempting to exit, CNA N left him to go answer call lights. Both CNA N and CNA M began assisting other residents. At 08:20 AM, Administrative Staff A entered the parking lot and headed to the door of the facility. She heard someone say, Good Morning. When she looked back to the east, she saw R1 in the parking lot, sitting in his wheelchair. Administrative Staff A approached R1 and asked what he was doing outside, and he said, I am going home to see my wife and brother. Administrative Staff A called Administrative Nurse D and she came to assist R1 back into the facility. The investigation revealed the door alarm to the smoker's room sounded, but staff could not hear it. The facility's failure to provide adequate supervision to prevent R1 from eloping placed R1 in immediate jeopardy.
Findings included:
- R1's Electronic Medical Record (EMR) documented diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), muscle weakness, history of falling, difficulty in walking, and hypertension (high blood pressure).
The Quarterly Minimum Data Set (MDS), dated 05/22/24, documented R1 had a Brief Interview for Mental Status (BIMS) score of seven which indicated severe cognitive impairment. The MDS documented R1 used a wheelchair for locomotion and required moderate to maximum assistance from one staff for toileting, dressing, bed mobility, and bathing. R1 was able to use his wheelchair to move from one place to another without assistance. The MDS documented R1 had no behaviors.
The Functional Abilities Care Area Assessment (CAA), dated 11/29/23, documented R1 required assistance with bed mobility, transfers, dressing, bathing, and personal hygiene tasks. The CAA documented R1 was able to eat independently with set-up assistance as needed. The CAA documented R1 was able to self-propel independently for short distances.
The Fall CAA, dated 11/29/23, documented R1 was at risk for falls due to generalized weakness, unsteadiness, decreased safety awareness, and actual falls.
R1's Care Plan documented R1 was an elopement risk/wanderer, and his safety would be maintained (06/11/24). R1's information was added to the elopement risk binder. The care plan directed staff to identify a pattern of wandering and intervene as appropriate and provide R1 with structured activities like toileting, walking inside and outside, and reorientation strategies. The care plan directed staff when R1 wanted to go home or stated that he needed to go home, to use redirection and remove R1 away from the door.
The Elopement Risk Evaluation, dated 06/10/24, documented R1 had a score of three which indicated R1 was at risk for elopement.
The Fall Risk Evaluation, dated 06/10/24, documented R1 had a score of twenty which indicated he was at risk for falls.
The Facility Incident Report, dated 06/13/24, documented at approximately 07:55 AM on 06/13/24, R1 was seen in the facility's smoking room by CNA N. CNA N stated R1 was not exit seeking so she left him in the smoking room and went to answer call lights. At 08:20 AM, Administrative Staff A observed R1 sitting in the parking lot in his wheelchair. R1 told Administrative Staff D he was waiting for his family. R1 was easily redirected. R1 had on a sweatshirt, pants, socks, and shoes. The temperature outside was 71 degrees, sunny, with a light breeze. R1 was taken back into the facility and a head count of all residents was performed. A head-to-toe assessment of R1 revealed no injuries. R1 went outside through the smoke room door. The door alarm was alarming, but the staff did not respond to the door alarm because they could not hear the alarm where they were. Staff were in residents' rooms and two CNAs were in the dining room. Interventions included R1 was one-to-one with staff until it was determined he was not exiting seeking. All the door alarms were checked and functioning properly. Education was performed with all staff to respond to door alarms. Maintenance is looking for ways the smoking-room door alarm can be made louder.
CNA M's Witness Statement, dated 06/13/24, documented CNA M had just finished giving another resident a shower and walked the resident out of the shower room and to their room. CNA M saw R1 heading from the dining room onto the south hall at 07:50 AM.
Housekeeping Staff U's Witness Statement, dated 06/13/24, documented at around 07:55 AM Housekeeping Staff U saw R1 in the smoke room. R1 stated he was going home. Housekeeping Staff U removed R1 from the smoke room and R1 said the smoke room was his home. A couple of minutes later, R1 went back into the smoke room and Housekeeping Staff U notified CNA N of R1's location.
CNA N's Witness Statement, dated 06/13/24, was documented at around 07:55 AM Housekeeping Staff U informed CNA N R1 was in the smoke room, and she attempted to keep R1 out of the room, but he had gone in again stating the room was his home. CNA N attempted to remove R1 from the smoke room but R1 refused to come out. R1 was just sitting in the room and not attempting to leave. CNA N stated she made sure R1 was just sitting there and left to go answer call lights.
Administrative Staff A's Witness Statement, dated 06/13/24, documented she pulled into the facility parking lot around 08:20 AM. Administrative Staff A stated she walked to the front door of the facility when she heard someone say, Good morning. Administrative Staff A looked to her right and saw R1 sitting in his wheelchair in the middle of the parking lot. Administrative Staff A asked R1 where he was going and R1 said to see his wife and his brother. Administrative Staff A asked R1 how he got outside and R1 said the back door. Administrative Staff A called Administrative Nurse D at 08:23 AM and informed her of the situation. Administrative Staff A then moved R1 out of the parking lot and onto the sidewalk. Administrative Nurse D arrived to assist R1 back into the facility.
On 06/17/24 at 09:15 AM, observation revealed a sidewalk leading out to the parking lot which was full of cars. There was multiple car-stops. The pavement in the parking lot had cracks and weeds growing up in the cracks.
On 06/17/24 at 09:30 AM, observation revealed R1 sat up in his bed drinking water. R1 was very pleasant and friendly. R1 was not oriented to time or place. A CNA sat outside of R1's room providing one-on-one supervision.
On 06/17/24 at 09:15 AM, CNA O stated R1 could not walk and used a wheelchair for locomotion but R1 had poor safety awareness and had falls where he had tried to stand up and walk.
On 06/17/24 at 10:30 AM, CNA M stated she was working the day R1 eloped, and she did not hear the door alarm sound when she was in another resident's room. CNA M stated she thought R1 would be safe in the smoke room, or she would not have left him there.
On 06/17/24 at 11:30 AM, Administrative Nurse D stated when she was outside with R1 she could hear the alarm sounding outside, but as soon as she came into the building, the alarm was not sounding at the alarm panel to alert staff. Maintenance fixed the alarm so it was sounding at the alarm panel and staff could hear the alarm throughout the building. Administrative Nurse D stated she expected all staff to respond to door alarms and provided education to all the staff regarding elopements and conducted elopement drills twice a day to ensure everyone knew what to do.
The facility Wandering and Elopement Policy, dated 07/01/24, documented the purpose of the policy is to provide a system of identification of residents at risk for unsafe wandering and elopement, provide a program of supervision and interventions to minimize the risk of resident elopements, improve resident safety through timely investigations of elopements and elopement attempts, and provide staff education in effective wandering/elopement management through in-services and elopement drills.
On 06/17/24 at 01:06 PM Administrative Staff A received a copy of the Immediate Jeopardy [IJ] Template and was informed that the facility's failure to provide adequate supervision to prevent R1 from eloping placed R1 in immediate jeopardy.
The facility identified and implemented immediate corrective actions, which were completed on 06/13/24 and included:
All nursing staff were re-educated on wandering/elopement. R1 is one-on-one with staff until it is determined he is not exiting seeking.
Maintenance fixed the smoke room door alarm, so it would alarm not only in the room and outside but at the alarm panel to alert staff.
Maintenance staff and the manager on duty on the weekends are checking all door alarms twice a day.
Care plans of residents at risk for elopement were reviewed and new elopement risk evaluations were completed on all residents.
Due to the corrective action completed before the onsite survey, the citation was deemed past noncompliance at a J scope and severity.

The facility identified a census of 65 residents with three residents reviewed for medication errors. Based on record review, observation, and interview, the facility failed to follow the physician's orders for Resident (R)1's insulin (a hormone that lowers the level of glucose in the blood) administration which resulted in R1's blood sugar decreased to 44 milligrams per deciliter (mg/dl) and had to be transferred to a higher level of care. On 12/17/23 Licensed Nurse (LN) G administered eight units of insulin aspart (short-acting insulin) to R1 right as R1 started to eat supper, despite the physician's order which directed staff to only give insulin aspart if the resident ate greater than 50% of the meal. R1 only ate three to four bites of her supper. This deficient practice resulted in a hypoglycemic (less than normal amount of sugar in the blood typically less than 70 mg/dl) episode and placed R1 at risk for other related complications.
Findings included:
- R1's Electronic Medical Record (EMR) documented that R1 had diagnoses of diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), dementia (progressive mental disorder characterized by failing memory, confusion), Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), and hypertension (high blood pressure).
The Quarterly Minimum Data Set (MDS), dated 12/17/23, documented that R1 was rarely/never understood and had short and long-term memory problems. The MDS further documented R1 was dependent on staff for personal hygiene, bed mobility, transfer, toileting, and bathing. R1 required moderate assistance for eating.
The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 06/27/23, documented R1 had a Brief Interview for Mental Status score of six which indicated severely impaired cognition.
The Activities of Daily Living (ADL)/Rehabilitation Potential CAA, dated 06/27/23, documented R1 required assistance with bed mobility, transfers, dressing, bathing, and mobility. The CAA documented R1 used the sit-to-stand lift to transfer and was able to verbalize her needs to staff.
R1's Care Plan, revised on 12/21/22, documented R1 was at risk for alterations in her blood sugar levels and hypoglycemia. The care plan directed staff to monitor for any signs and symptoms of hypoglycemia, administer medications as ordered, and notify the physician if R1's blood sugar was less than 70 mg/dl or greater than 350 mg/dl.
The Order Summary Tab documented the physician's order, dated 07/12/23, which directed licensed staff to administer eight units of insulin aspart subcutaneously (under the skin) three times a day and to hold the dose if R1 ate less than fifty percent of her meal.
The Weights and Vitals Tab documented on 12/17/23, R1's blood sugar was 80 mg/dl at 07:26 AM, 132 mg/dl at 11:07 AM, and 200 mg/dl at 05:01 PM.
The electronic Medication Administration Record (MAR), dated December 2023, documented R1 received eight units of insulin aspart on 12/17/23at 05:30 PM by LN G.
