Advanced Health Care Of Overland Park

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 38 residents. The sample included six residents with three residents reviewed for abuse/neglect. Based on record review and interviews, the facility failed to conduct a complete investigation to rule out abuse and neglect after receiving allegations from representatives for Resident (R) 1 and R2. Findings included:- R1 admitted to the facility on [DATE] and discharged to home on [DATE]. R2 admitted to the facility on [DATE] and transferred to the hospital on [DATE]. Review of the facility's notifications to the State Agency (SA) revealed the following: The facility reported intake number 2715968 to the SA on 01/13/26. The intake documented on 01/12/26 at 03:00 PM. The facility received an email from R1's representative that on 01/12/26 between the hours of 02:00 AM and 03:00 AM, R1 put on her call light to request urgent medical assistance, and staff failed to respond in a timely manner. As a result, R1 remained unattended while in acute physical distress and R1 told her representative in the morning when she called. The facility talked to R1 and she did not remember what time she vomited. The facility did not provide a copy of a completed investigation to the State Agency or to the onsite surveyor as requested on 02/26/26. The facility reported intake number 2744352 to the SA on 02/16/26. The intake documented on 01/31/26, R2 had a clogged catheter and staff pushed R2 into the lobby for discharge, so a new admission could have R2's room. R2's representative canceled transportation for his discharge and R2 went to the hospital at his representative's request. The facility did not provide a copy of a completed investigation to the State Agency or to the onsite surveyor as requested on 02/26/26. Upon request for the completed investigations into 2715968 and 2744352, the facility provided only staff witness statements. On 02/26/26 at 01:08 PM, Administrative Nurse D stated R1's representative said the facility neglected R1 when she threw up at night. She stated due to R1's representative's insistence that R1 threw up and staff did not chart on it, she reported the allegation to the SA. Administrative Nurse D stated she reported R2's representative's concerns with his discharge and catheter. On 02/26/26 at 02:16 PM, Administrative Nurse D stated R1's representative emailed her directly and she reported the allegations. She stated she tracked down staff that worked for three days prior to the alleged date to make sure R1 did not throw up on a different night. Administrative Nurse D stated she spoke to R1 and reviewed her chart. She stated she let Administrative Staff A know the investigation was ready to go with the witness statements in a folder. She stated she followed up with a couple of other residents regarding the allegations but did not fill out any documentation. She stated she finished her part of R1's investigation within a couple of days, then let Administrative Staff A know she was finished because she thought the facility only had a certain amount of time for an investigation. Administrative Nurse D stated R2's representative emailed Administrative Staff A with her allegations. She stated she reached out to two nurses who were mentioned in the complaint and got their recollection of events. She stated Administrative Staff A looked at the cameras for R2's discharge. She stated she did not submit the completed investigations for R1 or R2 to the SA. On 02/26/26 at 02:22 PM, Administrative Staff A stated R1's representative reported R1 vomited, and the facility did not clean the vomit up. He stated he checked R1's room and it looked fine and did not smell. He stated R1's representative escalated the concerns later with more complaints. Administrative Staff A stated Administrative Nurse D interviewed staff and he assumed Administrative Nurse D sent the investigation to the SA. He stated he did not send the completed investigation to the SA on R1. He stated the facility had five working days to send the completed investigation to the SA. Administrative Staff A stated he received notification that R2's representative was not happy with catheter care, and she believed he was left in distress in the hallway during discharge. He notified Administrative Nurse D, who reviewed R2's catheter care notes and did not find any issues. Administrative Staff A stated he reviewed the video and R2 was not in distress and was always supervised. He stated he completed a brief note on the video but that was all he did on the investigation. Administrative Staff A stated he did not send the completed investigation on R2 because he thought Administrative Nurse D did that one. The facility's Abuse Policy and Procedure, not dated, directed the Administrator or Director of Nursing (DON) completed an investigation of the incident including a written summary of the findings no later than five working days of the reported occurrence. The summary included interview notes; incident report, and written, signed, and dated statements from the accused witnesses and the person reporting the incident. The policy directed a thorough investigation was critical to developing effective prevention strategies. The facility maintained a written record of all investigations of reported abuse, neglect, mistreatment, misappropriation, exploitation, or deprivation of goods and/or services. The policy directed any investigation and follow-through abided by facility polices and State and Federal laws and regulations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 38 residents. The sample included six residents with three residents reviewed for abuse/neglect. Based on record review and interviews, the facility failed to submit completed investigations within the required five working-day timeframe following reported allegations to the State Agency (SA) for Residents (R) 1 and R2. Findings included:- R1 admitted to the facility on [DATE] and discharged to home on [DATE]. R2 admitted to the facility on [DATE] and transferred to the hospital on [DATE]. Review of the facility's notifications to the State Agency (SA) revealed the following: The facility reported intake number 2715968 to the SA on 01/13/26. The intake documented on 01/12/26 at 03:00 PM. The facility received an email from R1's representative that on 01/12/26 between the hours of 02:00 AM and 03:00 AM, R1 put on her call light to request urgent medical assistance, and staff failed to respond in a timely manner. As a result, R1 remained unattended while in acute physical distress and R1 told her representative in the morning when she called. The facility talked to R1, and she did not remember what time she vomited. The facility did not submit the completed investigation to the State Agency within the required five working days. The facility reported intake number 2744352 to the SA on 02/16/26. The intake documented on 01/31/26, R2 had a clogged catheter and staff pushed R2 into the lobby for discharge, so a new admission could have R2's room. R2's representative canceled transportation for his discharge and R2 went to the hospital at his representative's request. The facility did not submit the completed investigation to the State Agency within the required five working days. On 02/26/26 at 02:16 PM, Administrative Nurse D stated she did not submit the completed investigations for R1 or R2 to the State Agency. On 02/26/26 at 02:22 PM, Administrative Staff A stated Administrative Nurse D interviewed staff and he assumed Administrative Nurse D sent the investigation on R1 to the State Agency. He stated he did not send the completed investigation to the SA on R1. He stated the facility had five working days to send the completed investigation to the SA. Administrative Staff A stated he did not send the completed investigation on R2 because he thought Administrative Nurse D did that one. The facility's Abuse Policy and Procedure, not dated, directed the Administrator or Director of Nursing (DON) completed an investigation of the incident including a written summary of the findings no later than five working days of the reported occurrence. The summary included interview notes; incident report, and written, signed, and dated statements from the accused witnesses and the person reporting the incident. The policy directed a thorough investigation was critical to developing effective prevention strategies. The facility maintained a written record of all investigations of reported abuse, neglect, mistreatment, misappropriation, exploitation, or deprivation of goods and/or services. The policy directed any investigation and follow-through abided by facility polices and State and Federal laws and regulations. The policy did not address the required timeframe to submit completed investigations to the SA.

The facility identified a census of 35 residents with one kitchen. Based on observation, record review, and interviews, the facility failed to maintain sanitary dietary standards related to food storage. This deficient practice placed the residents who received food from the facility kitchen at risk related to food-borne illnesses and food safety concerns.
Findings included:
- On 09/23/24 at 07:27 AM, an observation in the kitchen's dry food storage room revealed one container of pistachios. The container was not labeled and lacked a date.
On 09/23/24 at 07:31 AM, an observation in the kitchen's dry food storage room revealed one opened box of puree pasta mix. The box had an opened bag inside that contained the pasta mix. The box and bag lacked a date.
On 09/23/24 at 07:33 AM, an observation in the kitchen's dry food storage room revealed one opened box of honey wheat flavoring. The box had an opened bag inside that contained the honey wheat flavoring. The box and bag lacked a date.
On 09/23/24 at 07:35 AM, an observation in the kitchen's dry food storage room revealed one opened package of potato pearls mashed potatoes. The package was open to air and lacked a date.
On 09/23/24 at 07:37 AM, an observation in the kitchen's dry food storage room revealed two containers of white rice. The container was unlabeled and lacked a date.
On 09/23/24 at 07:38 AM, an observation in the kitchen's dry food storage room revealed one opened bottle of browning and seasoning sauce. The bottle lacked a date.
On 09/23/24 at 07:39 AM, an observation in the kitchen's dry food storage room revealed one opened package of bran flakes. The package lacked a date.
On 09/23/24 at 07:44 AM, an observation on a shelf in the main kitchen area revealed a plastic container of brown powder. The container was not labeled and lacked a date.
On 09/23/24 at 07:45 AM, an observation on a shelf in the main kitchen area revealed two opened bags of pie filling mix. The bags lacked a date.
On 09/23/24 at 07:46 AM, an observation on a shelf in the main kitchen area revealed three opened bags of yellow cake mix. The bags lacked a date.
On 09/23/24 at 07:47 AM, an observation on a shelf in the main kitchen area revealed two opened bags of pretzels. The bags lacked a date.
On 09/23/24 at 07:53 AM, an observation in the kitchen's walk-in freezer revealed one opened bag of carrots. The bag lacked a date.
On 09/23/24 at 07:54 AM, an observation in the kitchen's walk-in freezer revealed one opened bag of green beans. The bag lacked a date.
On 09/23/24 at 07:56 AM, an observation in the kitchen's walk-in freezer revealed one opened bag of hashbrowns. The bag lacked a date.
On 09/23/24 at 07:57 AM, an observation in the kitchen's walk-in freezer revealed one resealable bag of steaks. The bag was unlabeled and lacked a date.
On 09/25/24 at 02:43 PM, Dietary BB stated food packaging needed to be labeled and dated when opened. Dietary BB stated if something was opened that day, it should be dated with that day's date on it. Dietary BB further stated any bins or containers that contained food should have been labeled and dated accordingly. Dietary BB he was in the process of implementing some of the changes that were recommended during the mock survey; however, he stated he did not have everything ready.
The facility's Food Storage policy, with a created date of 01/19/21, documented that food should be dated as it is placed on the shelves if required by state regulation. Date marking will be visible on all high-risk food to indicate the date by which a ready-to-eat Time/Temperature Control for Safety (TCS) food should be consumed, sold, or discarded. Plastic containers with tight-fitting covers must be used for storing grain products, sugar, dried vegetables, and lots of bulk foods. All containers must be legible and accurately labeled and dated. Frozen Foods: all foods should be covered, labeled, and dated. All foods will be checked to assure that foods will be consumed by their safe use by dates or discarded.
The facility failed to maintain sanitary dietary standards related to food storage. This deficient practice placed the residents who received food from the facility kitchen at risk related to food-borne illnesses and food safety concerns.

The facility identified a census of 35 residents. The sample included 12 residents with two reviewed for nutritive diets. Based on observation, record review, and interviews, the facility failed to ensure meals were served at a palatable, safe, and appetizing temperature for Residents (R)75 and R76. This deficient practice placed the residents at risk for impaired nutrition and decreased quality of life.
Findings included:
- On 09/23/24 at 07:45 AM R75 stated the facility would often serve the food cold in the mornings. She stated staff were available to warm up the food in the microwaves if asked.
On 09/23/24 at 08:00 AM R76 stated breakfast often was served cold by the time it reached her room.
On 09/23/24 at 12:51 PM, R18 stated the meals were often cold by the time the food was delivered to the rooms. She stated she was told by staff she would have to eat in the cafeteria if she wanted her meals to be served hot. (R18 was sent out to an acute care facility at 04:30 PM on 09/23/24)
On 09/24/24 at 08:20 AM R75 received her breakfast tray. A temperature test was completed on her breakfast. The test revealed her scrambled eggs were 90 degrees Fahrenheit, oatmeal was 98 degrees Fahrenheit, and the cherry crumble was 94 degrees. R75 reported the food was cold but she did not want it to be reheated.
On 09/23/24 at 08:26 AM R76 received her breakfast tray. A temperature test was completed on her breakfast. The test revealed her scrambled eggs were 92 degrees Fahrenheit, oatmeal was 95 degrees Fahrenheit, and the cherry crumble was 90 degrees.
On 09/25/24 at 01:30 PM, Certified Nurse's Aide (CNA) M stated the residents often had concerns with the food being delivered to the room. He stated staff should often test the food temperatures before serving it to the rooms. He stated staff should offer to warm the food up for the residents. He said it sometimes takes longer for the food to be delivered from the kitchen to the rooms which may be why the meals arrived cold.
On 09/25/24 at 03:00 PM Dietary Staff BB stated the facility recently had a mock survey and identified concerns with meal service. He stated the facility should be using heaters to keep the food cold and temping test trays to ensure food temperatures were being held. He stated the meal trays would hold temperatures for 15 minutes before they cool down.
The facility's Food Service policy 01/2024 indicated the facility would ensure all meals served were safe, nutritious, palatable, and within appropriate temperature ranges. The policy indicated the facility will ensure safe transport of meals between the dining rooms and rooms.
The facility failed to ensure meals were served at a palatable, safe, and appetizing temperature for R75 and R76. This deficient practice placed the residents at risk for impaired nutrition and decreased quality of life.