The General Progress Note, dated 12/17/23, documented R1 was found non-responsive and diaphoretic (sweaty) at 08:15 PM. R1's blood sugar was 44 mg/dl. Staff administered R1 a tube of glucose gel (gel used to increase blood sugar) and R1 moaned and opened her eyes. Staff notified Emergency Medical System (EMS) and EMS arrived at 08:44 PM. R1's blood sugar at the time was 29 mg/dl. EMS started an intravenous line (IV) gave R1 D10 (dextrose 10%) and transported R1 to the hospital. Five different staff tried to assist R1 with supper and she refused to eat except for three to four bites.
The Conversation with Practitioner Note, dated 12/17/23, documented staff notified R1's primary care physician that R1's insulin was given to her before supper and R1 only ate three to four bites. Multiple staff tried to assist her and R1 refused to eat any more supper; R1 had a low blood sugar of 44 mg/dl.
The Facility Incident Report, dated 12/22/23, documented on 12/17/23 at approximately 08:15 PM, R1, a COVID-19 (highly contagious respiratory virus) positive resident, was found to be less responsive and diaphoretic. Upon evaluation by the charge nurse, R1's blood sugar was 44 mg/dl. Staff notified R1's primary care physician and received a new order to administer one tube of dextrose gel and send R1 to the emergency room (ER) for evaluation and treatment. Upon review, R1 had an order for insulin aspart eight units subcutaneously three times a day and to hold the dose if R1 ate 50% or less of her meals. R1 was administered her insulin before supper and R1 only ate three to four bites of supper. R1 had a decrease in mental status and meal intake due to being COVID-19-positive. ER documentation noted R1 was hypoglycemic but became more responsive with the dextrose gel and D10 treatment.
The Hospital Health and Physical, documented R1 was at the emergency department due to a low blood sugar of 29 mg/dl and hypotension (low blood pressure) with systolic blood pressure in the 70's. R1 was transferred to a higher level of care. On examination, R1 had diagnoses of septic shock due to cystitis (inflammation of the bladder), hypoglycemia, and infection.
On 01/11/24 at 09:00 AM, observation revealed R1 laid in bed with an oxygen cannula in her nostrils. R1 slept soundly.
On 01/11/24 at 09:15 AM, CMA R stated that R1 could not eat by herself and had to be fed by staff.
On 01/11/24 at 10:00 AM, Administrative Nurse D stated that she expected all of her nurses to follow physicians' orders exactly as written to ensure the safety of the residents. Administrative Nurse D stated all of the nurses at the facility were re-educated regarding following physician orders and insulin administration. Administrative Nurse D stated LN G was suspended pending the investigation but returned to work after re-education. Administrative Nurse D stated LN G did not know why she gave R1 her insulin before she ate that day because she had never done that before.
The facility's Insulin Administration Policy, dated September 2014, documented the purpose of the policy was to provide guidelines for the safe administration of insulin to residents with diabetes. The type of insulin, dosage requirements, strength, and method of administration must be verified before administration to ensure that it corresponds with the order on the medications sheet and the physician's order.
The facility failed to follow the physician's orders for R1's insulin administration. This deficient practice resulted in a hypoglycemia episode which required emergent treatment and placed R1 at risk for related complications.
On 12/21/23 the facility identified and completed the following corrective actions:
All nurses received education regarding physician orders and insulin administration.
All residents who received insulin were reviewed and had care plans updates as needed.
A risk meeting was held and presented to Quality Assurance and Performance Improvement (QAPI), and insulin orders were audited.
All corrective actions were completed prior to the onsite survey, therefore the deficient practice was deemed past noncompliance at a G scope and severity.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 64 residents. The sample included 19 residents. Based on observation, record review, and interview, the facility failed to honor resident rights when the facility revoked Resident (R) 31's smoking privilege as a form of reprisal for the facility's inadequate supervision which allowed R31 to obtain cigarettes and a lighter from another resident's room; R31 lit a cigarette in the hall outside of the smoking room. (See F689). This deficient practice placed R31 at risk for impaired self-determination about things that were important to her, including smoking.
Findings included:
- R31's Electronic Medical Record (EMR) documented diagnoses of generalized anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear) disorder, major depressive disorder (major mood disorder which causes persistent feelings of sadness), nicotine dependence (an addictive organic compound found in tobacco plants), mild intellectual disabilities (a significantly below-average score on a test of mental ability or intelligence and by limitations in the ability to function in areas of daily life), bipolar disorder (major mental illness that caused people to have episodes of severe high and low moods), delusional disorders (untrue persistent belief or perception held by a person although evidence shows it was untrue), schizophrenia (mental disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought), vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), and acquired absence of left leg above knee.
The Annual Minimum Data Set (MDS) dated [DATE] documented R31's had a Brief Interview for Mental Status (BIMS) score of 13 which indicated intact cognition. R31 rejected cares four to six days of the observation period but not daily. She had no wandering during the observation period. The Behavioral Care Area Assessment documented R31 had diagnoses of schizophrenia, bipolar disorder, anxiety, psychosis, and mild intellectual disabilities; R31's behavior and noncompliance were chronic. The MDS recorded R31 had current tobacco use.
The Quarterly Minimum Data Set (MDS), dated [DATE], documented R31 had intact cognition with a BIMS of 14. She had no delirium (sudden severe confusion, disorientation and restlessness) or psychosis (any major mental disorder characterized by a gross impairment in reality perception). The MDS recorded R31 had no wandering or rejection of cares during the observation period, but she did exhibit physical and verbal behaviors directed toward others which occurred one to three days during the observation period. The MDS further documented R31 required partial/moderate assistance with sit to lying and lying to sitting and substantial/maximal assistance with chair to bed to chair transfers; R31 used a manual wheelchair. R31 received insulin (hormone that lowers the level of glucose in the blood), antipsychotic (class of medications used to treat major mental conditions which cause a break from reality), antianxiety (class of medications that calm and relax people), and antibiotic (medication to treat infections) on a routine basis. The question regarding current tobacco use on the MDS was unanswered.
R31's Care Plan, initiated on 02/17/21 and revised on 08/31/23 documented R31 had impaired cognition or thought processes due to dementia. The plan listed an intervention initiated on 07/13/21 and revised on 12/05/22 which documented R31 had tobacco use and would adhere to the tobacco and smoking policies of the facility. The care plan listed an intervention dated 07/13/21 which directed staff to conduct a smoking evaluation on admission and as needed; educate the resident and responsible party on the facility's tobacco and smoking policies.
R31's Care Plan further documented R31 had a history of hoarding behavior, dated 08/17/21 and directed staff to provide alternative activities to use for meaningful work/tasks and distraction. The plan further listed an intervention dated 03/25/22 which documented R31 had a history of going into other residents' rooms at times and directed staff to re-orient R31 as indicated.
R31's Care Plan recorded an intervention dated 08/31/23 which directed that due to R31's use of psychotropic (alters mood or thought) medication, R31 had times for smoking cigarettes. The nurse would monitor and give R31 three cigarettes every two hours.
R31's Smoking and Safety Evaluation dated 05/16/23, documented R31 did not demonstrate safe smoking behavior in interacting with peers and required an assistive device for smoking. Other risk level considerations included R31 had diagnoses of dementia/memory impairment. The team deemed R31 unsafe to smoke, therefore she required staff supervision for smoking.
R31's Smoking and Safety Evaluation dated 08/14/23, documented R31 used tobacco two to five times a day, morning, afternoon and evening. The assessment recorded R31 was not on a smoking cessation plan and was not interested in quitting. The assessment documented R31 understood the community safety rules and articulated an understanding of the danger of smoking near flammable materials or a resident wearing oxygen. According to the assessment, the team decided the resident could smoke with a safe smoking care plan. Due to R31's diagnosis of dementia/memory loss impairment and psychotropic medications use, staff would light the cigarette for R31.
A nurse's note in the Progress Notes section recorded on 06/29/23 R31 went into R43's room and took his cup of medication that was left in his room. Staff educated R31 on not going into another resident's room and that she cannot take medication that she does not get from staff.
The facility's Investigation report, dated 11/02/23, documented R31 had been smoking in the South hallway. R31 took cigarettes and a lighter from another resident's room and lit the cigarette in the hallway. Staff put the cigarette out. Staff informed R31's guardian that the resident's smoking privileges had been removed as R31 was unable to follow policy and was not safe to smoke. R31 denied taking cigarettes out of another resident room and did not realize what she did.
On 11/02/23 at 12:24 PM, observation revealed R31 sat in R43's room. R43 was in the bathroom and yelled at R31 to get out of his room stating that R31 was not to be in his room. R31 left the room stating she was confused and thought she was in her room.
On 11/02/23 at approximately 12:28 PM, R31 sat in the hallway outside the smoking room with a lit cigarette. Staff intervened immediately and put out the cigarette; staff retrieved the cigarettes and lighter which belonged to another resident.
On 11/06/23 at 09:47 AM Certified Medication Aide (CMA) S reported R31's smoking routine was she could get two cigarettes and her lighter every two hours.
On 11/07/23 at 10:30 AM, Licensed Nurse (LN) G stated R31 could no longer smoke because R31 was able to get cigarettes from someone else's room and lit up and smoked in the hallway. LN G stated occasionally R31's visitor would bring in lighters and R31 would stash them in her room. LN G reported R31 had been known to take things from R43's room in the past.
On 11/07/23 at 11:27 AM Administrative Nurse D verified R31's smoking privileges were revoked because she obtained cigarettes and a lighter from another resident's room and lit a cigarette in the hallway. Administrative Nurse D provided documentation of notifying R31's physician of offering R31 Nicorette gum which was refused and requested nicotine patches. Administrative Nurse D verified the facility had not provided/offer R31 with alternative options with safe smoking practices.
The facility's Resident Rights policy, date 12/2016, documented employees shall treat all residents with kindness, respect, and dignity. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to self-determination, to exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility.
The revoking of R31's smoking privileges as a form of reprisal placed the resident at risk for loss of self-determination related to what was important to the resident.

The facility identified a census of 64 residents. The sample included 19 residents, with three reviewed for abuse. Based on record reviews and interviews, the facility failed to establish and implement an admissions agreement that explained and protected resident's right to personal property, safeguarded by the facility in a manner which allowed full accessibility to the valuable by the resident.
Findings included:
- The facility's admission Agreement under Valuables on page five, stated the resident, or the responsible party (if applicable), accepted the responsibility of safeguarding all valuables, money, appliances, and all other pieces of the resident's personal property, while the resident stayed at the facility. Pursuant to applicable law, the facility exercised reasonable care to protect the resident's personal property and made all reasonable efforts to recover any misplaced items. However, the facility was not responsible for replacing any missing items, other than was required by applicable law.
On 11/07/23 at 10:39 AM PM, Social Services X stated residents signed a valuables policy on the admission agreement and that she had been the one having them sign until recently.
On 11/07/23 at 10:52 AM, Administrative Staff A stated residents were offered lock boxes or trust accounts in order to safeguard their valuables or money. Administrative Staff A stated if the resident did not use the lock box or trust account, the facility could not determine if a residnet really had money and if the money was really missing. Administrative Staff A further stated, because residents were offered the lock boxes and trust accounts, if the resident did not accept, the facility was not responsible for the loss of the resident's property.
The facility's admission Agreement policy, last revised August 2018, directed the facility did not ask or require residents/potential residents to waive facility liability of personal property.
The facility failed to establish and implement an admissions agreement that explained and protected resident's right to personal property, safeguarded by the facility in a manner which allowed full accessibility to the valuable by the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 64 residents. The sample included 19 residents with nine reviewed for accidents. Based on observation, record review, and interview, the facility failed to provide the care planned amount of staff assistance for Resident (R) 29 to prevent falls, and failed to provide supervision for R31, who entered another resident's room and engaged in unsafe activity. These deficient practices placed the affected residents at risk for further falls and preventable injury.
Findings included:
- The Electronic Medical Record (EMR) for R29 documented diagnoses of cerebral infarction due to embolism of cerebral artery (the pathological process that result in an area of necrotic tissue in the brain), hemiparesis (muscular weakness of one half of the body), hemiplegia (paralysis of one side of the body), repeated falls, and difficulty walking.
R29's Quarterly Minimum Data Set (MDS), dated [DATE], documented R29 had intact cognition and required extensive assistance of two staff for bed mobility, transfers, and toileting. The MDS recorded ambulation only occurred once or twice with two staff assistance. The MDS further documented R29 had upper and lower functional impairment on one side, unsteady balance, and had one fall with injury.
The Fall Risk Assessments, dated 10/18/23 and 10/26/23, documented the resident was at risk for falls.
R29's Care Plan, dated 08/28/23, initiated on 06/02/23, educated R29 to call for assistance. It directed staff to obtain therapy referrals as ordered by physician, provide the resident with a safe environment free of clutter, and ensure R29 wore appropriate shoes and clothing. The update dated 06/06/23, documented R29 required assistance of one or two staff for transfers. The update, dated 06/20/23, directed staff to use two staff for transfers, and have R29 call staff for assistance. The update, dated 08/25/23, directed staff to ensure cords were not under the bed prior to leaving the room. The update, dated 09/05/23, directed staff to provide R29 with a reacher. The update, dated 10/16/23, directed staff to keep a wheelchair within reach until R29 stated he felt steady while standing. The update, dated 10/26/23, directed staff to reeducate R29 to call for assistance and place signage in his room for extra reminder. The update, dated 11/02/23, directed staff to use one staff member with transfers.
The Nurse's Note, dated 10/16/23 at 05:31 PM, documented R29 was on the floor next to his recliner. Hehad both shoes on, and a gait belt. His bottom legs faced forward, and the bedside table was broken. The note further documented the Certified Nurse Aide (CNA) stated R29 broke the table as he reached for it during the fall.
The Fall Investigation, dated 10/16/23 at 04:07 PM, documented R29's right leg went weak and he fell down. The investigation further documented R29 did not sustain any injury, and was educated to tell staff when he felt weak. The investigation further recorded staff were reeducated to transfer R29 with two staff when he was weak or unsteady.
On 11/06/23 at 09:00 AM, observation revealed R29 sat on the toilet, CNA N placed a gait belt around R29's waist, and instructed him to grab onto the bar in front of him and stand up. Continued observation revealed CNA N had to cue R29 to take his time, turn, reach back to feel for the recliner, and sit down.
On 11/06/23 at 09:10 AM, CNA N stated R29 used to be a two person transfer but he worked with therapy and was now a one person assistance for transfers and ambulation.
On 11/07/23 at 11:20 AM, Licensed Nurse (LN) H stated she encouraged staff to use two staff for R29's transfers and ambulation because the resident's cognition had declined, he was weak, and unpredictable.
On 11/07/23 at 11:45 AM Administrative Nurse D stated R29 received therapy and was now a one person staff assistance with transfers, and ambulation. Administrative Nurse D stated she felt the care plan had incorrect documentation but stated staff should follow the care plan.
The facility's Fall and Fall Risk policy, dated 03/2018, documented based on previous evaluations and current data, the staff would identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falls.
The facility failed to follow R29's plan of care to ensure two staff for transfers, which resulted in a fall. This placed the resident at risk for further falls and preventable injury.
- R31's Electronic Medical Record (EMR) documented diagnoses of generalized anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear) disorder, major depressive disorder (major mood disorder which causes persistent feelings of sadness), nicotine dependence (an addictive organic compound found in tobacco plants), mild intellectual disabilities (a significantly below-average score on a test of mental ability or intelligence and by limitations in the ability to function in areas of daily life), bipolar disorder (major mental illness that caused people to have episodes of severe high and low moods), delusional disorders (untrue persistent belief or perception held by a person although evidence shows it was untrue), schizophrenia (mental disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought), vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), and acquired absence of left leg above knee.
The Annual Minimum Data Set (MDS) dated [DATE] documented R31's had a Brief Interview for Mental Status (BIMS) score of 13 which indicated intact cognition. R31 rejected cares four to six days of the observation period but not daily. She had no wandering during the observation period. The Behavioral Care Area Assessment documented R31 had diagnoses of schizophrenia, bipolar disorder, anxiety, psychosis, and mild intellectual disabilities; R31's behavior and noncompliance were chronic. The MDS recorded R31 had current tobacco use.
The Quarterly Minimum Data Set (MDS), dated [DATE], documented R31 had intact cognition with a BIMS of 14. She had no delirium (sudden severe confusion, disorientation and restlessness) or psychosis (any major mental disorder characterized by a gross impairment in reality perception). The MDS recorded R31 had no wandering or rejection of cares during the observation period, but she did exhibit physical and verbal behaviors directed toward others which occurred one to three days during the observation period. The MDS further documented R31 required partial/moderate assistance with sit to lying and lying to sitting and substantial/maximal assistance with chair to bed to chair transfers; R31 used a manual wheelchair. R31 received insulin (hormone that lowers the level of glucose in the blood), antipsychotic (class of medications used to treat major mental conditions which cause a break from reality), antianxiety (class of medications that calm and relax people), and antibiotic (medication to treat infections) on a routine basis. The question regarding current tobacco use on the MDS was unanswered.
R31's Care Plan, initiated on 02/17/21 and revised on 08/31/23 documented R31 had impaired cognition or thought processes due to dementia. The plan listed an intervention initiated on 07/13/21 and revised on 12/05/22 which documented R31 had tobacco use and would adhere to the tobacco and smoking policies of the facility. The care plan listed an intervention dated 07/13/21 which directed staff to conduct a smoking evaluation on admission and as needed; educate the resident and responsible party on the facility's tobacco and smoking policies.
R31's Care Plan further documented R31 had a history of hoarding behavior, dated 08/17/21 and directed staff to provide alternative activities to use for meaningful work/tasks and distraction. The plan further listed an intervention dated 03/25/22 which documented R31 had a history of going into other residents' rooms at times and directed staff to re-orient R31 as indicated.
R31's Smoking and Safety Evaluation dated 05/16/23, documented R31 did not demonstrate safe smoking behavior in interacting with peers and required an assistive device for smoking. Other risk level considerations included R31 had diagnoses of dementia/memory impairment. The team deemed R31 unsafe to smoke, therefore she required staff supervision for smoking.
R31's Smoking and Safety Evaluation dated 08/14/23, documented R31 used tobacco two to five times a day, morning, afternoon and evening. The assessment recorded R31 was not on a smoking cessation plan and was not interested in quitting. The assessment documented R31 understood the community safety rules and articulated an understanding of the danger of smoking near flammable materials or a resident wearing oxygen. According to the assessment, the team decided the resident could smoke with a safe smoking care plan. Due to R31's diagnosis of dementia/memory loss impairment and psychotropic medications use, staff would light the cigarette for R31.
A nurse's note in the Progress Notes section recorded on 06/29/23 R31 went into R43's room and took his cup of medication that was left in his room. Staff educated R31 on not going into another resident's room and that she cannot take medication that she does not get from staff.
The facility's Investigation report, dated 11/02/23, documented R31 had been smoking in the South hallway. R31 took cigarettes and a lighter from another resident's [R43] room and lit the cigarette in the hallway. Staff put the cigarette out. Staff informed R31's guardian that the resident's smoking privileges had been removed as R31 was unable to follow policy and was not safe to smoke. R31 denied taking cigarettes out of another resident room and did not realize what she did.
On 11/02/23 at 12:24 PM, observation revealed R31 sat in R43's room. R43 was in the bathroom and yelled at R31 to get out of his room stating that R31 was not to be in his room. R31 left the room stating she was confused and thought she was in her room.
On 11/02/23 at approximately 12:28 PM, R31 sat in the hallway outside the smoking room with a lit cigarette. Staff intervened immediately and put out the cigarette and retrieved the cigarettes and lighter which belonged to another resident.
On 11/06/23 at 09:47 AM Certified Medication Aide (CMA) S reported R31's smoking routine was she could get two cigarettes and her lighter every two hours.
On 11/07/23 at 10:30 AM, Licensed Nurse (LN) G stated R31 could no longer smoke because R31 was able to get cigarettes from someone else's room and lit up and smoked in the hallway. LN G stated occasionally R31's visitor would bring in lighters and R31 would stash them in her room. LN G reported R31 had been known to take things from R43's room in the past. LN G also reported the smoke room was not equipped with a camera.
On 11/07/23 at 11:27 AM Administrative Nurse D verified R31's smoking privileges were revoked because she obtained cigarettes and a lighter from another resident's room and lit a cigarette in the hallway. Administrative Nurse D provided documentation of notifying R31's physician of offering R31 Nicorette gum which was refused and requested nicotine patches. Administrative Nurse D verified the facility had not provided/offer R31 with alternative options with safe smoking practices.