The facility identified a census of 35 residents. The sample included 12 residents with three reviewed for bowel and bladder management. Based on observation, record review, and interviews, the facility failed to ensure appropriate Foley catheter (a tube inserted into the bladder to drain urine into a collection bag) care for Resident (R)16 when staff failed to maintain the urine collection bag below R16's bladder to encourage dependent drainage. This deficient practice placed R16 at risk for catheter-related complications including urinary tract infections (UTI).
Findings Including:
- The Medical Diagnosis section within R16's Electronic Medical Records (EMR) included diagnoses of chronic kidney disease, spinal stenosis (degenerative condition of the spine that could cause weakness and loss of use of extremities), hemiplegia and hemiparesis (weakness and paralysis on one side of the body), and anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear).
R16's admission Minimum Data Set (MDS) completed 08/23/24 noted a Brief Interview for Mental Status (BIMS) score of 14 indicating intact cognition. The MDS indicated he was dependent on staff assistance for dressing, transfers, personal hygiene, toileting, bed mobility, and bathing. The MDS indicated he had an indwelling urinary catheter.
R16's Urinary Incontinence Care Area Assessment (CAA) completed 08/30/24 indicated he had a urinary catheter and was at risk for skin breakdown. The CAA instructed staff to provide peri and catheter care each shift. The CAA indicated a care plan will be created to minimize the risk related to his urinary catheter use.
R16's Care Plan initiated on 08/20/24 indicated he was at risk for self-care deficits, skin breakdown, and pressure injuries related to his medical diagnoses. The plan indicated he had an indwelling urinary catheter. The plan instructed staff to provide catheter care each shift and ensure the urine collection bag remained below the level of his bladder. The plan indicated R16 required staff assistance with dressing, personal hygiene, toileting, repositioning, transfers, and bathing.
On 09/24/24 at 10:58 AM an inspection of R16's room revealed he was on enhanced barrier precautions (EBP) related to his urinary catheter. EBP signage was posted on the sink close to his bed. R16's bed had a low air-loss mattress set to his weight at 250 pounds (lbs.). R16's urinary catheter collection bag was positioned on the center of his footboard. The collection bag was positioned higher than his bladder due to the bag placement and a large amount of foamy yellow urine pooled in the drainage tubing towards his body.
On 09/25/24 at 01:51 PM, Certified Nurse's Aide (CNA) M stated all urinary catheters and medical drains should be positioned below the level of the bladder to allow urine to drain. He stated catheters should be securely placed on the beds and never allowed to make contact with contaminated surfaces.
On 09/25/24 at 02:07 PM Licensed Nurse (LN) G stated staff was to check the catheter's placement and positioning each time they entered the room. She stated urinary catheters should be positioned in a privacy bag below the level of the resident's bladder.
On 09/25/24 at 03:34 PM Administrative Nurse D stated staff were expected to check the placements of the urinary catheter bags during each interaction with the residents. She stated the catheter tubing and collection bags should be placed below the level of the bladder to allow sufficient drainage.
The facility's Indwelling Urinary Catheter Site Care policy revised 07/2023 indicated staff will ensure sanitary placement and storage of the urinary drainage bags. The policy indicated the facility would ensure the drainage bag remained below the level of the resident's bladder, off the floor, and had a privacy bag at all times.
The facility failed to ensure appropriate Foley catheter care for R16 when staff failed to maintain the urine collection bag below R16's bladder to encourage dependent drainage. This deficient practice placed R16 at risk for catheter-related complications including UTI.

The facility had a census of 35 residents. The sample included 12 residents with three reviewed for accidents. Based on observation, record review, and interview, the facility failed to ensure a safe environment free from hazardous chemicals and materials for eight cognitively impaired independently mobile residents. This deficient practice placed the residents at risk for preventable accidents and injuries.
Findings Included:
- On 09/23/24 at 07:30 AM a walkthrough of the facility's Two Hall revealed an unlocked wound treatment cart. The cart contained multiple bottles of medicated diclofenac (used to treat pain) and nystatin (used to treat fungal infections) ointments with the warning of Keep medication out of reach of children. The cart also contained three purple containers of Sani-Cloth bleach wipes with the Keep out of reach from children warning label. CNA M stated the cart belonged to the nurse but secured it.
On 09/24/24 at 07:10 AM an inspection of the facility's One Hall revealed the wound cart was unsecured. The cart contained five bottles of diclofenac, a box of disposable medical scalpels, and five containers of Sani-Cloth bleach wipes. At 07:15 AM Administrative Staff A stated carts should be locked with the items listed and secured the cart. He stated the residents should not have access to the items in the cart.
On 09/24/24 at 07:15 AM a Sani-cloth bleach wipes container was on the railing outside Resident (R)76's room.
On 09/25/24 at 01:51 PM, Certified Nurse's Aide (CNA) M stated the treatment carts should be always secured. He stated the chemical wipes should be locked up away from the resident.
On 09/25/24 at 02:07 PM Licensed Nurse G stated the wound treatment cart should be locked when not in use by the nurses.
On 09/23/24 at 03:30 PM Administrative Nurse D stated the treatment cart was to be locked when not in use. She stated that chemical cleaning products should always be locked up.
The facility's Accident and Incident policy revised 06/2024 indicated the facility will provide an environment free from potential hazards related to falls, unsafe equipment, chemicals, behaviors, and other assessed or identified factors. The policy indicated the facility will provide ongoing evaluation and supervision to ensure resident safety.
The facility failed to ensure a safe environment free from hazardous chemicals and materials for eight cognitively impaired independently mobile residents. This deficient practice placed the residents at risk for preventable accidents and injuries.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 35 residents. The sample included 12 residents with three reviewed for activities of daily living (ADLs). Based on observation, record review, and interviews, the facility failed to provide consistent bathing opportunities for Residents (R)18. This deficient practice placed R16 at risk for decreased psychosocial well-being and other complications.
Findings Including:
- The Medical Diagnosis section within R18's Electronic Medical Records (EMR) included diagnoses of malignant neoplasm of the pancreas (pancreatic cancer), nausea with vomiting, and gastroesophageal reflux disease (GERD-backflow of stomach contents to the esophagus).
R18's admission Minimum Data Set (MDS) completed 09/08/24 revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The MDS indicated she required supervision and/or touch assistance from staff for bathing, toileting, dressing, personal hygiene, bed mobility, and transfers. The MDS indicated she admitted with no 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) or wounds, but the MDS indicated she was at risk. The MDS indicated she had nonsurgical dressings and ointments to prevent skin breakdown.
R18's Pressure Ulcer Care Area Assessment (CAA) completed 09/13/24 indicated she was at risk for pressure injuries and skin breakdown due to her immobility. The CAA indicated her skin was intact upon assessment. The assessment indicated she required staff assistance to move sufficiently to relieve pressure. The CAA noted she had incontinence and poor nutrition. The CAA indicated a care plan will be implemented to address her risks.
R18's Care Plan initiated on 09/06/24 indicated she was at risk for deficits in her ADL and skin breakdown related to her immobility, urinary incontinence, and biliary (bile) drain. The plan instructed staff to assess her skin weekly, flush her drain as ordered, and always keep her skin clean. The plan indicated staff will need to assist as needed with all her ADLs. The plan indicated staff will assist with showers twice weekly and as needed per patient preference.
R18's EMR under Treatment Administration Report (TAR) indicated bathing was signed off as completed on 09/06/23 and 09/11/24. The TAR indicated bathing was not administered on 09/10/24, 09/14/24, 09/18/24, and 09/20/24. The TAR indicated the resident refused bathing on 09/14/24. The TAR noted on 09/20/24 that staff would bathe her the following morning, but this task was not completed.
R18's EMR under Progress Notes indicated she was transferred to an acute care facility for emergency treatment related to her worsening cancer symptoms on 09/23/24 at 04:23 PM.
On 09/23/24 at 09:01 AM R18 slept in her bed. Her biliary drain collection bag and tubing rested on the floor to the right of her bed. R18 awoke and reported she had felt ill all week. She reported her drainage bag had no specific place to secure it and it often fell on the floor. She stated she only had one bath since her admission to the facility on [DATE]. She stated she refused one shower offered due to her illness, but she was not offered other opportunities. R18's room smelled heavily of urine and body odor. Her hair was greasy and unwashed. Her fingernails were untrimmed and dirty. R18 stated she was supposed to receive a bath on the previous Saturday, 09/21/24, but never received one.
On 09/25/24 at 09:45 AM Consultant GG stated when R18 arrived at the hospital from the facility, she had a pressure injury. She stated R18 smelled heavily of urine, feces, and body and R18's hair was unwashed and greasy.
On 09/25/24 at 01:51 PM, Certified Nurse's Aide (CNA) M stated the facility followed a bathing schedule and each resident would get a minimum of two baths each week. He stated the bathing documentation would be turned in to nursing for review. He stated any skin impairments or refusals would also be reported to the nurses. He stated that repeated refusals would be reported to the interdisciplinary team to address.
On 09/25/24 at 02:07 PM, Licensed Nurse (LN) G stated resident's bathing would be documented in the TAR section of the EMR. She stated that missed bathing or refusals should have been noted in progress notes.
On 09/25/24 at 03:34 PM Administrative Nurse D stated staff were expected to document refusals or missed bathing. She stated that R18's bathing would have been noted in the TAR.
The facility's Shower/Bath policy revised 07/2023 indicated the residents will be scheduled for bathing twice weekly. The policy indicated staff will ensure appropriate monitoring and documentation for completed, missed, or refused bathing opportunities.
The facility failed to provide consistent bathing opportunities for R18. This deficient practice placed her at risk for decreased psychosocial well-being and other complications.

The facility identified a census of 35 residents. The sample included 12 residents. Based on interview and record review, the facility failed to develop and implement a policy that prohibited and prevented the facility from employing or engaging staff with criminal backgrounds when the facility failed to conduct a background check as required for one employee and the facility policy allowed for 10 days of employment prior to the check. The deficient practice placed all residents at risk for abuse, neglect, misappropriation, or mistreatment.
Findings included:
- Employee review of Licensed Nurse (LN) H revealed a hire date of 07/03/19. The facility was unable to provide evidence a criminal background check had been completed by the facility for LN H upon request.
On 09/25/24 at 11:55 AM Administrative Staff A stated the facility did not have a criminal background check on file for LN H. Administrative Staff A stated he was unable to find LN H's background check after searching through the older files in storage. Administrative Staff A stated LN H was originally hired for home health and hospice when it was owned by the same company as the facility and the background check was done on the home health and hospice end; however, the facility did not complete a background check for LN H when she hired on the work weekends at the facility. Administrative Staff A stated the home health and hospice was no longer owned by the same company as the facility, but he was able to obtain a copy of the background check home health and hospice had completed. Administrative Staff A stated the facility should have completed its own hiring documentation and background checks for employees who worked in their facility. Administrative Staff A stated he placed an order for a new background check to be completed for LN H.
The facility's undated Abuse Policy and Procedure policy documented The facility will not knowingly employ any individual who has been found guilty of abuse, neglect, misappropriation of property, or mistreatment in a court of law; has had a finding entered into the State Nurse Aide Registry concerning abuse, neglect, mistreatment of a patient or misappropriation of patient property; or has had a disciplinary action against a professional license issued by a State licensure body as a result of a finding of abuse, neglect, mistreatment of a patient, misappropriation of patient property, exploitation of a patient or deprivation of goods and/or services. The facility will submit criminal background checks, which include sex offender checks within 10 days of employment or per state regulations.
The facility failed to develop and implement a policy that prohibited and prevented the facility from employing or engaging staff with criminal backgrounds when the facility failed to conduct a background check as required for one employee and the facility policy allowed for 10 days of employment prior to the check. The deficient practice placed all residents at risk for abuse, neglect, misappropriation, or mistreatment.