The facility's Smoking Policy-Residents, dated 08/2022, documented the facility has established and maintains safe resident smoking practices. Prior to, and upon admission, residents are informed of the facility smoking policy, including designated resident smoking areas, and the extent to which the facility can accommodate their smoking or non-smoking preferences. Smoking, regardless of method of tobacco consumption is only permitted in designated resident smoking area. The facility may impose smoking restrictions on a resident at any time if it is determined that the resident cannot smoke safely with the available levels of supervision. Any resident with smoking privileges requiring monitoring shall have the direct supervision of a staff member, family member, visitor or volunteer worker at all times while smoking.
The facility failed to provide adequate supervision to R31, who had a history of taking unsafe items from R43's room, which allowed her to wander into R43's room, obtain smoking materials, and light a cigarette in the hall outside the smoking area. This deficeint practice placed R31 at risk for preventable accidents and injuries.

The facility had a census of 64 residents. The sample included 19 residents. Based on observation, interview, and record review, the facility failed to discard expired stock medication. These deficient practices placed the affected resident at risk for ineffective medications.
Findings included:
- On 11/01/2023 at 08:50 AM, observation of the medication cart for the Southwest hall revealed the following:
One bottle of Melatonin (sleep supplement,) 1 milligram (mg), 180 tablets, expired 06/2023
One bottle of Oyster shell calcium, 500 mg, 100 tablets, expired 07/2023
One bottle of Thera-M- multivitamin 100 caplets, expired 09/2023
On 11/01/23 at 08:55AM, Certified Medication Aide (CMA) R verified the nurses were to discard expired medications. CMA R said staff had recently went through the medications carts and stated the expired medications must have been missed.
On 11/02/23 at 8:30 AM, Administrative Nurse D verified the nurses should look at the stock bottles and verify the medication expiration date with each administration and discard expired medications.
The facility's Storage of Medications policy, dated November 2020, documented the facility shall store all drugs and biologicals in a safe, secure and orderly manner. Drug containers that have missing incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed.
The facility failed to dispose of expired medication placing the residents at risk for ineffective medication.

The facility had a census of 64 residents. Based on observation, interview, and record review the facility failed to provide adequate nutritional servings during a meal, as specified in the recipe. This deficient practice placed residents who received their meals from the facility kitchen at risk for inadequate nutrition.
Findings included:
- The facility's recipe from DiningRD.com for pureed Chicken Penne Pasta-No Bacon stated the portion size after the pureed process was a #6 dip (equal to 4.58 ounces). The recipe for regular diet Chicken Bacon Penne Pasta stated the portion size was an 8-ounce spoodle (cross between a serving spoon and a ladle).
On 11/02/23 at 11:20 AM, observation revealed Dietary Staff (DS) CC prepared pureed diets for three residents, including the following food:
Chicken alfredo with penne noodles: three one-half cups of the pasta, three-quarters of a cup chicken broth, and one tablespoon of thickener.
On 11/02/23 at 11:35 AM, observation revealed DS CC served meals from the steam table. She used a four-ounce gray colored scoop to dish up the chicken alfredo pasta for the pureed diets and a different four-ounce gray scoop to dish up the chicken alfredo pasta for the regular diets.
On 11/02/23 at 03:15 PM, DS BB verified staff did not provide the serving size at lunch as specified in the recipe for the chicken bacon pasta.
The facility's Kitchen Weights and Measures policy, dated April 2007, stated food services staff would be trained in proper use of cooking and serving measurements to maintain portion control. The policy stated staff would be trained in the appropriate measurement and type of serving utensil to use for each food. Signs or posters explaining coded measurement indicators on utensils would be prominently displayed for reference.
The facility failed to provide adequate nutritional servings during a meal, as specified in the recipe, placing residents who received their meals from the facility kitchen at risk for inadequate nutrition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 56 residents. The sample included 15 residents. Based on observation, record review and interview the facility failed to provide adequate supervision, security and maintain accurate records of narcotic pain medications (medications used to treat moderate to severe pain) for two sampled residents, Resident (R) 106 and R7. This placed the residents at risk for lack of pain control and misappropriation of medications.
Findings included:
- R106's Physician Order Sheet, dated 01/03/22, recorded diagnoses of end-stage ovarian cancer (late stages of cancer that is difficult to treat and can be fatal), end-stage renal disease (longstanding disease of the kidneys leading to renal failure), and chronic pain.
R106's admission Minimum Data Set (MDS), dated 11/12/21, documented the resident had a Brief Interview for Mental Status (BIMS) score of 15 (cognitively intact). The MDS documented R106 received scheduled and as needed (PRN) pain medications and received opioid medication (medication used to treat moderate to severe pain) seven days a week.
The Medication Care Plan, dated 01/07/22, recorded R106 received hospice services, had chronic pain, and directed staff to assess the resident's pain every shift. The Medication Care Plan directed staff to administer pain medications as ordered by the physician and monitor the effectiveness of the pain medications.
The Physician's Order, dated 11/08/21, directed staff to administer Percocet (opioid medication used to treat moderate to severe pain) 5 milligrams (mg)/325 mg every six hours PRN to R106 for severe pain.
The facility's investigation for Complaint #168992, dated 01/21/22, recorded on 01/20/22 at 02:00 PM, Licensed Nurse (LN) L was working on the Covid unit, received a 30 count bubble pack medication card of Percocet 5 mg/325 mg, and left the medication card unsecured and unsupervised on the nurse station counter. On 01/20/22 at 03:30 PM, LN L left the facility due to illness and was replaced on the Covid unit by Certified Nurse Aide (CNA) P. On 01/20/22 at 07:50 PM, Certified Medication Aide (CMA) R assessed R106 for pain, was not able to locate the medication card of Percocet and reported the missing medication to the charge nurse and Director of Nursing (DON). This incident was reported to law enforcement. LN L, CMA R, CNA P and Therapy Staff GG (provided therapy to a resident on the Covid unit during the time of the incident) completed witness statements and were interviewed by the police. The facility replaced R106's missing medication.
On 04/04/22 at 03:33 PM, Licensed Nurse (LN) K stated when narcotic medication was delivered to the facility, the nurse should enter the pertinent medication information and count onto a narcotic control sheet, and immediately secure the medication in the locked box on a secured medication cart.
On 04/05/22 at 09:33 AM, Administrative Nurse D stated the Percocet should have been supervised by the nurse until the narcotic count documentation was completed and the medication secured in the lock box of a secured medication cart.
The Controlled Substances Policy, dated April 2019, directed staff to enter all relevant information on a narcotic count sheet upon receipt of a controlled substance, and ensure access to controlled medications were locked at all times.
The facility failed to provide adequate supervision, security and maintain accurate records of narcotic pain medications for R106, placing the resident at risk for lack of pain control and misappropriation of medications.
- The electronic medical record (EMR) documented R7 had diagnoses of pain (physical suffering or discomfort caused by illness or injury), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and hypertension (high blood pressure).
The Quarterly Minimum Data Set (MDS), dated [DATE], documented R7 had intact cognition, independent with bed mobility, transfers and independent with set-up assistance with dressing, eating, toileting, and personal hygiene. R7 had scheduled pain medications and did not exhibit any complaints of pain.
The Pain Care Plan, dated 03/03/22, directed staff to evaluate the effectiveness of pain management, notify the physician if R7 had inadequate pain relief, provide pain medication as ordered, and utilize non-pharmacological interventions for pain relief.
The Pain Assessment, dated 11/12/21, documented the resident had a history of right shoulder pain and received as needed (PRN) hydrocodone (used to treat moderate to severe pain) without any side effects.
The Pain Assessment, dated 01/04/22 documented the resident did not have any pain.
The Physician's Order, dated 10/24/21, directed staff to administer hydrocodone, 5 milligrams (mg), one tablet, by mouth every six hours, prn for pain.
The Narcotic Inventory Count Verification Sheet, lacked documentation R7's hydrocodone medication was counted and verified to have 60 pills from 02/05/22 to 02/06/22.
The Investigation Report, dated 02/06/22, documented at approximately 12:30 AM, Certified Medication Aide (CMA) S and Licensed Nurse (LN) J counted the bottled hydrocodone for R7 and found that the bottle contained 50 pills instead of the 60 pills that were documented on the narcotic sign out sheet. LN J and CMA S recounted the pills and found the count was still not correct. LN J contacted Administrative Nurse E, the on call nurse, who then contacted Administrative Nurse D. At 08:30 AM, CMA O contacted Administrative Nurse D again that the hydrocodone medication for R7 did not look right and looked like Tylenol (a mild pain reliever). Administrative Nurse D arrived at the facility and counted all the narcotics and found no other discrepancies except for R7's hydrocodone. The local police department was notified and a report was made for the missing narcotics.
On 03/31/22 at 08:13 AM, observation revealed the narcotic sign out sheet for R7's hydrocodone medication. The hydrocodone medication was no longer in a bottle but packaged in a medication card and the 11 hydrocodone tablets matched the sign out sheet for the resident.
On 03/31/22 at 08:20 AM, CMA O stated the on 02/06/22, the night shift nurse had counted the hydrocodone medication with the CMA and that the pills did not look right. The pills had been packed into the bottle so tight that some of the pills broke in half. CMA O further stated the pills in the bottle looked like Tylenol. CMA O stated Administrative Nurse D called the police to fill out a report and that all the staff involved, including herself, were drug tested but was unsure of the outcome of the investigation. CMA O stated Administrative Nurse D or other nursing administrative staff would watch staff count the narcotics almost daily every shift.
On 04/05/22 at 09:35 AM, LN L stated R7 did not often complain of pain and did have prn pain medication. LN L further stated the off going nurse or CMA count with the oncoming nurse or CMA, and at this time, all the narcotic counts are correct.
On 04/05/22 at 10:30 AM, Administrative Nurse D verified R7's pain pills were not counted each shift by the nurses and medication aides. Administrative Nurse D stated she had completed daily audits for narcotic counts and recently changed the audits to weekly. Administrative Nurse D further stated she watched staff count the narcotics, have had meetings with nursing staff, and they have not been able to pinpoint when the hydrocodone was switched.
On 04/05/22 at 02:10 PM, CMA S stated, before she had left for a week, R7's hydrocodone count was correct with 60 pills in the bottle. When she returned and was back on the medication cart, she counted R7's hydrocodone with LN J and found 10 were missing and the pills were not hydrocodone. CMA S further stated LN J and herself recounted the pills several times and called Administrative Nurse D. CMA S stated Administrative Nurse D watched them count the pills every other day each shift.
The facility's Controlled Substances policy, dated April 2019, documented the controlled medications are
counted at the end of each shift. The nurse coming on duty and the nurse going off duty determine the count together. Any discrepancies in the controlled substance count are documented and reported to the director of nursing services immediately. The policy further documented, the director of nursing services investigates all discrepancies in controlled medication reconciliation to determine the cause and identify any responsible parties, and reports the findings to the administrator. The director of nursing services consults with the provider pharmacy and the administrator to determine whether further legal action was indicated.
The facility failed to maintain accurate medication records for R7 whose hydrocodone medication was switched for Tylenol, placing the resident at risk for uncontrolled pain.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 57 residents. The sample included 15 residents with two reviewed for hydration. Based on observation, interview, and record review the facility failed to clarify the order for fluid restriction, plan the amount of fluids per shift and meals, and thoroughly document the fluid amounts Resident (R) 36 consumed daily. This placed the resident at risk for consuming greater amounts of fluids than the physician considered safe for his health.
Findings included:
- R36's Physician Order Sheet (POS), dated 03/14/22, documented diagnoses of end stage renal disease (ESRD- medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life) requiring dialysis (the process of removing excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally), hypertension (high blood pressure), and heart failure (chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the body's needs).
The admission Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of five, indicating severely impaired decision-making skill. The MDS documented R36 was independent with eating, required limited assistance for hygiene, and extensive assistance of two staff for all other activities of daily living. R36 had no wound, no problems with swallowing, weighed 137 pounds, and received insulin, oxygen, and dialysis.
The Hydration Care Plan, dated 02/20/22, directed staff with the following information:
R36 on (Specify amount) cc per day fluid restriction.
Nursing to provide (specify amount)
Dietary to provide (specify amount)
Please remind and educate R36 on risks or benefits of compliance. Report to his physician if R36 chose not to comply. Monitor, document, and report as needed if R36 had any signs of dehydration ( harmful reduction in the amount of water in the body) or if he had new or worsening edema (swelling caused by excess fluid trapped in your body's tissues). Obtain and monitor R36''s labwork as ordered. Provide him as needed, lemon glycerin swabs, ice chips and/or moisturizer on his lips.
The Physician Order, dated 02/18/22, directed staff to provide fluid restriction of 1500 milliliters (ml) every shift (day, night).
Review of R36's Hydration Record, dated 03/07/22 to 04/02/22, revealed staff documented fluids two shifts per day, 300 ml to 2400 ml per day. On 04/03/22 and 04/04/22 staff documented only one shift per day.
R36's meal fluid intake documented separately and 17 days out of 30 (03/07/22 to 04/04/22) lacked fluid intake with all meals.
R36's weight record, dated 02/15/22 to 03/15/22, documented the resident gained seven pounds.
On 03/31/22 at 09:00 AM, observation revealed R36 in bed and independently drinking apple juice from a 240 ml glass without problems.
On 03/31/22 at 01:55 PM, observation revealed R36 in bed, leaning over by the bedside table and drinking independently from a 500 ml beverage mug.
On 04/04/22 at 09:55 AM, Certified Nurse Aide (CNA) M stated R36 had a fluid restriction of 1500 ml per day. She stated R36 monitored himself, and just requested ice and chewed on it throughout the day, but occasionally asked for extra soda or iced tea. CNA stated she documented fluid intake in POC (electronic record) and the directions in the POC stated 1500 ml every shift.
On 04/05/22 at 11:31 AM, Administrative Nurse D stated CNAs wrote fluid amounts on a board in the nurse's station or document in POC and at the end of the shift the nurses were to count the amount of fluids consumed. Administrative Nurse D verified the amount of fluids for each shift should be on the care plan. She verified the physician order for fluid restriction directed 1500 ml per shift needed to be clarified and verified missing documentation of R36's fluid intake.
The facility's Resident Hydration and Prevention of Dehydration policy, dated October 2017, documented physician orders to limit fluids would take priority over calculated fluid needs. The policy stated nurse aides would document intake in the medical records, nursing would monitor and document fluid intake, and the interdisciplinary team would update the care plan.
The failed to clarify the order for fluid restriction, care plan the amount of fluids per shift and meals, and thoroughly document the fluid amounts R36 consumed daily. This placed the resident at risk for consuming greater amounts of fluids than the physician considered safe for his health.

The facility had a census of 56 residents. The sample included 15 residents, with one reviewed for bladder and bowel incontinence. Based on observation, record review, and interview, the facility failed to develop a personalized toileting plan for R42 who had urinary incontinence (loss of bladder control), history of skin breakdown due to recently healed moisture associated skin damage (inflammation or skin erosion caused by prolonged exposure to a source of moisture such as urine) on the resident's buttocks, and a history of Urinary Tract Infections (UTI's - bladder infection). This deficient practice placed R42 at risk for UTIs and skin breakdown.
Findings included:
- The electronic medical record (EMR) documented R42 had diagnoses of vascular dementia without behavioral disturbance (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain) and chronic kidney disease (damaged kidneys that can't filter blood as they should).
The Significant Change Minimum Data Set (MDS), dated 02/10/22, documented R42 required extensive assistance of two staff for bed mobility, transfers, dressing, and toileting. The resident was frequently incontinent of bladder.
The Bladder and Bowel Assessment, dated 04/02/22, documented R42 had long and short term memory loss and would sometime asked to be toileted, had a history of UTIs, and was confined to a chair.
The Bladder and Bowel Incontinence Care Plan dated 04/02/22, directed staff to use one to two staff for toileting and hygiene, monitor for urinary tract infections, check for incontinence episodes every two hours and as needed, and apply moisture barrier after each incontinence episode.
Review of the EMR lacked documentation a three day voiding diary was obtained.
On 04/04/22 at 11:00 AM, observation revealed Certified Nurse Aide (CNA) M and CNA MM transferred R42 from the wheelchair to the toilet. The resident's wheelchair cushion was wet and the back of the resident's pants were soiled. R42's incontinent brief was heavily soiled with urine. CNA MM whispered to CNA M to clean the resident's wheelchair cushion and to get the resident a new pair of pants.
On 04/04/22 at 11:30 AM, CNA MM stated R42 incontinence brief was checked every two hours and she was taken to the bathroom.
On 04/05/22 at 11:00 AM, Administrative Nurse D stated R42 should be checked and toileted more frequently so she was not saturated in urine. Administrative Nurse D further stated the resident drinks a lot of fluids and they were going to do a three day voiding diary on the resident.
The facility's Urinary Incontinence policy, dated April 2018, documented the nursing staff would identify and document circumstances related to the incontinence and identify individuals with complications of existing incontinence such as skin maceration or breakdown. The document directed staff to provide scheduled toileting, prompted toileting, or other interventions to try to improve the individual's continence status.
The facility failed to obtain a three day voiding diary to personalize R42's toileting habits, placing her at risk for skin breakdown and UTI's.

The facility had a census of 57 residents. The sample included 15 residents with seven reviewed for pressure ulcers (injuries to skin and underlying tissue resulting from prolonged pressure on the skin). Based on observation, interview, and record review the facility failed to perform proper infection control during an open wound dressing change for Resident (R) 36. This placed R36 at risk for infection.
Findings included:
- On 03/31/22 at 10:47 AM, observation revealed Licensed Nurse (LN) H donned gloves, cleansed R36's left heel wound with wound cleanser and cotton, did not remove her soiled gloves, then applied a wound dressing to the open wound.
On 03/31/22 at 10:50 AM, LN H verified she had not removed her soiled gloves after cleansing R36's wound before applying the clean wound dressing and stated she should have changed her soiled gloves.
On 04/05/22 at 11:31 AM, Administrative Nurse D verified she expected staff to change gloves and wash hands between dirty and clean items or wound dressings and expected nurses to use disinfectant hand gel or wash hands when changing gloves.
The facility's Handwashing and Hand Hygiene policy, dated August 2019, directed all personnel to follow handwashing, hand hygiene procedures to help prevent the spread of infection. The policy directed staff to use an alcohol-based hand rub or soap and water for the following situations: Before handling clean or soiled dressings, gauze pads, etc., after handling used dressing, after removing gloves. The policy stated the use of gloves does not replace handwashing, hand hygiene.
The facility failed to perform proper infection control during an open wound dressing change for R36, placing him at risk for infection.

The facility had a census of 56. The sample included 15 residents. Based on observation, record review and interview the facility failed to ensure blood sugar parameters were provided to direct assessment, treatment and physician notification for one sampled resident, Resident (R) 32. This placed the resident at risk for adverse side effects from abnormal blood sugars and lack of physician oversight.
Findings included:
- R32's Physician Order Sheet, dated 03/02/22, recorded diagnoses of dementia (progressive mental disorder characterized by failing memory and confusion) and diabetes mellitus (disease that impairs the body's ability to regulate blood sugar).
R32's Quarterly Minimum Data Set (MDS), dated 02/16/22, documented the resident had a Brief Interview for Mental Status (BIMS) score of 11 (moderate cognitive impairment). The MDS documented R32 had a diagnosis of diabetes and received insulin (medication used to regulate blood sugar levels) injections seven days a week.
The Diabetic Care Plan, dated 03/07/22, directed staff to check R32's blood sugars as ordered by the physician, monitor for signs and symptoms of hyperglycemia (more than normal amount of sugar in the blood) and hypoglycemia (less than normal amount of sugar in the blood), and notify the physician as needed.
The Physician's Order, dated 11/16/21, directed staff to administer Tresiba insulin (slow acting medication to regulate blood sugars) ten units to R32 at bedtime.
The Physician's Order, dated 11/17/21, directed staff to administer Novolog insulin (fast acting medication to regulate blood sugars) four units to R32 before meals.
The Physician's Order, dated 02/09/22, directed staff to check R32's blood sugar levels before meals and at bedtime (06:30 AM, 11:00 AM, 05:00 PM, 08:00 PM).
Review of R32's medical record lacked documentation of physician ordered blood sugar parameters to direct staff to provide assessments, treatment, and physician notification for abnormal blood sugars.