The facility identified a census of 35 residents. The sample included 12 residents with one reviewed for accommodation of needs. Based on record review, interviews, and observations, the facility failed to ensure Resident (R) 75 had her call light to communicate her needs or call for help. This deficient practice placed the resident at risk for unmet care needs.
Findings Including:
- The Medical Diagnosis section within R75's Electronic Medical Records (EMR) included diagnoses of fracture of her sacrum (bone break of the large triangular bone/area between the two hip bones), fracture of the lumber vertebra (spinal fracture of the lower back), insomnia (difficulty sleeping), and history of repeated falls.
R75's admission Minimum Data Set (MDS) completed 09/20/24 noted a Brief Interview for Mental Status (BIMS) score of 11 indicating mild cognitive impairment. The MDS indicated she required supervision with bed mobility, toileting, transfers, personal hygiene, dressing, and personal hygiene. The MDS noted no falls since her admission.
R75's Functional Abilities Care Area Assessment (CAA) completed 09/23/24 indicated she required limited stand-by assistance from staff for her mobility and activities of daily living (ADLs).
R75's Falls CAA completed 09/23/24 indicated she was at risk for falls related to weakness, limited mobility, and forgetfulness.
R75's Care Plan initiated 09/10/24 indicated she required stand-by assistance with all her ADLs. The plan indicated she was at risk for falls related to her limited mobility, weak gait, urinary catheter, and cognitive impairment. The plan instructed staff to ensure her call light remained within reach.
On 9/23/24 at 08:15 AM R75 slept in her bed. R75's bed was in the lowest position and her urinary catheter collection bag rested directly on the floor to the right of her bed. R75's call light rested on the floor on the left side of her bed out of her reach. R75 stated she wasn't sure how her call light or urinary catheter bag got on the floor. She stated she could not safely reach her call light. At 08:20 AM Certified Nurse's Aid (CNA) M entered the room, reattached the catheter bag, and placed the call button back on her bed. CNA M stated the items should never be on the floor. CNA M stated R75's call light should always be within reach.
On 09/25/24 at 01:45 PM Licensed Nurse (LN) G stated call lights should either be clipped onto the resident's clothing or on the bed within reach.
On 09/26/24 at 03:34 PM Administrative Nurse D stated staff were to ensure call light remained within reach after each encounter.
The facility's Call System policy 07/2023 indicated the facility will ensure a working call system. The policy noted the call lights will be placed in a manner to ensure accessibility.
The facility failed to ensure R75 had her call light to communicate her needs. This deficient practice placed the residents at risk for unmet care needs.

The facility identified a census of 35 residents. The sample included 12 residents with three residents reviewed for beneficiary notices review. Based on record review, and interviews, the facility failed to provide Resident (R)82 with a Centers for Medicare and Medicaid Services (CMS) Notice of Medicare Non-Coverage (NOMNC) CMS -10095 Form upon discharge from Medicare A services. This deficient practice placed the resident at risk for uninformed decisions and inability to exercise her rights.
Findings Included:
- R82's Discharge Minimum Data Set (MDS) completed 08/30/24 noted a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The MDS indicated she was discharged home and was not anticipated to return to the facility.
A review of R82's Beneficiary Protection Notification Review completed on 09/24/24 indicated she started Medicare Part A skilled services on 07/08/24. The form designated her last covered day (LCD) as 08/29/24. The form indicated the facility initiated her discharge from skilled with benefit days remaining and she left the facility upon her discharge from services.
The facility was unable to provide a completed NOMNC for R82 requested on 09/24/24.
On 09/24/24 at 01:23 PM Administrative Nurse D stated the facility did not have the NOMNC for R82. She stated the facility recently identified missing NOMNC documentation and was working to correct the issue.
The facility's Notice of Medicare Non-Coverage (NOMNC) policy revised 09/2022 indicated the facility will provide Form 10095 at least two days prior to termination of services.
The facility failed to provide R82 with a NOMNC upon discharge from Medicare A services. This deficient practice placed the resident at risk for uninformed decisions and inability to exercise her rights.

The facility identified a census of 35 residents. Based on record reviews, observations, and interviews, the facility failed to follow sanitary infection control standards related to maintaining biliary drains (catheter drain inserted in the liver) and Foley catheters (a tube inserted into the bladder to drain urine into a collection bag). These deficient practices placed the residents at risk for infectious diseases.
Findings Included:
- On 9/23/24 at 08:15 AM Resident(R)75 slept in her bed. R75's bed was in the lowest position and her urinary catheter collection bag rested flat on the floor to the right of her bed.
On 09/23/24 at 10:18 AM R18 slept in her bed. R18's bed was in the lowest position. R18's tubing for her biliary drain ran over her covers to the right side of her bed. Her drainage collection bag rested on the floor to the right of her bed.
On 09/25/24 at 01:51 PM Certified Nurse's Aide (CNA) M stated the medical drains and catheter bags should never touch the floor. He stated they should be positioned below the level of the bladder to ensure proper drainage and prevent urine from flowing back into the resident's body.
On 09/25/24 at 02:07 PM Licensed Nurse G stated staff was to check the catheter's placement and positioning each time they entered the room. She stated urinary catheters should be positioned in a privacy bag below the level of the resident's bladder.
On 09/25/24 at 03:34 PM Administrative Nurse D stated staff was expected to check the placements of the urinary catheter bags during each interaction with the residents. She stated the catheter tubing and collection bags should be placed below the level of the bladder to allow sufficient drainage and never touch contaminated surfaces.
The facility's Indwelling Urinary Catheter Site Care policy revised 07/2023 indicated staff will ensure sanitary placement and storage of the urinary drainage bags. The policy indicated the facility will ensure the drainage bag remained below the level of the resident's bladder, off the floor, and have a privacy bag.
The facility failed to follow sanitary infection control standards related to maintaining medical drains and Foley catheters. These deficient practices placed the residents at risk for infectious diseases.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 38 residents. The sample included three residents reviewed for accidents. Based on record review, interview, and observations, the facility failed to identify hazards and implement adequate supervision and care to ensure safe smoking for Resident (R) 1. R1 admitted to the facility on [DATE] at approximately 01:00 PM. R1 was alert and oriented to person place time and situation and received oxygen via nasal cannula at six liters per minute (LPM). At 05:15 PM on 12/08/23, Certified Nurse Aide (CNA) M took R1 outside for a cigarette break while R1 wore his oxygen. CNA M locked R1's wheelchair brakes and went back inside. Between 05:26 PM and 05:29 PM, R1 lit his cigarette. Around 05:34 PM R1's nasal cannula ignited. R1 removed the nasal cannula, shook it, and attempted to put out the flame. At approximately 05:35 PM, Licensed Nurse (LN) H approached the facility for her scheduled shift. LN H observed R1 swinging the nasal cannula tubing around and trying to put out the fire. LN H disconnected the tubing from the oxygen cylinder on the back of the wheelchair and turned off the oxygen flow. R1 sustained facial burns and later became hypoxic (insufficient oxygen), which required emergent treatment. The failure placed R1 in immediate jeopardy.
Findings included:
- R1's Electronic Medical Record (EMR), under the Face Sheet tab, recorded diagnoses of acute respiratory failure with hypoxia, chronic obstructive pulmonary disease (COPD- progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing) with acute exacerbation (worsening of a disease or an increase in its symptoms), pneumonia (inflammation of the lungs), and dependence on supplemental oxygen.
R1's Entry Minimum Data Set (MDS) dated [DATE] documented R1 admitted to the facility.
R1's Baseline Care Plan initiated 12/08/23 lacked directives related to R1's smoking preference or interventions to address R1's ability to smoke safely.
R1's admission Nursing Observation assessment dated [DATE] documented R1 was alert and oriented to person, place, time, and situation. The assessment inaccurately recorded R1 did not smoke.
R1's Inter-Agency Transfer Order dated 12/08/23 documented R1 required continuous oxygen at six LPM at rest and eight LPM with activity via nasal cannula with concentrator, portability, and/or conserving device.
R1's Orders in the EMR ordered oxygen per nasal cannula to maintain oxygen saturation (SpO2-the amount of oxygen in the bloodstream) greater than 90 percent (%). Document LPM every shift. Oxygen may be titrated or discontinued as tolerated by R1 while SpO2 maintained over 90 %.
The Progress Note dated 12/08/23 at 01:21 PM documented R1 arrived with no signs or symptoms of distress noted. R1 was on six LPM oxygen per nasal cannula continuously and might need to be increased to eight LPM per report from the hospital. The note recorded R1 stated he was unable to sign anything due to fine tremors in his hands.
The Progress Note dated 12/08/23 at 06:19 PM documented LN H arrived early and reported R1 was outside trying to smoke with his oxygen on and burned himself. LN H reported she disconnected R1's oxygen tubes and noted when R1 was brought in, R1 had soot all over his face.
The Progress Note dated 12/08/23 at 06:35 PM documented LN G was notified by LH H at approximately 05:50 PM that R1 was outside smoking with his oxygen cannula on and six LPM of oxygen flowing. LN H saw flames and immediately shut off the oxygen tank. LN G went outside and observed R1 upright in his wheelchair with soot on his face, hands, and around his nose. LN G cleaned the soot off the R1's hands, nose, and face. R1 had redness to areas of his face, nose and cheeks, as well as singed hair on his mustache and eyebrows. R1 did not have any blisters or wounds observed at that time. Upon return to R1's room, R1's SpO2 was at 91% on six LPM per nasal cannula. LN J notified Consultant GG and awaited call back. R1's cigarettes and lighter were removed from R1's room and placed in the medication cart.
The Progress Note dated 12/08/23 at 08:50 PM documented R1 had thick mucus blocking his airway. R1 had an SPO2 of 85% despite supplemental oxygen flowing via nasal cannula at six LPM. The facility sent R1 to the emergency room at 09.04 PM.
The Progress Note dated 12/09/23 at 09:00 AM documented R1 admitted to the hospital burn unit.
CNA M's Witness Statement dated 12/11/23 documented CNA M entered R1's room and R1's daughter immediately told CNA M to make sure R1 got his smoke breaks. A few hours later, LN G told CNA M to take R1 outside to smoke. CNA M stated that with everything going on, she did not really think about R1's oxygen. CNA M took R1 outside and then came back into the building to get meal trays.
LN H's Witness Statement dated 12/11/23 documented LN H pulled up to the building around 05:40 PM and noted R1 outside in his wheelchair. As LN H walked towards R1, LN H saw R1 swinging his oxygen tubing trying to put out a fire. LN H quickly approached R1, disconnected the cannula tubing from the concentrator to stop the oxygen supply, then checked on R1. R1 had black soot around his face, cheeks, and nose. LN H established R1 was out of danger, then went and reported to the admission nurse and LN G. LN G and LN H brought R1 in from outside, cleaned the soot from all over his nose and cheeks, and then LN G took over cares.
On 12/13/23 at 12:00 PM Administrative Nurse D stated she expected staff to ask new admission (residents) if they smoke or not, and to assess if the newly admitted resident was safe to smoke or required supervision.
On 12/13/23 at 12:19 PM LN I stated she did not ask R1 about smoking. LN I further stated she reviewed the hospital paperwork and did not see any information related to a history of smoking or that R1 did smoke.
On 12/13/23 at 02:01 PM CNA M stated that R1's family member wanted to make sure R1 received his smoke breaks. CNA M further stated LN G asked CNA M to take R1 out for a smoke break. CNA M took R1 outside to smoke, asked what time R1 wanted to come back inside and the left R1 outside alone. CNA M revealed she forgot about R1's oxygen being on when she left R1 outside to smoke.
The facility's Smoking Policy lacked a date documented residents could not carry smoking materials unless the patient has demonstrated safe smoking habits and practices determined by the assessment for residents who smoke. Residents may smoke in the designated smoking area without staff supervision if the resident has demonstrated safe smoking habits and practice determined by the assessment for residents who smoke.
The facility failed to ensure staff identified smoking related hazards and provided adequate care and supervision to avoid preventable smoking related accidents for admitting resident R1. A facility CNA brought R1 outside to smoke with is oxygen on per nasal canula, which caught on fire and caused facial burns to R1, who subsequently admitted to a burn unit. This failure placed R1 in immediate jeopardy.
The facility completed the following corrective actions by 12/11/23:
The smoking policy was updated, and the facility has changed to a non-smoking facility with smoking residents that were already admitted grandfathered in.
The two smoking residents had a safety smoking assessment completed on 12/09/23.
The Nurses have received training related to asking the residents about smoking and performing the smoking assessment even though the facility is no longer a smoking facility to assure safety.
The facility staff received training related to smoking safety on 12/11/23
The corrective actions were completed prior to the onsite survey therefore the citation was issued as past noncompliance at the scope and severity of J.