R32's Medication Administration Record (MAR) for March 2022 recorded the following blood sugars with insulin administered and no documentation of assessment, treatment or physician notification:
03/03/22 at 07:30 AM - blood sugar 73 milligrams/deciliter (mg/dl)
03/12/22 at 07:30 AM - blood sugar 75 mg/dl
03/13/22 at 07:30 AM - blood sugar 67 mg/dl
03/14/22 at 07:30 AM - blood sugar 71 mg/dl
03/18/22 at 07:30 AM - blood sugar 76 mg/dl
03/24/22 at 07:30 AM - blood sugar 70 mg/dl
03/31/22 at 07:30 AM - blood sugar 67 mg/dl
R32's MAR for March 2022 recorded the following blood sugars with no documentation of assessment, treatment or physician notification:
03/06/22 at 08:00 PM - blood sugar 378 mg/dl
03/09/22 at 08:00 PM - blood sugar 350 mg/dl
03/14/22 at 08:00 PM - blood sugar 390 mg/dl
03/19/22 at 08:00 PM - blood sugar 379 mg/dl
03/26/22 at 08:00 PM - blood sugar 358 mg/dl
On 03/31/22 at 08:04 AM, observation revealed R32 sat in her wheelchair at the dining table and ate independently with staff supervision.
On 04/04/22 at 03:40 PM, Licensed Nurse (LN) K stated staff checked R32's blood sugar and administered insulin as ordered by the physician. LN K stated R32 did not have physician ordered blood sugar parameters to direct staff to provide assessments, treatments and physician notification for abnormal blood sugars.
On 04/05/22 at 08:52 AM, Administrative Nurse D stated R32 should have physician ordered blood sugar parameters to direct cares and physician notification of abnormal blood sugars.
The facility's Obtaining Glucose Level policy, dated October 2011, directed staff to check blood sugar levels as ordered by the physician, assess residents with abnormal blood sugars, notify the physician as directed, and monitor the effectiveness of treatment interventions.
The facility failed to provide physician ordered blood sugar parameters to direct assessment, treatment and physician notification for R32. This placed the resident at risk for adverse side effects from abnormal blood sugars and lack of physician oversight.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 57 residents. The sample included 15 residents. Based on observation, interview, and record review the facility failed to revise Resident (R) 36's care plan to include the amount of fluids to be given each shift and from each source. This placed R36 at risk to not receive interventions designed to limit his fluid intake.
Findings included:
- R36's Physician Order Sheet (POS), dated 03/14/22, documented diagnoses of end stage renal disease (ESRD- medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life) requiring dialysis (the process of removing excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally), hypertension (high blood pressure), and heart failure (chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the body's needs).
The admission Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of five, indicating severely impaired decision-making skill. The MDS documented R36 was independent with eating, required limited assistance for hygiene, and extensive assistance of two staff for all other activities of daily living. R36 had no skin issues, no problems with swallowing, weighed 137 pounds, and received insulin, oxygen, and dialysis.
The Hydration Care Plan, dated 02/20/22, directed staff with the following information:
R36 on (Specify amount) cc per day fluid restriction.
Nursing to provide (specify amount)
Dietary to provide (specify amount)
Please remind and educate R36 on risks or benefits of compliance. Report to his physician if R36 chose not to comply. Monitor, document, and report as needed if R36 had any signs of dehydration ( harmful reduction in the amount of water in the body) or if he had new or worsening edema (swelling caused by excess fluid trapped in your body's tissues). Obtain and monitor R36's labwork as ordered. Provide him as needed, lemon glycerin swabs, ice chips and/or moisturizer on his lips.
The Physician Order, dated 02/18/22, directed staff to provide fluid restriction of 1500 milliliters (ml) every shift (day, night).
Review of R36's Hydration Record, dated 03/07/22 to 04/02/22, revealed staff documented fluids two shifts per day, 300 ml to 2400 ml per day. On 04/03/22 and 04/04/22 staff documented only one shift per day.
R36's meal fluid intake documented separately and 17 days out of 30 (03/07/22 to 04/04/22) lacked fluid intake with all meals.
R36's weight record, dated 02/15/22 to 03/15/22, documented the resident gained seven pounds.
On 03/31/22 at 01:55 PM, observation revealed R36 in bed, leaning over by the bedside table and drinking independently from a 500 ml beverage mug.
On 04/04/22 at 09:55 AM, Certified Nurse Aide (CNA) M stated R36 had a fluid restriction of 1500 ml per day. She stated R36 monitored himself, and just requested ice and chewed on it throughout the day, but occasionally asked for extra soda or iced tea. CNA stated she documented fluid intake in POC (electronic record) and the directions in the POC stated 1500 ml every shift.
On 04/05/22 at 11:31 AM, Administrative Nurse D stated CNAs write fluid amounts on a board in the nurse's station or document in POC and at the end of the shift the nurses were to count the amount of fluids consumed. Administrative Nurse D verified the amount of fluids for each shift should be on the care plan. She verified the physician order for fluid restriction directed 1500 ml per shift, it needed to be clarified, and verified missing documentation of R36's fluid intake.
The facility's Resident Hydration and Prevention of Dehydration policy, dated October 2017, documented physician orders to limit fluids would take priority over calculated fluid needs. The policy stated nurse aides would document intake in the medical records, nursing would monitor and document fluid intake, and the interdisciplinary team would update the care plan.
The facility failed to care plan the amount of fluids per shift and meals for R36. This placed the resident at risk at risk to not receive interventions designed to limit his fluid intake.

The facility had a census of 57 residents. The sample included 15 residents with four reviewed for Beneficiary Notices. Based on record review and interview the facility failed to inform Resident (R) 17, R38, R42, and R48 or their representative of the monetary cost to stay in the facility after Medicare Part A services ended. This deficient practice placed the four residents at risk to make an uninformed decision regarding the cost of their continued stay.
Findings included:
- R17's skilled services ended 03/21/22. The facility provided R17 the Advance Beneficiary Notice (ABN) form, Center for Medicaid Medicare Services (CMS)-R-131, without documenting the specific monetary amount it would cost R17 to continue staying in the facility. The form documented R17 chose option 2- I want Medicare Part A, physical therapy, occupational therapy, facility room and board, pharmacy and ancillary services.
R38's skilled services ended 01/01/22. The facility provided R38 the Advance Beneficiary Notice (ABN) form, Center for Medicaid Medicare Services (CMS)-R-131, without documenting the specific monetary amount it would cost R38 to continue staying in the facility. The form documented R38 chose option 2- I want Medicare Part A, physical therapy, occupational therapy, facility room and board, pharmacy and ancillary services.
R42's skilled services ended 12/21/21. The facility provided R42 the Advance Beneficiary Notice (ABN) form, Center for Medicaid Medicare Services (CMS)-R-131, without documenting the specific monetary amount it would cost R42 to continue staying in the facility. The form documented R42 chose option 2- I want Medicare Part A, physical therapy, occupational therapy, facility room and board, pharmacy and ancillary services. Further information revealed R42 chose Hospice services instead.
R48's skilled services ended 03/29/22. The facility provided R48 the Advance Beneficiary Notice (ABN) form, Center for Medicaid Medicare Services (CMS)-R-131, without documenting the specific monetary amount it would cost R42 to continue staying in the facility. The form documented R48 chose option 2- I want Medicare Part A, physical therapy, occupational therapy, facility room and board, pharmacy and ancillary services.
The Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) provides information to residents/beneficiaries so that they can decide if they wish to continue receiving the skilled services that may not be paid for by Medicare and assume financial responsibility. The facility must provide form CMS-10055, to inform the beneficiary of his or her potential liability for payment if the resident elects to stay in the facility.
The facility's Medicare Advanced Beneficiary Notice policy, dated April 2021, documented the facility would notify the resident in writing of the potential liability for payment of non-covered services and issue the SNFABN (CMS form 10055) to the resident prior to providing care that Medicare usually covers, but may not pay for because the care is considered not medically reasonable and necessary, or custodial. The policy stated the resident may choose to continue receive the skilled services and assume financial responsibility.
On 04/05/22 at 12:50 PM, Social Services Staff X verified the specific monetary estimate was not provided to the four residents and stated she was unaware the CMS form 10055 was to be used instead of the CMS form R 131. She verified all four residents stayed in the facility.
The facility failed to fully inform R17, R38, R42, and R48 or their representative of the liability or cost of their continued stay in the facility after Medicare Part A services ended. This deficient practice placed the four residents at risk to make an uninformed decision regarding the cost of their continued stay.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 56 residents. The sample included 15 residents, with seven reviewed for pressure ulcers. Based on observation, record review, and interview, the facility failed to prevent the development of a suspected deep tissue injury (an injury to the soft tissue under the skin due to pressure and is usually over a bony prominence) for one sampled resident, Resident (R) 44. This placed the resident at risk for further skin breakdown.
Findings included:
- The electronic medical record (EMR) documented R44 had diagnoses of contracture of the left hand (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to the deformity and rigidity of joints), vascular dementia without behavioral disturbance (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear).
The Quarterly Minimum Data Set (MDS), dated [DATE], documented R44 had moderately impaired cognition and required limited assistance of one staff for transfers, ambulation, toileting, and extensive assistance of one staff for dressing and personal hygiene. R44 was at risk for pressure ulcers, had no skin breakdown, and did not wear a splint.
The Braden Scale Assessment, dated 02/21/22, documented R44 was at risk for skin breakdown.
The Pressure Ulcer Care Plan, revised 04/05/22, originally dated 05/20/21, directed staff to inspect R44's skin weekly and as needed, evaluate and monitor for pressure ulcer potential every three months and as needed. An intervention, dated 02/24/22, directed staff to check the splint placement to his left hand every shift and monitor for skin breakdown. An intervention, dated 02/25/22, directed staff to monitor nutritional status, administer treatments as ordered, and monitor for effectiveness. Assess wound healing weekly and as needed, follow facility policies and protocols for the prevention/treatment of skin breakdown, and inform the resident/family/caregivers of any new areas of skin breakdown.
The Nurse's Note, dated 02/11/22 at 10:29 PM, documented R44 did not want to put the splint on his left hand because it was making his hand sore.
The Skin Alteration Evaluation Sheet, dated 02/24/22, documented the resident had a deep tissue injury on his fifth finger on his left hand with no drainage or pain. The sheet further documented the area measured 1.5 centimeter (cm) x 0.5 cm and was caused due to the splint rubbed his finger.
A Physician's Order, dated 02/26/22, directed staff to apply skin prep (forms a protective film or barrier) on the resident's finger daily.
The Skin Alteration Evaluation Sheet, dated 03/03/33, documented R44 had a suspected deep tissue injury to his left fifth finger which measured 1.5 cm x 0.5 cm.
A Physician's Order, dated 03/06/22, directed staff to not apply the splint until the pressure sore was resolved.
A Physician's Order, dated 03/15/22, directed staff to use a therapy carrot hand contracture appliance in R44's left hand at night.
The Skin Alteration Evaluation Sheet, dated 03/17/22, documented R44 had a suspected deep tissue injury which measured 1.2 cm x 1.8 cm, appeared deep purple and non blanchable (discoloration of the skin that does not turn white when pressed).
The Skin Alteration Evaluation Sheet, dated 03/24/22, documented R44 had a suspected deep tissue injury which measured 1.2 cm x 2.1 cm.
A Physician's Order, dated 03/29/22, directed staff to give R44 liquid protein, 30 milliliters (ml) daily, for skin integrity.
The Skin Alteration Evaluation Sheet, dated 03/31/22, documented R44 had a suspected deep tissue injury which measured 1.1 cm x 2.2 cm, continued to be deep purple in color and non-blanchable.
On 03/31/22 at 08:20 AM, observation revealed R44's left fifth digit was purple in color from the tip of his finger almost to the first joint.
On 04/05/22 at 07:55 AM, observation revealed Licensed Nurse (LN) H took a skin prep pad and wiped around R44s left fifth joint. The sore area was still purple and had not opened yet.
On 03/30/22 at 02:05 PM, R44 stated he had never had sores from his splint before and doesn't use the splint anymore because it had rubbed against his finger.
On 04/05/22 at 07:55 AM, LN H stated the deep tissue injury was from the splint rubbing against R44's finger. LN H further stated she did not know if staff checked the resident's hand for skin breakdown when the splint was removed daily.
On 04/05/22 at 11:00 AM, Administrative Nurse D stated staff should have been checking R44's skin underneath the splint for breakdown, especially when the resident stated his hand hurt from the splint.
On 04/05/22 at 02:00 PM, Certified Nurse Aide (CNA) NN stated she did not check R44's skin prior to putting the splint on the resident's hand, the nurses would do that. CNA NN further stated R44 does not wear the splint anymore because he had an area on his finger that was sore.
The facility's Pressure Ulcers/Skin Breakdown policy, dated April 2018, documented the nursing staff and practitioner would assess and document an individual's significant risk factors for developing pressure ulcers, for example, immobility, recent weight loss, and a history of pressure ulcers, the physician would help identify factors contributing or predisposing resident to skin breakdown. Any nutritional supplementation should be based on realistic appraisal of an individual's current national status.
The facility failed to prevent a suspected deep tissue injury to R44's left digit from a splint, placing the resident at risk for further skin breakdown.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 57 residents. The sample included 15 residents. Based on observation, interview, and record review the facility failed to dispose of one expired insulin (medication used to regulate blood sugar levels) pen for Resident (R) 36, in one of four facility medication carts. This deficient practice placed R36 at risk to receive expired, ineffective insulin.
Findings included:
- On [DATE] at 08:31 AM, Licensed Nurse (LN) G opened the south hall nurse medication cart and observation revealed one Aspart insulin pen, dated as opened [DATE], for Resident (R) 36.
On [DATE] at 08:31 AM, LN G verified the Aspart insulin pen was expired and should have been disposed of [DATE].
The Aspart insulin directions for storage documented after use Keep at room temperature (below 86 o F) or refrigerated for up to 28 days. Keep away from direct heat and light and dispose after 28 days.
The facility's Insulin Administration policy, dated [DATE], directed staff to check the expiration date of the insulin and follow manufacturer's recommendations for expiration after opening.
The facility failed to dispose of an expired insulin in a timely manner. This deficient practice placed R36 at risk to receive expired, ineffective insulin.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 56 residents. The sample included 15 residents with five reviewed for unnecessary medications. Based on observation, record review and interview, the facility failed to ensure an appropriate diagnosis for the use of an antipsychotic medication (medications used to treat significant mental health problems) for one sampled resident, Residents (R) 54. This placed R54 at risk to receive unnecessary antipsychotic medications and adverse medication side effects.
Findings included:
- The Physician Order Sheet, dated 01/06/22, recorded R54 had diagnoses of dementia with behaviors (persistent mental disorder marked by memory loss and impaired reasoning), depression (mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety (mental health disorder characterized by worry and fear that interferes with daily life), and insomnia (difficulty sleeping).
The Quarterly Minimum Data Set (MDS), dated [DATE], recorded R54 had a Brief Interview for Mental Status (BIMS) score of two (severe cognitive impairment) and no behaviors. The MDS recorded R54 transferred and walked independently and received scheduled antipsychotic medication and antidepressant medication (medication used to treat moods and symptoms associated with depression) seven days a week.
The Medication Care Plan, dated 02/10/22, recorded R54 received Risperdal (antipsychotic medication) with a Black Box Warning (highest safety-related warning that medications can have assigned by the Food and Drug Administration) that recorded the medication was not approved for treatment of elderly patients with dementia, and side effects increased mortality. The Medication Care Plan directed staff to monitor R54 and report life-threatening side effects to the physician.
The Physician's Order, dated 11/29/21, directed staff to administer Risperdal (antipsychotic medication used to treat severe behavior problems) 0.5 milligrams (mg) at bedtime to R54 for dementia with behaviors.
R54's Medication Administration Record (MAR) directed staff to monitor and record the following behaviors each shift due to the resident's use of Risperdal: yelling, agitation, hallucinations, combative and refusing care. The MARs, dated October 2021, November 2021, December 2021, January 2022, February 2022 and March 2022, recorded R54 exhibited none of the listed behaviors.
The Pharmacist Medication Reviews, dated 12/17/21, 01/17/22, 02/21/22, and 03/22/21, lacked documentation the pharmacist addressed the inappropriate diagnosis of dementia with behaviors for R54's use of Risperdal.
On 04/04/22 at 07:58 AM, observation revealed R54 walked independently to the dining room, made food and drink choices, conversed with other residents and staff, and had no behaviors.
On 04/04/22 at 01:27 PM, Licensed Nurse (LN) I stated R54 had severe cognitive impairment due to dementia, was resistive to cares at times, and the resident's occasional behaviors were easily directed.
On 04/04/22 at 01:41 PM, Certified Nurse Aide (CNA) N stated R54 was pleasantly confused, wandered at times but was easily redirected, and the resident had no combative behaviors.
On 04/05/22 at 09:32 AM, Administrative Nurse D stated dementia with behaviors was an inappropriate diagnosis for R54's use of Risperdal.
The facility's Medication Regimen Review policy, dated May 2019, directed staff to ensure medications had an appropriate diagnosis, and monitor medications for adverse side effects.
The facility failed to ensure an appropriate diagnosis for the use of an antipsychotic medication for R54, placing the resident at risk to receive unnecessary antipsychotic medications and adverse medication side effects.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 56 residents. The sample included 15 residents with five reviewed for unnecessary medications. Based on observation, record review, and interview the facility failed to provide physician ordered blood sugar parameters for two sampled residents, Resident (R) 32 and R3. This placed the residents at risk for abnormal blood sugars and lack of physician oversight.
Findings included:
- R32's Physician Order Sheet, dated 03/02/22, recorded diagnoses of dementia (progressive mental disorder characterized by failing memory and confusion), and diabetes mellitus (disease that impairs the body's ability to regulate blood sugar).
R32's Quarterly Minimum Data Set (MDS), dated 02/16/22, documented the resident had a Brief Interview for Mental Status (BIMS) score of 11 (moderate cognitive impairment). The MDS documented R32 had a diagnosis of diabetes and received insulin (medication used to regulate blood sugar levels) injections seven days a week.
The Diabetic Care Plan, dated 03/07/22, directed staff to check R32's blood sugars as ordered by the physician, monitor for signs and symptoms of hyperglycemia (more than normal amount of sugar in the blood) and hypoglycemia (less than normal amount of sugar in the blood), and notify the physician as needed.
The Physician's Order, dated 11/16/21, directed staff to administer Tresiba insulin (slow acting medication to regulate blood sugars) ten units to R32 at bedtime.
The Physician's Order, dated 11/17/21, directed staff to administer Novolog insulin (fast acting medication to regulate blood sugars) four units to R32 before meals.
The Physician's Order, dated 02/09/22, directed staff to check R32's blood sugar levels before meals and at bedtime (06:30 AM, 11:00 AM, 05:00 PM, 08:00 PM).
Review of R32's medical record lacked documentation of physician ordered blood sugar parameters to direct staff to provide assessments, treatment and physician notification for abnormal blood sugars.
On 03/31/22 at 08:04 AM, observation revealed R32 sat in her wheelchair at the dining table and ate independently with staff supervision.
On 04/04/22 at 03:40 PM, Licensed Nurse (LN) K stated staff checked R32's blood sugar and administered insulin as ordered by the physician. LN K stated R32 did not have physician ordered blood sugar parameters to direct staff to provide assessments, treatments and physician notification for abnormal blood sugars.
On 04/05/22 at 08:52 AM, Administrative Nurse D stated R32 should have physician ordered blood sugar parameters to direct cares and physician notification of abnormal blood sugars.
The facility's Obtaining Glucose Level policy, dated October 2011, directed staff to check blood sugar levels as ordered by the physician, assess residents with abnormal blood sugars, notify the physician as directed, and monitor the effectiveness of treatment interventions.
The facility failed to provide physician ordered blood sugar parameters for R32, placing the resident at risk for abnormal blood sugars and lack of physician oversight.
- R3's Physician Order Sheet (POS), dated 03/14/22, documented diagnoses including diabetes, and diabetic peripheral angiopathy (blood vessel disease caused by high blood sugar levels.
The Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) of 14, indicating intact cognition. The MDS documented R3 independent with eating, bed mobility, locomotion, required supervision for hygiene, toileting, transfers, and limited staff assistance for dressing. The MDS documented R3 received insulin (hormone that lowers the level of sugar in the blood) seven days of the lookback period.
The Diabetes Care Plan, dated 03/28/22, directed staff to obtain fasting (not having anything to eat or drink (except water) for at least eight hours) blood sugar levels as ordered by the doctor. Provide diabetes medication, blood sugar checks, labwork as ordered, notify the physician as requested of the results, and any adverse drug reactions.