The facility identified a census of 30 residents. The facility had one main kitchen and one dining area. The facility failed to ensure that staff members properly tested the dishwashing sanitization chemicals and recording the dish machine temperatures. The facility also failed to ensure the ice machine lid was closed in the nourishment area was closed This deficient practice placed residents at risk for contamination and food borne illness.
Findings included:
- The initial tour of the facility on 02/23/23 at 07:04 AM the Dietary Staff DD reported the facility had changed chemical sanitization companies in the past two weeks and chemical strips provided by the new company had not been testing within the facility set guidelines. Dietary Staff DD stated the new distributor had been notified.
On 02/23/23 at 07:05AM the door of the ice machine in the nourishment was left open with the ice exposed.
Review of the Dish Machine Temperature Log from 02/01/23 to 02/27/23 revealed 17 undocumented dish machine water temperature opportunities out of 81 opportunities. Review of the parts per million column (PPM) revealed lack of documentation 16 days out of 27 opportunities.
On 02/28/23 at 11:46 AM Dietary Staff BB stated the facility had changed companies that provided the sanitization chemicals and the facility had notified the provider of the problem.
On 02/28/23 at 12:24 PM Dietary Staff CC stated the company had reviewed the concern of the chemical test strips the facility had used to check the PPM was for testing fruits and vegetables and not for dish machines.
On 02/28/23 at 01:50 PM Licensed Nurse (LN) H stated night was responsible for cleaning the ice machine in the nourishment area. LN H stated it was everyone\s responsibility to close the lid to ice machine when finished getting ice.
On 02/28/23 at 02:00 PM Certified Nurse's Aide (CNA) M stated the kitchen was responsible for any maintence of the ice machine. CNA M stated she cleaned the ice chest at the start of each shift. CNA M stated it was everyone's responsibility to ensure the ice machine lid was closed when not in use.
The facility's Food handling policy dated 08/06/20 documented sanitization solution must be changed when cloudy, when not with in the recommended concentration or temperature, or at least three times a day.
The facility failed to ensure that staff members properly tested the dishwashing sanitization chemicals and recording the dish machine temperatures. The facility also failed to ensure the ice machine lid was closed in the nourishment area was closed. This deficient practice placed residents at risk for contamination and food borne illness.

The facility had a census of 56 residents. The sample included 12 residents. Based on observation, record review and interview the facility failed to secure chemicals in a safe, locked area, and out of reach of the five cognitively impaired independently mobile residents. This placed the affected residents at risk for accidents.
Findings Included:
- On 02/23/23 at 07:05 AM an initial walkthrough of the facility revealed opened Micro-Kill germicidal cylindrical containers of disinfectant wipes were in the hallway, unsecured, outside of Residents (R)7, R23, R88, R90, and R142's rooms. The disinfectant wipes were also noted outside of unoccupied rooms 104, 105, 108, 114, and 134. The walkthrough revealed 12 total containers of chemical wipes left unsecured. The label of the wipes contained the warning, Keep out of reach of children, hazardous to humans can cause eye irritation, harmful if swallowed.
On 02/28/23 at 01:49 PM Certified Nurses Aid (CNA) M stated all chemical products should securely locked up away from resident access.
On 02/28/23 at 01:49 PM Licensed Nurse (LN) G stated that hazardous chemicals should be secured out of reach from the residents. She stated staff use the wipes to wipes down areas to prevent the spread of infections but should not leave the wipes out for resident to have access.
On 2/28/23 at 02:40 PM Administrative Nurse D stated she was not aware that the wipes had been left out but stated that staff used them in the isolation rooms and areas that may be of high contamination risks. She stated that she would educate staff on safety and securing the wipes.
The facility failed to secure chemicals in a safe, locked area, and out of reach of the five cognitively impaired independently mobile residents. This placed the affected residents at risk for accidents.

The facility identified a census of 30 residents. The sample included 12 residents with two reviewed for activities of daily living (ADL). Based on observations, record review, and interviews, the facility failed to provide consistent bathing opportunities and the level of assistance required for Resident (R)15. This deficient practice placed R15 at risk for impaired skin integrity, discomfort, and decreased psychosocial well-being.
Findings Included:
-The Medical Diagnosis section within R15's Electronic Medical Records (EMR) included diagnoses of multiple sclerosis (progressive disease of the nerve fibers of the brain and spinal cord), fibromyalgia (condition of musculoskeletal pain, spasms, stiffness, fatigue and severe sleep disturbance), muscle spasms, anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), and muscle weakness.
A review of R15's admission Minimum Data Set (MDS) dated 01/12/23 noted a Brief Interview for Mental Status (BIMS) score of six indicating severe cognitive impairment. The MDS indicated she required extensive assistance from one staff for bed mobility, transfers, dressing, toileting, and bathing. The MDS indicated she had no falls since admission. The MDS indicated she used a walker and wheelchair for mobility.
A review of R15's Activities of Daily Living Care Area Assessment (CAA) completed 01/12/23 indicated she declined in her ADLs related to her medical diagnoses. The CAA instructed staff to ensure call light devices remained within reach, help and therapy to improve transfers, and continue with supportive care plan.
A review of R15's Care Plan revised 01/07/23 indicated she required limited assistance for meals. The plan indicated she required moderate to total assistance for transfers, bed mobility, personal hygiene, dressing, toileting, and bathing.
A review of R15's Bathing History report from 01/01/23 through 02/27/23 (47 days reviewed) indicated she received six (1/12, 1/15, 2/2, 2/9, 2/16, 2/23) baths. No refusals were documented.
A review of R15's EMR revealed no therapy baths, refusals, or documentation showing why bathing did not occur.
On 02/23/23 at 08:02AM R15 sat in her wheelchair at the table in her room. R15 reported the facility had just given her a shower but did not properly dry her hair. R15 had a towel placed over her left shoulder and her hair was damp. R15 reported she was cold from not being fully dried off. She reported since arriving at the facility her bathing had been inconsistent. She stated that she was supposed to be bathed twice a week but had only been given one weekly. She stated that she missed a whole week of bathing a few weeks back. She indicated that she would like to receive bathing twice a week.
On 02/28/23 at 01:49 PM Certified Nurses Aid (CNA) M stated each resident should be bathed at least twice a week but residents could request to be bathed daily if they wished to be. She stated the unit nurses put out the schedule of which residents were to be bathed and the CNA staff were responsible for completing the bathing. She stated that all baths were to be documented in the Point of Care (EMR) under ADL Care. She stated that if a resident refused the CNA notified the nurse and documented the refusal.
On 02/28/23 at 01:49 PM Licensed Nurse (LN) G stated the CNA staff were responsible for completing baths and reporting to the nurses if cares were not completed. She stated that R15 received her baths, so she was not sure why they were not documented.
On 2/28/23 at 02:40 PM Administrative Nurse D stated that R15 should have received her baths weekly and then during each incontinent episode as part of her plan. She stated that staff should be documenting all bathing and refusals in the EMR. She was not sure why the EMR was missing bathing occurrences.
A review of the facility's ADL Charting policy 08/2020 indicated all resident will be provide ADL assistance based on the individualized plan provided. The policy indicated that staff will document all assistance provide and observed the resident throughout the shift for cares needed. The policy indicated staff will document if an activity did not occur.
The facility failed to provide consistent bathing opportunities and the required assistance for R15. This deficient practice placed R15 at risk for impaired skin integrity, discomfort, and decreased psychosocial well-being

The facility identified a census of 30 residents. The sample included 12 residents with two residents reviewed for care plan revisions related to accidents. Based on observation, record review, and interviews, the facility failed to revise Residents (R)15 and R33's care plans to reflect interventions implemented for recent falls. This deficient practice placed both residents at risk for uncommunicated care needs.
Findings Included:
- The Medical Diagnosis section within R15's Electronic Medical Records (EMR) included diagnoses of multiple sclerosis (progressive disease of the nerve fibers of the brain and spinal cord), fibromyalgia (condition of musculoskeletal pain, spasms, stiffness, fatigue and severe sleep disturbance), muscle spasms, anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), and muscle weakness.
A review of R15's admission Minimum Data Set (MDS) dated 01/12/23 noted a Brief Interview for Mental Status (BIMS) score of six indicating severe cognitive impairment. The MDS indicated she required extensive assistance from one staff for bed mobility, transfers, dressing, toileting, and bathing. The MDS indicated she had no falls since admission. The MDS indicated she used a walker and wheelchair for mobility.
A review of R15's Activities of Daily Living (ADLs) Care Area Assessment (CAA) completed 01/12/23 indicated she declined in her ADLs related to her medical diagnoses. The CAA instructed staff to ensure call light devices remained within reach, help and therapy to improve transfers, and continue with supportive care plan.
R15's was triggered for Falls CAA on 01/12/23 but no comments were documented.
A review of R15's Care Plan revised 01/07/23 indicated she required limited assistance for meals. The plan indicated she required moderate to total assistance for transfers, bed mobility, personal hygiene, dressing, toileting, and bathing. The plan lacked documentation related to her landing strip (fall mat) located on the right side of her bed.
A review of R15's Comprehensive Care Plan lasted revised 02/10/23 reflected previous admission care approaches created on 08/11/16. R15's ADL Functional entry indicated she only required limited assistance for ambulation, bed mobility, transfers, and toileting.
A review of R15's EMR revealed a Fall Incident note on 01/28/23. The note revealed R15 was found on the floor next to her bed. The note revealed that R15 stated she had slid down her bed and onto the floor. The note revealed a landing strip was added to prevent her from sliding.
On 02/23/23 at 08:02AM R15 sat in her wheelchair at the table in her room. R15's bed was in the low position and a landing strip was placed of the right side of her bed. R15 stated she slid out of bed and staff placed the landing strip next to her bed. She stated that she was not sure if staff was supposed to remove the mat when she was out of bed or just leave it on the floor all day. She stated that the landing strip was hard to maneuver around to get to her bed and it often forced her wheelchair backwards when she attempted to go over it. She stated that some staff move it so she could access that side of her room and the sink area.
On 02/28/23 at 01:49 PM Certified Nurses Aid (CNA) M stated R15 required staff assistance for all her ADLs and was a high fall risk. She stated all staff have access to the care plan in the Point of Care (EMR). She stated that a resident fall intervention should be listed in the care plan. She stated that R15 should have a fall mat and bed in the lowest position.
On 02/28/23 at 01:49 PM Licensed Nurse (LN) G stated the R15 was a fall risk. She stated R15's fall interventions included a landing strip, frequent checks, call light within reach, and having her bed in the lowest position. She was not sure if the landing strip was to be moved during the day or remain in place while R15 was mobile.
On 2/28/23 at 02:40 PM Administrative Nurse D stated R15's care plan should have included her active interventions. She stated the care plan should be based upon the admission assessment and revised each time an event or change occurs with the resident. She stated that all staff have access to the care plans and should be following the provided interventions.
A review of the facility's Care Plan policy revised 09/2022 indicated the resident care plans will be continually evaluated to ensure interventions are being followed and effective to maintain the specified goals. The policy noted the plans should be updated to reflect changes, goals, and interventions are identified and effectively treated.
The facility failed to revise R15's care plan to reflect implemented fall interventions. This deficient practice both residents at risk for preventable falls and injuries due to uncommunicated care needs.
-The Medical Diagnosis section within R33's Electronic Medical Records (EMR) included diagnoses of chronic kidney disease, chronic obstructive pulmonary disorder (COPD - progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), muscle weakness, benign prostatic hyperplasia (BPH- non-cancerous enlargement of the prostate which can lead to interference with urine flow, urinary frequency and urinary tract infections), and type two diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin).
A review of R33's admission Minimum Data Set (MDS) dated 01/26/23 noted a Brief Interview for Mental Status (BIMS) score of five indicating severe cognitive impairment. The MDS indicated he required extensive assistance from one staff for bed mobility, transfers, dressing, toileting, and bathing. The MDS indicated he had two or more non-injury falls since admission. The MDS indicated he was taking insulin (hormone which regulates blood sugar) medication. The MDS indicated he used a walker and wheelchair for mobility.
A review of R33's Activities of Daily Living (ADLs) Care Area Assessment (CAA) completed 01/26/23 indicated he required limited to extensive assistance from one staff member for his ADLs. The CAA instructed staff to offer and assist in ways that were familiar and safe for R33. The CAA instructed staff to promote independence and provide the least restrictive environment as permitted to enhance his quality of life.
R33's Fall CAA completed 01/26/23 indicated that he was at risk for falls related to his medical diagnoses, impaired cognition, and weakness. The CAA noted for staff to ensure he was oriented with his new environment and provide reminders as needed. The CAA instructed that his bed be in the low position, call light within reach, and for staff to anticipate his needs.
R33's Cognitive Loss CAA completed 01/26/23 noted that he was at risk for impaired cognition due to his diabetes mellitus diagnosis and hypoglycemia. The CAA instructed staff to monitor for changes in cognition, mood, behavior, and confusion.
A review of R33's Care Plan initiated 01/25/23 indicated R33 was at risk for falls related to his fall history, medications, and functional deficits. The plan instructed staff to assist with ambulation and transfers, educate him on fall safety, encourage to call for assistance with his call light, added bolsters (cushioning or pillows used to prevent falls) to his mattress, and monitor him for medication side effects. R33's care plan lacked documentation related to his fall on 01/28/23 or include the increased glucose monitoring intervention put in place after his fall incident.
A review of R33's EMR revealed a Fall Incident note on 01/28/23. The note indicated R33 was found on the floor bundled in his blankets. The note indicated R33's blood glucose (blood sugar) was tested. R33's blood glucose was 39 milligram per deciliter (mg/dL). R33 was sent out to an acute care facility for treatment and evaluation and returned five hours later.
A review of R33's Physician's Orders revealed an order dated 01/28/22 instructing staff to complete blood glucose checks daily at 12:00AM and 04:00AM related to hypoglycemia (low blood sugar).
A review of R33's Blood Glucose history indicated that his levels was checks at 09:45PM on 01/27/23 before his fall incident occurred the morning of 01/28/23. His glucose level was 138mg/dL.
On 02/23/23 at 01:23PM R33 sat in his recliner watching television. He wore non-slip shoes. His bed had mattress bolsters in place and was in the low position. His call light was within reach. R33 reported he had fallen several times before coming to the facility but could not remember his recent fall. He stated that he knows he fell but was not feeling well that day.
On 02/28/23 at 01:49 PM Certified Nurses Aid (CNA) M stated that R33 was fall risk and has had a fall at the facility. She stated that R33 struggled with remembering and needed reminders to ask for help.
On 02/28/23 at 01:49 PM Licensed Nurse (LN) G stated that staff should be following the given physician orders for checking vitals (heart rate, blood pressure, temperatures) as well as blood glucose. She stated that R33 had fallen before and gets his blood glucose checked at bedtime and overnight.
On 2/28/23 at 02:40 PM Administrative Nurse D stated R33's care plan should have included active interventions. She stated the care plan should be based upon the admission assessment and revised each time an event or change occurs with the resident. She stated that all staff have access to the care plans and should be following the provided interventions.
A review of the facility's Care Plan policy revised 09/2022 indicated the resident care plans will be continually evaluated to ensure interventions are being followed and effective to maintain the specified goals. The policy noted the plans should be updated to reflect changes, goals, and interventions are identified and effectively treated.
The facility failed to revise R33's care plan to reflect implemented fall interventions. This deficient practice both residents at risk for preventable falls and injuries due to uncommunicated care needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** - R82's electronic medical record (EMR) from the Diagnoses tab documented diagnoses of congestive heart failure (CHF - a condition with low heart output and the body becomes congested with fluid), depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness), and hypertension (elevated blood pressure).
The admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of nine which indicated moderately impaired cognition. The MDS documented that R82 required extensive assistance of one staff member for activities of daily living (ADL's). The MDS documented R82 received antidepressant (class of medications used to treat mood disorders and relieve symptoms of depression) medication for six days. anticoagulant (class of medications used to prevent the formation of blood clots) medication for seven days, and antibiotic (class of medication used to treat bacterial infections) medication for four days.
R82's Nutritional Status Care Area Assessment (CAA) dated 08/26/21 documented she was at risk for alteration in weight related to her increase edema and staff to monitor her weight.
R82's Baseline Care Pan dated 08/13/21 directed staff to monitor weight daily.
Review of the EMR under the Orders revealed physician orders:
Daily weight, diagnosis CHF dated 08/13/21.
Fluid restriction: 200 cubic centimeter (CC) daily (360cc with breakfast, 240cc with lunch, 240cc with dinner, 580cc each shift in room, diagnosis CHF and hyponatremia (low sodium), dated 08/13/21.
Lasix (diuretic- medication to promote the formation and excretion of urine) tablet 20 milligrams (mg) by mouth, diagnosis edema (swelling due to fluid accumulation) dated 08/30/21.
Review of the EMR under Medication Administration Record documented on 08/17/21 resident refused weight; 08/19/21 Certified Nurse Aide (CNA) did not obtain weight; 08/20/21 CNA did not obtain weight; 08/21/21 CNA did not obtain weight; 08/25/21 resident unavailable; 08/29/21 resident was unavailable.
Review of the clinical record lacked physician notification of physician notification of daily weight not completed or resident refusal.
Review of the EMR under Progress Notes dated 08/30/21 at 11:43 AM R82 was transferred out of the facility to the hospital, per request of her representative related to increased bilateral lower extremity edema.
Review of the clinical record lacked physician notification of physician notification of daily weight not completed or resident refusal.
On 08/30/21 at 11:43 AM R82 was transported out of the facility on gurney by two emergency medical staff.
The Monthly Medication Review (MMR), performed by the CP, reviewed August 2021 did not identify the lack of weight monitoring related to R82's CHF.
On 09/01/21 at 02:35 PM in an interview, CNA N stated she had never obtained a weight for a resident.
On 09/01/21 at 02:45 PM in an interview, Licensed Nurse (LN) H stated a daily weight were obtained for a resident with CHF to monitor for increased edema. LN H stated that a daily weight would be obtained prior to breakfast by the CNA and reported to the nurse. LN H stated that the physician would be notified if a daily weight was not obtained for several days.
On 09/01/21 at 03:35 PM in an interview, CNA M stated the nurse notified the CNA of who needed a daily weight and if dayshift could not get the weight, then evening shift would attempt to weigh the resident.
On 09/01/21 at 03:53 PM in an interview, Administrative Nurse D stated the CNA obtained the weekly or daily weights as ordered by the physician. Administrative Nurse D stated the physician was in the facility every day and would have documented weight changes in their progress notes.
On 09/02/21 at 11:28 AM in an interview, CP GG stated she reviewed the resident's record monthly. CP GG stated that she reviewed medications, blood glucose readings, bowel monitoring, duplicate medication, documentation and appropriate medication, then notified the director of nursing of any irregularities and make recommendations when needed.
The facility Drug Regimen Review policy lacked a date documented a licensed pharmacist would review a resident's drug regimen including the resident's chart monthly. The CP may need to conduct the medication regimen review more frequently depending on the resident condition, review of the short stay residents and risk of adverse consequences. The licensed pharmacist will report irregularities to the attending physician, the facility's medical director and the director of nursing to be acted upon.
The facility failed to ensure the CP identified and reported the lack of consistent daily weights for R82 to monitor for fluid retention related to CHF, which had the potential of unnecessary diuretic medication administration thus leading to possible harmful side effects.
- R78's electronic medical record (EMR) from the Diagnoses tab documented diagnoses of diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin) and chronic kidney disease (damaged kidneys and unable to filter blood the way they should).
The admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of eight which indicated moderately impaired cognition. The MDS documented that R78 required extensive assistance of one staff member for activities of daily living (ADL's). The MDS documented R78 had received antipsychotic (class of medications used to treat psychosis (any major mental disorder characterized by a gross impairment in reality testing) and other mental emotional conditions) medication for six days, and antidepressant (class of medications used to treat mood disorders and relieve symptoms of depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness) medication for seven days during the look back period.
R78's Dehydration/Fluid Maintenance Care Area Assessment (CAA) dated 08/19/21 documented he was at risk for alteration in fluid volume to chronic kidney disease and him receiving dialysis (is a process of removing excess water, solutions and toxins from the blood). Staff to monitor fluid.
R78's Nutritional Status CAA dated 08/19/21 documented nursing staff was to monitor blood glucose levels as ordered by the physician to monitor for hypoglycemia (less than normal amount of sugar in the blood) and hyperglycemia (greater than normal amount of glucose in the blood). R78's was at risk alteration in weight related to dialysis and staff was to continue to monitor weight.
R78's Care Plan dated 08/27/21 documented medication and treatment would be administered per physician orders and bowel protocol to was to be followed. The Care Plan documented to obtain blood glucose levels and monitor for adverse side effects of medications and to notify the physician as needed. The Care Plan documented the CP was to review medications and alert the physician of any recommendations.
Review of the EMR under the Orders revealed physician orders:
MiraLAX (laxative- medication used to stimulate or facility evacuation of the bowels) powder 17 grams by mouth daily for constipation (hold for loose stools) dated 08/07/21.
Tradjenta (medication used to lower blood glucose levels) tablet five milligrams (mg) by mouth daily for diabetes dated 08/07/21.
Check blood glucose every morning. Notify physician if blood glucose is less than (<) 60 or greater than (>) 400 dated 08/07/21.
Weight Monday, Wednesday and Friday dated 08/09/21.