The Physician Order, dated 10/15/21, directed staff to administer the following insulin:
Lispro (fast acting insulin), 10 units, three times daily.
Levemir (long acting insulin), 25 units at bedtime.
Review of R3's medical record revealed no physician orders for blood sugar checks or parameters to determine when to notify the physician of blood sugar levels.
R3's March 2022 Medication Administration Record revealed staff documentation of blood sugars ranging from 80 to 298 milligrams per deciliter (mg/dL) (normal is 70-110 mg/dL).
On 03/31/22 at 07:40 AM, observation revealed Certified Medication Aide (CMA) R administered medication to R3 who was in bed and took the medications whole with a few sips of water.
On 04/04/22 at 09:42 AM, Licensed Nurse (LN) G stated the resident did not have physician ordered blood sugar parameters for physician notification or holding of insulin. She stated R3's blood sugar levels were fairly steady and did not get too high or too low.
On 04/05/22 at 11:31 AM, Administrative Nurse D stated R3's blood sugar check order was included with the insulin order per facility standards. Administrative Nurse D stated if the physician requested accuchecks other than when insulin was ordered it would be in a specific order. Administrative Nurse D verified the lack of physician ordered blood sugar checks and parameters.
The facility's Obtaining a Fingerstick Glucose Level policy, dated October 2011, directed staff to verify there is a physician order for this procedure. The policy did not address parameters for determining when to notify the physician.
The facility failed to obtain physician orders for blood sugar checks and parameters for physician notification of abnormal blood sugars. This deficient practice placed R3 at risk for lack of physician oversight.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 56 residents. The sample included 15 residents with five reviewed for unnecessary medications. Based on observation, record review and interview, the facility failed to ensure the Consultant Pharmacist identified and reported to the Director of Nursing (DON), medical director, or physician about the lack of physician ordered blood sugar parameters for Resident (R) 32 and R3, and an inappropriate diagnosis for the use of an antipsychotic medication (medication used to treat significant mental health problems) for R54. This placed the residents at risk for adverse side effects related to abnormal blood sugars and antipsychotic medications.
Findings included:
- R32's Physician Order Sheet, dated 03/02/22, recorded diagnoses of dementia (progressive mental disorder characterized by failing memory and confusion) and diabetes mellitus (disease that impairs the body's ability to regulate blood sugar).
R32's Quarterly Minimum Data Set (MDS), dated 02/16/22, documented the resident had a Brief Interview for Mental Status (BIMS) score of 11 (moderate cognitive impairment). The MDS documented R32 had a diagnosis of diabetes and received insulin (medication used to regulate blood sugar levels) injections seven days a week.
The Diabetic Care Plan, dated 03/07/22, directed staff to check R32's blood sugars as ordered by the physician, monitor for signs and symptoms of hyperglycemia (more than normal amount of sugar in the blood) and hypoglycemia (less than normal amount of sugar in the blood), and notify the physician as needed.
The Physician's Order, dated 11/16/21, directed staff to administer Tresiba insulin (slow acting medication to regulate blood sugars) ten units to R32 at bedtime.
The Physician's Order, dated 11/17/21, directed staff to administer Novolog insulin (fast acting medication to regulate blood sugars) four units to R32 before meals.
The Physician's Order, dated 02/09/22, directed staff to check R32's blood sugar levels before meals and at bedtime (06:30 AM, 11:00 AM, 05:00 PM, 08:00 PM).
R32 was admitted to the facility on [DATE] and review of R32's medical record lacked documentation of physician ordered blood sugar parameters to direct staff to provide assessments, treatment and physician notification for abnormal blood sugars.
The Pharmacist Medication Reviews, dated 12/17/21, 01/17/22, 02/21/22, and 03/22/21, lacked documentation the pharmacist addressed R32 not having physician ordered blood sugar parameters.
On 03/31/22 at 08:04 AM, observation revealed R32 sat in her wheelchair at the dining table and ate independently with staff supervision.
On 04/04/22 at 03:40 PM, Licensed Nurse (LN) K stated staff checked R32's blood sugar and administered insulin as ordered by the physician. LN K stated R32 did not have physician ordered blood sugar parameters to direct staff to provide assessments, treatments and physician notification for abnormal blood sugars.
On 04/05/22 at 08:52 AM, Administrative Nurse D stated the consultant pharmacist had not addressed R32 not having physician ordered blood sugar parameters to direct cares and physician notification of abnormal blood sugars.
The facility's Medication Regimen Review policy, dated April 2019, directed the consultant pharmacist to address inadequate monitoring of medication effectiveness and adverse consequences.
The facility failed to ensure the Consultant Pharmacist identified and reported to the DON, medical director, or physician R32's lack of physician ordered blood sugar parameters, placing the resident at risk for adverse side effects related to abnormal blood sugars.
- The Physician Order Sheet, dated 01/06/22, recorded R54 had diagnoses of dementia with behaviors (persistent mental disorder marked by memory loss and impaired reasoning), depression (mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety (mental health disorder characterized by worry and fear that interferes with daily life), and insomnia (difficulty sleeping).
The Quarterly Minimum Data Set (MDS), dated [DATE], recorded R54 had a Brief Interview for Mental Status (BIMS) score of two (severe cognitive impairment) and no behaviors. The MDS recorded R54 transferred and walked independently and received scheduled antipsychotic medication and antidepressant medication (medication used to treat moods and symptoms associated with depression) seven days a week.
The Medication Care Plan, dated 02/10/22, recorded R54 received Risperdal (antipsychotic medication) with a Black Box Warning (highest safety-related warning that medications can have assigned by the Food and Drug Administration) that recorded the medication was not approved for treatment of elderly patients with dementia, and side effects increased mortality. The Medication Care Plan directed staff to monitor R54 and report life-threatening side effects to the physician.
The Physician's Order, dated 11/29/21, directed staff to administer Risperdal (antipsychotic medication used to treat severe behavior problems) 0.5 milligrams (mg) at bedtime to R54 for dementia with behaviors.
R54's Medication Administration Record (MAR) directed staff to monitor and record the following behaviors each shift due to the resident's use of Risperdal: yelling, agitation, hallucinations, combative and refusing care. The MARs, dated October 2021, November 2021, December 2021, January 2022, February 2022 and March 2022, recorded R54 exhibited none of the listed behaviors.
The Pharmacist Medication Reviews, dated 12/17/21, 01/17/22, 02/21/22, and 03/22/22, lacked documentation the pharmacist addressed the inappropriate diagnosis of dementia with behaviors for R54's use of Risperdal.
On 04/04/22 at 07:58 AM, observation revealed R54 walked independently to the dining room, made food and drink choices, conversed with other residents and staff, and had no behaviors.
On 04/05/22 at 09:32 AM, Administrative Nurse D stated the Consultant Pharmacist had not addressed R54's inappropriate diagnosis for the use of Risperdal.
The facility's Medication Regimen Review policy, dated April 2019, directed the consultant pharmacist to address inadequate monitoring of medication effectiveness and adverse consequences.
The facility failed to ensure the Consultant Pharmacist identified and reported to the DON, medical director, or physician R54's inappropriate diagnosis for the use of an antipsychotic medication, placing the resident at risk for adverse side effects related to antipsychotic medications.
- R3's Physician Order Sheet (POS), dated 03/14/22, documented diagnoses including diabetes and diabetic peripheral angiopathy (blood vessel disease caused by high blood sugar levels.
The Quarterly Minimum Data Set (MDS), dated [DATE] , documented a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The MDS documented R3 independent with eating, bed mobility, locomotion, required supervision for hygiene, toileting, transfers, and limited staff assistance for dressing. The MDS documented R3 received insulin (hormone that lowers the level of sugar in the blood)seven days of the lookback period.
The Diabetes Care Plan, dated 03/28/22, directed staff to obtain fasting (not having anything to eat or drink (except water) for at least eight hours) blood sugar levels as ordered by the doctor. Provide diabetes medication, blood sugar checks, labwork as ordered, notify the physician as requested of the results, and any adverse drug reactions.
The Physician Order, dated 10/15/21, directed staff to administer the following insulin:
Lispro (fast acting insulin), 10 units, three times daily.
Levemir (long acting insulin), 25 units at bedtime.
Review of R3's medical record revealed no physician orders for blood sugar checks or parameters to determine when to notify the physician of blood sugar levels.
R3's March 2022 Medication Administration Record revealed staff documentation of blood sugars ranging from 80 to 298 milligrams per deciliter (mg/dL) (normal is 70-110 mg/dL).
Pharmacist Reviews on 10/18/21, 11/28/21, 12/17/21, 01/06/22, 02/15/22, and 03/21/22 lacked notation for the lack of physician orders for blood sugar monitoring or parameters.
On 03/31/22 at 07:40 AM, observation revealed Certified Medication Aide (CMA) R administered medication to R3 who was in bed and took the medications whole with a few sips of water.
On 04/04/22 at 09:42 AM, Licensed Nurse (LN) G stated R3 did not have physician ordered blood sugar parameters for physician notification or holding of insulin. She stated R3's blood sugar levels were fairly steady and did not get too high or too low.
On 04/05/22 at 11:31 AM, Administrative Nurse D stated R3's blood sugar check order was included with the insulin order per facility standards. Administrative Nurse D stated if the physician requested accuchecks other than when insulin was ordered it would be in a specific order. Administrative Nurse D verified the lack of physician ordered blood sugar checks and parameters and verified the Consultant Pharmacist had not notified her of the lack of physician orders for blood sugar checks or parameters.
The facility's Obtaining a Fingerstick Glucose Level policy, dated October 2011, directed staff to verify there is a physician order for this procedure. The policy did not address parameters for determining when to notify the physician.
The facility's Medication Regimen Reviews policy, dated May 2019, documented the consultant pharmacist would perform a medication regimen review monthly to prevent, identify, report and resolve medication related problems, errors, and other irregularities. The consultant pharmacist would provide the director of nursing services and medical director with a copy of all medication regimen reports.
The facility failed to ensure the Consultant Pharmacist identified and reported to the Director of Nursing, medical director, or the physician, the lack of physician orders for blood sugar checks and parameters for physician notification of abnormal blood sugars. This deficient practice placed R3 at risk for lack of physician oversight.