Review of the EMR under Vitals for bowel movements (BM) for August 2021 revealed 08/08/21 to 08/11/21 (four days) no documented BM; 08/25/21 to 08/29/21 (four days) no BM documented. The clinical record lacked documentation any as needed medication or physician was notified.
Review of the EMR under Vitals for weights revealed: 08/11/21 Certified Nurse Aide (CNA) did not obtain weight; 08/13/21 CNA did not obtain weight; 08/18/21 due to condition weight was not obtained; 08/20/21 CNA did not obtain weight; 08/25/21 resident refused weight; 08/27/21 resident was not available to obtain weight. The clinical record lacked documentation that the physician was notified of resident's refusal or of the weights not consistently obtained as ordered by physician.
Review of the EMR under Medication Administration Record (MAR) for blood glucose levels for August 2021 revealed: 08/10/21 resident at dialysis; 08/18/21 resident refused; 08/19/21 resident was unavailable; 08/20/21 resident refused; 08/21/21 resident was at dialysis; 08/24/21 resident was at dialysis; 08/26/21 resident was unavailable; 08/28/21 resident was at dialysis; 08/29/21 resident refused; 08/31/21 resident was at dialysis. The clinical record lacked documentation that the physician was notified of resident refusal or staff was unable to monitor blood glucose levels as ordered.
The Monthly Medication Review (MMR), performed by the CP, reviewed August 2021 did not identify the lack of weight monitoring, bowel monitoring and monitoring blood glucose levels for R78 who received dialysis.
09/01/21 at 10:37 AM nursing staff assisted R78 on to his bed, head of bed was elevated, no complaint of pain or discomfort was noted. R78 lacked his skin protective sleeves to his upper extremities for protection and his pressure reducing device for his left lower extremity was not applied.
On 09/01/21 at 02:35 PM in an interview, CNA N stated she had never obtained a weight for a resident. CNA N stated she monitored residents bowel movements to prevent constipation and everyone was able to document in the computer for bowel movements.
On 09/01/21 at 02:45 PM in an interview, Licensed Nurse (LN) H stated a daily weight were obtained for a resident with CHF to monitor for increased edema. LN H stated that a daily weight would be obtained prior to breakfast by the CNA and reported to the nurse. LN H stated that the physician would be notified if a daily weight was not obtained for several days. LN H stated blood glucose should be obtained prior to breakfast to monitor for diabetes mellitus, should someone refuse for several days in row the physician would be notified and documented in the nurses note. LN H stated that the unit manager prints off the bowel monitoring sheet of the residents who had not had a bowel movement for 72 hours and the nurse would follow up with the bowel protocol or notify the physician. LN H stated that if as needed medication (PRN) was given for constipation it would have been documented on the MAR.
On 09/01/21 at 03:35 PM in an interview, CNA M stated the nurse notified the CNA of who needed a daily weight and if dayshift could not get the weight, then evening shift would attempt to weigh the resident.
On 09/01/21 at 03:53 PM in an interview, Administrative Nurse D stated the CNA obtained the weekly or daily weights as ordered by the physician. Administrative Nurse D stated the physician was in the facility every day and would have documented weight changes in their progress notes. Administrative Nurse D stated bowel monitoring sheet is printed off by the nurse manager and given to the unit nurse to follow up. Administrative Nurse D stated that if a PRN was given it would be charted on the MAR. Administrative Nurse D stated if a resident refused a blood glucose test for several days the physician would have been aware, because she was at the facility almost everyday and would have documented on the physician progress note.
On 09/02/21 at 11:28 AM in an interview, CP GG stated she reviewed the resident's record monthly. CP GG stated that she reviewed medications, blood glucose readings, bowel monitoring, duplicate medication, documentation and appropriate medication, then notified the director of nursing of any irregularities and make recommendations when needed.
The facility Drug Regimen Review policy lacked a date documented a licensed pharmacist would review a resident's drug regimen including the resident's chart monthly. The CP may need to conduct the medication regimen review more frequently depending on the resident condition, review of the short stay residents and risk of adverse consequences. The licensed pharmacist will report irregularities to the attending physician, the facility's medical director and the director of nursing to be acted upon.
The facility failed to ensure the CP reported irregularities related weight monitoring to monitor fluid retention related to dialysis, blood glucose monitoring for hyperglycemia and hypoglycemia, and bowel monitoring for constipation for R78. This deficit practice had the potential for unnecessary medication use and unwarranted side effects for R78.
The facility identified a census of 37 residents. The sample included 13 residents with five residents sampled for unnecessary medication review. Based on observation, record review, and interview, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported to the facility irregularities (bowel monitoring was not being documented daily for Resident (R)23, weights were not obtained as ordered for R81 and R82, blood sugars were not obtained as ordered for R78). This deficient practice placed the residents at increased risk for complications related to unnecessary medications and adverse effects.
Findings included:
-The electronic medical record (EMR) for R23 documented diagnoses of fractures (broken bone) of lumbar spine, hemiplegia (paralysis of one side of the body) and hemiparesis (muscular weakness of one half of the body) following cerebral infarction (disrupted blood flow to the brain), constipation (difficulty passing stools), and aphasia (condition with disordered or absent language function), chronic low back pain.
The admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) was not performed and R23 was hardly ever understood. He required supervision to extensive assistance of one staff for activities of daily living (ADLs), had impairment of the lower extremity on one side, and used a walker and/or a wheelchair for mobility. R23 was continent of bowel.
The Urinary Incontinence Care Area Assessment (CAA) for R23 dated 08/16/21 documented he required limited to extensive assist with toileting. He was able to use his call light as needed for assistance. Nursing was to encourage R23 to use call light as needed for assistance with toileting and assist as needed.
The Pain Care Plan revised 8/23/21, instructed staff to monitor for adverse side effects of medication regimen; consult with physician as needed.
The Orders tab dated 08/03/21 recorded an order for the Certified Nurse Aide (CNA) to document bowel movements (BM) every shift (day 06:00 AM to 02:00 PM, evening 02:00 PM to 10:00 PM, night 10:00 PM to 06:00 AM) for constipation.
The Orders tab recorded an order dated 08/03/21 for general day three (Bowel Brigade) administer milk of magnesia (a medication used to treat constipation) 30 cubic centimeter (cc's) by mouth in the morning as needed (PRN).
The Orders tab recorded an order dated 08/03/21: Day 4 (Bowel Brigade) administer Dulcolax (a medication taken by mouth or rectally for constipation) 10 milligrams (mg) by mouth or by rectum in the am PRN for constipation.
The Orders tab recorded an order dated 08/03/21: Day 5 (Bowel Brigade) administer Fleets enema (introduction of a solution into the rectum for cleansing or therapeutic purposes).
The Orders tab recorded an order dated 08/03/21: Day 6 (Bowel Brigade), if no BM in greater than five days notify physician for further orders as needed.
The Vitals and Progress Notes tab in the EMR reviewed from 08/03/21 to 08/31/21 lacked any documentation of R23 having a bowel movement prior to 08/16/21.
Review of R23's Medication Administration Record for the month of August 2021 lacked documentation R23 received any ordered as needed bowel brigade treatment for no bowel movement for three days or more as ordered.
On 08/31/21 at 1:15 PM, R23 was upright, sitting in his wheelchair, he had his back brace on, at the bedside table was in front of him with meal tray on it, call light was within reach.
In an interview with CNA N on 09/01/21 at 2:23 PM, she stated she normally would go into each resident's room and ask them if they have had a BM. CNA N stated the facility CNAs monitor BM's to make sure that a resident is not getting constipated. BM's are charted under the outputs in the EMR and should be done each shift.
In an interview on 09/01/21 at 2:37PM Licensed Nurse (LN) H stated, BM's are monitored daily by Administrative Nurse E, she prints out a daily report of residents that have gone three days without a BM and the Bowel Brigade protocol would begin. BM's show up under vitals as output and in a progress note. The aides are supposed to ask a resident every time the vital signs are obtained if they have had a BM.
In an interview with Administrative Nurse D on 09/01/21 at 3:51PM she stated each morning a report is ran that shows who has gone three days without a BM. That list is given to the staff nurses and the Bowel Brigade protocol would be started.
In an interview with CP GG on 09/02/21 at 11:28 AM stated, she does a monthly review of resident's records and looked at documentation, and charting. She also looked at insulins, and other medications, behaviors, bowels, duplicate medications, and appropriate medications. She would notify Administrative Nurse D if any irregularities were noted and make recommendations when needed.
The undated facility policy Drug Regimen Review Policy documented: a licensed pharmacist with review the resident drug regimen including the resident chart at least once a month. The CP will report in writing, any irregularities to the attending physician, the facility's medical director and the director of nursing to be acted upon. The object of this requirement is to try to minimize or prevent adverse consequences or to prevent residents from receiving unnecessary drugs. The CP will complete the drug regimen review by reviewing the comprehensive assessment information of the resident, identifying irregularities, syndromes potentially related to medication therapy, adverse mediation consequence, as well as potential for adverse drug reactions and medication errors.
The undated facility policy Bowel Brigade documented each patient will receive bowel care per general orders on a routine and consistent basis. The purpose of this policy is to ensure adequate bowel evacuation in order to prevent complications or discomfort that may arise related to acute constipation or fecal impaction.
The facility failed to ensure the CP identified and reported irregularities of no bowel monitoring being documented for R23, which had the potential for increased risk for constipation due to lack of PRN bowel medications as ordered.
- The electronic medical record (EMR) for R81 documented diagnoses of congestive heart failure (CHF- a condition with low heart output and the body becomes congested with fluid), chronic kidney disease (loss of kidney function), acute respiratory failure (condition in which your blood does not have enough oxygen or has too much carbon dioxide causing shortness of breath and feeling extremely tired).
The admission Minimum Data Set (MDS) dated [DATE] for R81 documented a Brief Interview for Mental Status (BIMS) score of 14 which indicated intact cognition. R81 required supervision to limited assistance of one for activities of daily living (ADLs) and she used the assistance of a walker for ambulation. R81 received a diuretic (a medication to promote the formation and excretion of urine).
The Nutritional Status Care Area Assessment (CAA) dated 08/26/21, documented R81 was at alteration in weight due to the diagnosis of CHF. She was also on a 2000 milliliter (ml) a day fluid restriction. Staff was to continue to monitor weight weekly.
The Baseline Nutrition Care Plan dated 08/16/21 documented daily weights to be obtained and a fluid restriction of 2000 milliliters a day.
The Orders tab recorded an order dated 08/16/21 for daily weight for diagnosis CHF. The order directed staff to notify the physician of a weight gain greater than two pounds in a day or five pounds in a week.
The Treatment Administration Record (TAR) in the EMR for the month of August 2021 for R81, lacked documentation for a daily weight on five of the 16 days reviewed. A note was charted on the TAR by the nurse that the Certified nurse Aid (CNA) was unable to obtain weight with no explanation as to why.
Review of R81's weights on the TAR revealed she had a weight increase of 4.5 pounds between the dates of 08/24/21 and 08/26/21 (no weight was obtained on 08/25/21). The clinical record lacked evidence the physician was notified.
Review of the Physician Progress Notes in R81's chart noted no reference to the change in R81's weight on the above dates.
In an interview on 09/01/21 at 2:23 PM with CNA N she stated that she never had to get a weight for a resident because typically the day shift aides get weights. She would get a weight at the beginning of her shift if she needed to get one for a resident.
In an interview on 09/01/21 at 3:15PM with CNA M, she stated the only time a weight would not get done was if they got far behind. The nurse prints out a sheet that has a list of residents that need weighed that day. She would let the nurse know if a resident refused or if she was unable to get the weight done. Weights results are written on the weight sheet and then she would chart the weight under Vitals in the EMR.
In an interview on 09/01/21 at 2:37PM with Licensed Nurse (LN) H, LN H stated that daily weights are obtained for resident's that have CHF or are on a fluid restriction, or if they were on dialysis. The CNA's are who obtain the weights and they typically tried to get them done before a resident has had breakfast. The aide should try at least twice to get the weight, then tell they nurse that they were unable to get the weight or if the resident refused, then she would go in herself and ask the resident if she could get there weight. If they still refused, then she would chart a note on their TAR as well as a progress note. The weights are charted by the nurses. The nurse manager monitors the weights and reports changes to the physician. If a weight has not been obtained for more than three days, then she would call the physician to notify him if there was a change of two pound or more.
In an interview on 09/01/21 at 3:27 PM LN G stated that a resident could sign a refusal form to refuse getting their weight taken; but staff should try at least twice to obtain the weight before having the resident sign a refusal form. The physician should be notified when there is a weight change of more than two pounds in a day or five pounds in a week.
In an interview on 09/01/21 at 3:51 PM Administrative Nurse D stated that weights were done as ordered either daily or weekly by the CNA. If CNA staff were unable get the weight, the nurse should try to get a weight and if they were unable to obtain the weight, they would chart not able to obtain. Weight changes, if noticed by CP, would be noted on a physician progress note. The physician will note any weight changes in his progress notes as he was in the facility daily.
In an interview with CP GG on 09/02/21 at 11:28 AM stated, she does a monthly review of resident's records and looked at documentation, and charting. She also looked at insulins, and other medications, behaviors, bowels, duplicate medications, and appropriate medications. She would notify Administrative Nurse D if any irregularities were noted and make recommendations when needed.
The undated facility policy Drug Regimen Review Policy documented: a licensed pharmacist with review the resident drug regimen including the resident chart at least once a month. The CP will report in writing, any irregularities to the attending physician, the facility's medical director and the director of nursing to be acted upon. The object of this requirement is to try to minimize or prevent adverse consequences or to prevent residents from receiving unnecessary drugs. The CP will complete the drug regimen review by reviewing the comprehensive assessment information of the resident, identifying irregularities, syndromes potentially related to medication therapy, adverse mediation consequence, as well as potential for adverse drug reactions and medication errors.
The undated facility policy Weights documented: The clinical nurse manager will post all residents requiring charting for weight variances, please chart every shift three times daily speaking to the problem; ensure physician is notified of weight change.
The facility failed to ensure that the CP identified and reported missing daily weights and/or increases in R81's daily weight, which had the potential for unnecessary medication administration or complications related to CHF.

The facility identified a census of 37 residents, the sample included 13 residents. Based on observations, record reviews, and interviews, the facility failed to perform hand hygiene after doffing (removing) gloves or before donning (putting on) gloves during dressing changes. This deficient practice had the risk to spread illness and infection to all residents and prolonged wound healing for Resident (R) 179 and 78.
Findings included:
- On 09/01/21 at 09:30 AM, Administrative Nurse E performed hand hygiene in R179's sink. She then donned gloves and elevated R179's left arm on a pillow in preparation for the peripherally inserted central catheter (PICC- a form of intravenous access that can be used for a prolonged period of time) dressing change. She doffed gloves then donned new gloves, no hand hygiene performed between. She removed the previous dressing.
On 09/01/21 at 09:34 AM, Administrative Nurse E doffed gloves and performed hand hygiene. She opened the sterile (meaning free from microorganisms) dressing change tray on R179's bedside table. She opened her additional packaged supplies that sat on the bedside table and dropped into the sterile tray appropriately. She donned sterile gloves without performing hand hygiene. She asked another nurse to bring a smaller pair of sterile gloves. She doffed sterile gloves.
On 09/01/21 at 09:40 AM, Administrative Nurse E received new pair of sterile gloves from the other nurse and donned sterile gloves, no hand hygiene performed before she donned second pair of sterile gloves. After she cleansed R179's PICC line insertion site and surrounding skin, she applied the dressing as ordered. Once finished with the dressing change, she doffed sterile gloves. No hand hygiene performed after doffing gloves. She donned gloves and proceeded to assist resident.
On 09/01/21 at 10:41 AM, Administrative Nurse E performed hand hygiene and donned gloves. She prepared her supplies for R78's dressing change on a clean barrier which she then placed on R78's bed. R78 sat in a wheelchair in his room, Administrative Nurse E cleansed R78's left shin area and applied skin prep (a solution when applied that forms a protective waterproof barrier on the skin) then removed a soiled dressing from top of left foot. She doffed gloves then donned clean gloves, no hand hygiene between. She applied skin prep to top of left foot then applied dressing. She doffed gloves and donned clean gloves, no hand hygiene between. She assisted R78 into bed, doffed gloves and donned clean gloves, no hand hygiene between. Administrative Nurse E cleansed R78's coccyx (small triangular bone at the base of the spine) area, doffed gloves then donned clean gloves, no hand hygiene between. She applied barrier cream to coccyx region then doffed gloves.
On 09/01/21 at 03:15 PM, Certified Nurse Aide (CNA) M stated hand hygiene was performed before entering or exiting resident rooms, before and after eating, after touching hair or face, and after doffing gloves.
On 09/01/21 at 03:26 PM, Licensed Nurse (LN) G stated hand hygiene was performed before entering or exiting resident rooms, after doffing gloves and before putting on gloves, and whenever hands were soiled.
On 09/01/21 at 03:50 PM, Administrative Nurse D stated hand hygiene was performed before entering and exiting resident rooms, between meal tray deliveries, and after doffing and before putting on gloves.
The facility's Handwashing policy, not dated, directed handwashing occurred before applying and after removing gloves, during any treatment as dictated by professional standards, before handling sterile supplies, and after contact with any equipment or environmental surface that might have been soiled or contaminated.
The facility failed to perform hand hygiene after doffing and before donning gloves during dressing changes. This deficient practice had the risk to spread illness and infection and prolong wound healing for R179 and R78.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 37 residents. The sample included 13 residents; one resident sampled for hospitalization. Based on record review and interviews, the facility failed to provide a written notification of transfer, as soon as was practicable, to Resident (R) 178 or to her family/durable power of attorney (DPOA- legal document that named a person to make healthcare decisions when the resident was no longer able to). This deficient practice had the risk of miscommunication between facility and resident/family and possible missed opportunity for healthcare services.
Findings included:
- R178 was admitted to facility on 07/12/21, transferred to hospital 07/22/21, returned to facility 07/23/21, discharged to hospital 07/23/21, readmitted to facility 07/28/21, then discharged to hospital 08/06/21.
R178's Electronic Medical Record (EMR) documented diagnoses of fracture of unspecified part of right clavicle (bone that connects the breastplate to the shoulder), cellulitis (skin infection caused by bacteria characterized by heat, redness and swelling) of face, and repeated falls.
The Baseline Person Centered Care Plan dated 07/12/21 documented R178 was alert and oriented to person, place, time, and situation.
R178's medical record lacked documentation of a written notification of transfer to resident or family for the transfers to the hospital on [DATE], 07/23/21, and 08/06/21.
Facility unable to provide written notification of transfer for transfers to hospital on [DATE], 07/23/21, and 08/06/21.
On 09/01/21 at 11:08 AM, Administrative Nurse D stated the facility did not provide a written notification of transfer to resident or family. She stated the residents who were transferred to the hospital were in an emergency and were not coherent enough to understand. She stated the family was notified of transfers by phone call.
On 09/01/21 at 03:26 PM, Licensed Nurse (LN) G stated when a resident was transferred to the hospital, the family was notified by phone call. LN G had not heard of a written notification of transfer to family or resident.
On 09/01/21 at 03:50 PM, Administrative Nurse D stated the facility did not provide written notification of transfers to resident or family because the facility did not know if the resident was discharged or if the resident would return to facility.
The facility's Transfer Agreement policy, not dated, lacked direction of a written notification of transfer to resident or family/DPOA.
The facility failed to provide a written notification of transfer to R178 or her family/DPOA. This deficient practice had the risk of miscommunication between facility and resident/family and possible missed opportunity for healthcare services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 37 residents. The sample included 13 residents with three residents sampled for falls. Based on observations, record reviews, and interviews, the facility failed to investigate causative factors and ensure interventions were followed for the prevention of falls for Resident (R) 8. This deficient practice placed R8 at increased risk for further falls, possible injuries from falls, and unwarranted physical complications.
Findings included:
- R8's Electronic Medical Record (EMR) documented a diagnosis of hemiplegia (paralysis of one side of the body) and hemiparesis (muscular weakness of one half of the body) following cerebral infarction (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) affecting right dominant side.
The admission Minimum Data Set (MDS) dated [DATE], documented R8 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. R8 required extensive physical assistance with one staff for bed mobility, transfers, dressing, and toileting. R8 had not fallen since admission at time of assessment.
The Falls Care Area Assessment (CAA) dated 07/22/21, documented R8 was at risk for falls related to weakness and nursing encouraged her to use call light for assistance with all mobility.
The Care Plan dated 08/03/21, documented R8 was identified at risk for falls and documented an intervention with a start date of 08/22/21 for 15 minute checks. The Care Plan lacked interventions for fall on 08/19/21.
A Progress Note in R8's EMR on 08/19/21 at 06:26 AM documented the Certified Nurse Aide (CNA) found R8 on the floor. R8 was on the floor on the left side of her bed wrapped with blankets and stated she turned on her side then slide out of bed. Hourly checks initiated.
The investigation provided by facility for fall on 08/19/21 documented R8 was on hourly checks for fall prevention. The investigation lacked a root cause analysis.
A Progress Note in R8's EMR on 08/20/21 at 08:02 AM documented R8 was found at the side of the bed on the floor next to the dresser. R8 complained of back and left lower extremity pain and had a bleeding skin tear on her left upper extremity. R8 was not moved per protocol and Emergency Medical Technicians (EMTs) were notified and transported R8 to the hospital.
A Progress Note in R8's EMR on 08/20/21 at 04:52 PM documented R8 returned to facility around 11:30 AM and continued on 30 minute checks.
The investigation provided by facility for fall on 08/20/21 documented R8 was on hourly checks for fall prevention then every 30 minute checks and then 15 minute checks for fall prevention. The investigation lacked a root cause analysis.
The Orders section of R8's EMR documented an order with a start date of 08/23/21 for every 15 minute checks every shift for fall prevention.
The Room Visual Checks documentation in R8's medical record revealed six out of 12 available pages were dated 08/19/21 and listed R8 was on hourly checks. Three pages dated 8/24/21, 08/25/21, and 08/26/21 listed R8 was on hourly checks and lacked documentation from 06:15 AM to 09:45 PM. A page dated 08/27/21 documented R8 was on hourly checks and lacked documentation from 12:00 AM to 01:45 PM and from 10:15 PM to 11:45 PM. A page dated 08/30/21 documented R8 was on hourly checks and lacked documentation from 07:00 AM to 11:45 PM. A page dated 08/31/21 documented R8 was on 15 minute checks and lacked documentation from 12:00 AM to 05:45 AM.
On 08/31/21 at 04:46 PM, R8 laid in bed, staff assisted her with repositioning in bed for comfort. She appeared comfortable and without signs of discomfort or distress.
On 08/31/21 at 11:02 AM, Administrative Nurse D stated the root cause analysis was completed on the back of the investigations and new interventions were documented there as well
On 09/01/21 at 10:32 AM, Administrative Nurse F stated she was unable to locate any resolved fall interventions on R8's care plan.
On 09/01/21 at 03:15 PM, CNA M stated if a resident fell, she immediately called for help from the nurse. While she waited for help, she asked the resident what happened. She stated new interventions for fall prevention were passed on during report and there was communication with the nurse. She stated there was a document that listed what room numbers were on visual checks and stated R8 was on visual checks, was previously hourly checks but currently required 15 minute checks. CNA M stated visual checks were documented on paper. She was unsure of a way to look up the interventions in the computer.
On 09/01/21 at 03:26 PM, Licensed Nurse (LN) G stated when a resident fell, she investigated and assessed the resident. She found out who last saw the resident and how they fell if it was unwitnessed. LN G stated interventions were put into place to prevent further falls, R8 received a perimeter mattress since she rolled out of bed. She stated new interventions were placed on the Treatment Administration Record (TAR) and CNAs were notified each morning which residents were on visual checks. It was the nurse's responsibility to let the aide know and the aide was to grab a new visual check sheet to complete during the shift for the correct duration.
On 09/01/21 at 03:50 PM, Administrative Nurse D stated if a resident was found on the floor, the staff member who found them reported it to the nurse. An incident report was filled out, unwitnessed falls were placed on neurological checks and the incident report went into her box. The Interdisciplinary Team met every morning to discuss falls and what interventions were to be implemented. Interventions were placed in the EMR as orders. The CNA was to get a new visual check sheet at the beginning of the shift or day.
The facility's Fall Prevention policy, not dated, directed safety interventions were implemented and monitored with appropriate documentation as indicated. The assigned LN was responsible for ensuring the safety checks were in place as care planned and initialed the Treatment Administration Record indicating checks were completed.
According to the Centers for Medicare and Medicaid Services (CMS) the definition of a Root Cause Analysis (RCA) is a structured facilitated team process to identify root causes of an event that resulted in an undesired outcome and develop corrective actions. The RCA process provides the facility with a way to identify breakdowns in processes and systems that contributed to the event and how to prevent future events.
The facility failed to investigate causative factors and ensure interventions were followed for the prevention of falls for R8. This deficient practice had the risk for further falls, possible injuries from falls, and unwarranted physical complications.

The facility identified a census of 37 residents, two medication carts, one treatment cart, and one medication storage room. Based on observations, record reviews, and interviews, the facility failed to discard expired medications and influenza (a common viral infection that can be deadly, especially in high-risk groups) vaccinations; failed to properly store and date Tubersol (tuberculin purified protein derivative [PPD- sterile solution of a purified protein derivative used in the diagnosis of tuberculosis]); failed to properly store and date insulin (medication used to treat a chronic condition that affected the way the body processed blood sugar); failed to properly store and date medicated eye drops; and failed to properly store and date a medicated inhaler (device used for administering a medication that was breathed in to relieve asthma [disorder of narrowed airways that caused wheezing and shortness of breath] or other lung disorders). This deficient practice had the risk for unwarranted physical complications and ineffective treatment for affected residents.
Findings included:
- On 08/30/21 at 09:10 AM, the 200 hall medication cart revealed a bottle of cetirizine (allergy medication) that expired July 2021 and an Ozempic (non-insulin medication used to help improve blood sugars) pen not labeled with resident name or dated.
On 08/30/21 at 09:18 AM, the medication storage room revealed the following:
Four vials of Flucelvax influenza vaccinations, expired 06/30/2021
Three boxes of Afluria influenza vaccination prefilled syringes, expired 06/30/2021
Four vials of Tubersol, opened and not dated
On 08/30/21 at 09:26 AM, the 100 hall medication cart revealed the following:
One bottle of cetirizine, expired July 2021
Two bottles of Timolol (medication used to treat high pressure in the eye) eye drops, opened and not dated
Two insulin lispro (Humalog) pens, not dated
Three Lantus insulin pens, not dated
One Trelegy (medication used to prevent and control symptoms of asthma) inhaler, opened and not dated
On 08/30/21 at 09:10 AM, Licensed Nurse (LN) I stated the Ozempic pen was refrigerated and the resident it belonged to received it this morning. LN I stated the pen came out of a box so it was not labeled when removed from the box.
On 08/30/21 at 09:21 AM, LN I stated she was not sure how long Tubersol vials were good once opened.
On 09/01/21 at 04:28 PM, LN J stated the facility checked the medication storage room and medication carts every couple of months. She stated when a new insulin pen was opened, the bag was dated, and inhaler boxes were dated when opened. She had not seen a medication reference sheet for expiration dates.
On 09/01/21 at 04:32 PM, Administrative Nurse D stated medical records was responsible for checking the medication storage room and medication storage carts monthly. She stated when a new insulin pen, inhaler, or eye drop bottle was opened, it was dated.
The facility's Diabetes: Insulins and Storage Requirements 2018 reference guide from pharmacy directed insulin lispro pens were good for 28 days once opened or removed from refrigeration, Lantus insulin pens were good for 28 days once opened or removed from refrigeration, and Ozempic was good for 56 days once opened or removed from refrigeration. All three of these insulins were to be stored at room temperature once opened.
A review of the manufacturer's instructions for Tubersol vials directed Tubersol vials were discarded 30 days after first opening.
A review of the manufacturer's instructions for timolol eye drops directed timolol eye drops were discarded four weeks after opening.
A review of the manufacturer's instructions for Trelegy inhaler directed Trelegy inhalers were discarded six weeks after opening the foil packet.
The facility's Medication Storage policy, not dated, directed medications were stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. The policy directed outdated medications were immediately removed stock and disposed of according to procedures for medication disposal. The policy directed drug references were available for all drugs used in the facility.
The facility failed to ensure expired medications and influenza vaccinations were discarded after expiration date; failed to properly store and date Tubersol vials, insulin pens, eye drops, and an inhaler. This deficient practice had the risk for unwarranted physical complications and ineffective treatment for affected residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 38 residents. The sample included 13 residents with five residents reviewed for medications. Based on record review, observations and interviews, the facility failed to ensure Resident (R)18 was free from unnecessary psychotropic (affecting mood or thinking) medications when the facility failed to ensure R18's as needed (PRN) lorazepam ( psychotropic antianxiety medication) had the required stop date of 14 days. This placed R18 at risk for unnecessary medications and side effects associated with lorazepam use.
Findings included:
- R18's electronic medical record (EMR) recorded diagnoses of generalized anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), falls and altered mental status.
The admission Minimum Data Set (MDS) dated [DATE] recorded R18 had a Brief interview for mental Status (BIMS) score of eight which indicated severely impaired cognition. The MDS recorded R18 had no behaviors. The MDS recorded R18 did not receive an antianxiety medication during the lookback period.
The Cognitive Loss Care Area Assessment (CAA) dated 08/05/21 recorded R18 was forgetful and received therapy for cognitive skills. The CAA recorded medications were reviewed by the physician and adjusted as needed. Staff provided reorientation as needed and assisted with activities of daily living (ADLs).
The Psychotropic Medication CAA did not trigger.
The Care Plan documented a problem, dated 08/19/21 which recorded R18 had an alteration in mood status (anxiety) evidenced by restlessness. The Care Plan recorded interventions dated 08/19/21 which directed staff to administer medications, Ativan (lorazepam), per physician order. It further directed staff to monitor for the side effects of the psychotropic medication which included sedation, ataxia (drunk walk), dizziness, nausea, vomiting, confusion, headache, blurred vision and skin rash. The Care Plan further directed staff to monitor for increased signs of anxiety and offer counseling services as needed.
The Orders tab of the EMR recorded a physician order dated 07/30/21 for lorazepam 0.5 milligrams (mg) give 0.25 mg by mouth every eight hours PRN. The order was open-ended and did not contain a specific stop date.
The Psychopharmacological Medication Review dated 08/06/21 and signed by a nurse but lacking a pharmacist signature recorded R18 received lorazepam 0.25 mg for anxiety. The frequency recorded 0. The form indicated R18 consented to the psychotropic medication and had been notified of the possible side effects. The form indicated the therapy was not initiated in-house and there was no duplication of therapy. The form indicated the medication as appropriate for use in geriatric (elderly) patients, was within the recommended guidelines and had an appropriate diagnosis. Side effects monitoring were in place and R18's plan of care addressed the use of the medication. The form lacked evidence the physician reviewed, indicated a need for ongoing therapy and lacked a duration for the PRN medication.
R18's medical record lacked documentation of physician evaluation and rationale for continued lorazepam use and lacked a duration for the PRN order.
The Medication Administration Record (MAR) for August 2021 recorded 18 received the PRN lorazepam on 08/13/21, 08/16/21, 08/20/21, 08/21/21, 08/22/21, 08/23/21, 08/24/21, 08/25/21, 08/26/21, 08/27/21, twice on 08/30/21, and on 08/31/21.
The Monthly Medication Review dated 08/26/21 by Consultant Pharmacist (CP) GG documented R18 had an active order for PRN lorazepam. CP GG recommended if appropriate to extend the order beyond 14 days, ensure proper documentation existed in R18's medical record and ensure it indicated the duration for the PRN order.
On 08/31/21 at 12:27 PM R18 sat up in bed and ate lunch. She appeared comfortable, and no behaviors were observed.
On 09/01/21 at 02:45 PM Licensed Nurse (LN) H stated she was unaware of the need for any type of evaluation or risk versus benefit review for nay medications. She also stated the only medications the required a stop date were antibiotics.
On 09/01/21 at 03: 53 PM Administrative Nurse D stated medications risk versus benefit evaluations were completed by LN K. Administrative Nurse D declined to offer a further statement other than to say they're done.
The undated Psychopharmacological Med Management policy recorded psychotropic medication included antianxiety medication. It further directed residents admitted to the facility receiving psychotropic medications would receive a comprehensive and ongoing evaluation of their current medication regimen. Evaluation examined appropriateness of medication, dosage, duration and diagnosis. The policy further directed all PRN psychotropic medications would not exceed 14 days unless medically necessary and rational documented by the resident's physician.
The facility failed to ensure R18 was free from unnecessary psychotropic medication use when the facility failed to ensure the physician evaluated and documented a rationale for continued use of PRN lorazepam and failed to ensure a specified duration for the PRN psychotropic lorazepam. This placed R18 at increased risk for unnecessary medications and increased s risk for adverse effects related to psychotropic medication use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** - R82's electronic medical record (EMR) from the Diagnoses tab documented diagnoses of congestive heart failure (CHF - a condition with low heart output and the body becomes congested with fluid), depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness), and hypertension (elevated blood pressure).
The admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of nine which indicated moderately impaired cognition. The MDS documented that R82 required extensive assistance of one staff member for activities of daily living (ADL's). The MDS documented R82 received antidepressant (class of medications used to treat mood disorders and relieve symptoms of depression) medication for six days. anticoagulant (class of medications used to prevent the formation of blood clots) medication for seven days, and antibiotic (class of medication used to treat bacterial infections) medication for four days.
R82's Nutritional Status Care Area Assessment (CAA) dated 08/26/21 documented she was at risk for alteration in weight related to her increase edema and staff to monitor her weight.
R82's Baseline Care Plan dated 08/13/21 directed staff to monitor weight daily.
Review of the EMR under the Orders revealed physician orders:
Daily weight, diagnosis CHF dated 08/13/21.
Fluid restriction: 200 cubic centimeter (CC) daily (360cc with breakfast, 240cc with lunch, 240cc with dinner, 580cc each shift in room, diagnosis CHF and hyponatremia (low sodium), dated 08/13/21.
Lasix (diuretic- medication to promote the formation and excretion of urine) tablet 20 milligrams (mg) by mouth, diagnosis edema (swelling due to fluid accumulation) dated 08/30/21.
Review of the EMR under Medication Administration Record documented on 08/17/21 resident refused weight; 08/19/21 Certified Nurse Aide (CNA) did not obtain weight; 08/20/21 CNA did not obtain weight; 08/21/21 CNA did not obtain weight; 08/25/21 resident unavailable; 08/29/21 resident was unavailable.
Review of the clinical record lacked physician notification of daily weight not completed or resident refusal.
Review of the EMR under Progress Notes dated 08/30/21 at 11:43 AM R82 was transferred out of the facility to the hospital, per request of her representative related to increased bilateral lower extremity edema.
On 08/30/21 at 11:43 AM R82 was transported out of the facility on gurney by two emergency medical staff.
On 09/01/21 at 02:35 PM in an interview, CNA N stated she had never obtained a weight for a resident.
On 09/01/21 at 02:45 PM in an interview, Licensed Nurse (LN) H stated a daily weight were obtained for a resident with CHF to monitor for increased edema. LN H stated that a daily weight would be obtained prior to breakfast by the CNA and reported to the nurse. LN H stated that the physician would be notified if a daily weight was not obtained for several days.
On 09/01/21 at 03:35 PM in an interview, CNA M stated the nurse notified the CNA of who needed a daily weight and if dayshift could not get the weight, then evening shift would attempt to weigh the resident.
On 09/01/21 at 03:53 PM in an interview, Administrative Nurse D stated the CNA obtained the weekly or daily weights as ordered by the physician. Administrative Nurse D stated the physician was in the facility every day and would have documented weight changes in their progress notes.
The facility Drug Regimen Review policy lacked a date documented a licensed pharmacist would review a resident's drug regimen including the resident's chart monthly. The CP may need to conduct the medication regimen review more frequently depending on the resident condition, review of the short stay residents and risk of adverse consequences. The licensed pharmacist will report irregularities to the attending physician, the facility's medical director and the director of nursing to be acted upon.
The facility failed to ensure the daily weights for R82 had been obtained to monitor for fluid retention related to CHF, which had the potential of unnecessary diuretic medication administration thus leading to possible harmful side effects.
- R78's electronic medical record (EMR) from the Diagnoses tab documented diagnoses of diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin) and chronic kidney disease (damaged kidneys and unable to filter blood the way they should).
The admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of eight which indicated moderately impaired cognition. The MDS documented that R78 required extensive assistance of one staff member for activities of daily living (ADLs). The MDS documented R78 had received antipsychotic (class of medications used to treat psychosis [any major mental disorder characterized by a gross impairment in reality testing) and other mental emotional conditions] medication for six days, and antidepressant (class of medications used to treat mood disorders and relieve symptoms of depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness) medication for seven days during the look back period.
R78's Dehydration/Fluid Maintenance Care Area Assessment (CAA) dated 08/19/21 documented he was at risk for alteration in fluid volume to chronic kidney disease and him receiving dialysis (a process of removing excess water, solutions and toxins from the blood). Staff to monitor fluid.
R78's Nutritional Status CAA dated 08/19/21 documented nursing staff was to monitor blood glucose levels as ordered by the physician to monitor for hypoglycemia (less than normal amount of sugar in the blood) and hyperglycemia (greater than normal amount of glucose in the blood). R78's was at risk alteration in weight related to dialysis and staff was to continue to monitor weight.
R78's Care Plan dated 08/27/21 documented medication and treatment would be administered per physician orders and bowel protocol to was to be followed. The Care Plan documented to obtain blood glucose levels and monitor for adverse side effects of medications and to notify the physician as needed. The Care Plan documented the Consultant Pharmacist (CP) was to review medications and alert the physician of any recommendations.
Review of the EMR under the Orders revealed physician orders:
MiraLAX (laxative- medication used to stimulate or facility evacuation of the bowels) powder 17 grams by mouth daily for constipation (hold for loose stools) dated 08/07/21.
Tradjenta (medication used to lower blood glucose levels) tablet five milligrams (mg) by mouth daily for diabetes dated 08/07/21.
Check blood glucose every morning. Notify physician if blood glucose is less than (<) 60 or greater than (>) 400 dated 08/07/21.
Weight Monday, Wednesday and Friday dated 08/09/21.
Review of the EMR under Vitals for bowel movements (BM) for August 2021 revealed 08/08/21 to 08/11/21 (four days) no documented BM; 08/25/21 to 08/29/21 (four days) no BM documented. The clinical record lacked documentation any as needed medication or physician was notified.
Review of the EMR under Vitals for weights revealed: 08/11/21 Certified Nurse Aide (CNA) did not obtain weight; 08/13/21 CNA did not obtain weight; 08/18/21 due to condition weight was not obtained; 08/20/21 CNA did not obtain weight; 08/25/21 resident refused weight; 08/27/21 resident was not available to obtain weight. The clinical record lacked documentation that the physician was notified of resident's refusal or of the weights not consistently obtained as ordered by physician.
Review of the EMR under Medication Administration Record (MAR) for blood glucose levels for August 2021 revealed: 08/10/21 resident at dialysis; 08/18/21 resident refused; 08/19/21 resident was unavailable; 08/20/21 resident refused; 08/21/21 resident was at dialysis; 08/24/21 resident was at dialysis; 08/26/21 resident was unavailable; 08/28/21 resident was at dialysis; 08/29/21 resident refused; 08/31/21 resident was at dialysis. The clinical record lacked documentation that the physician was notified of resident refusal or staff was unable to monitor blood glucose levels as ordered.
09/01/21 at 10:37 AM nursing staff assisted R78 on to his bed, head of bed was elevated, no complaint of pain or discomfort was noted. R78 lacked his skin protective sleeves to his upper extremities for protection and his pressure reducing device for his left lower extremity was not applied.
On 09/01/21 at 02:35 PM in an interview, CNA N stated she had never obtained a weight for a resident. CNA N stated she monitored residents bowel movements to prevent constipation and everyone was able to document in the computer for bowel movements.
On 09/01/21 at 02:45 PM in an interview, Licensed Nurse (LN) H stated a daily weight were obtained for a resident with CHF to monitor for increased edema. LN H stated that a daily weight would be obtained prior to breakfast by the CNA and reported to the nurse. LN H stated that the physician would be notified if a daily weight was not obtained for several days. LN H stated blood glucose should be obtained prior to breakfast to monitor for diabetes mellitus, should someone refuse for several days in row the physician would be notified and documented in the nurses note. LN H stated that the unit manager prints off the bowel monitoring sheet of the residents who had not had a bowel movement for 72 hours and the nurse would follow up with the bowel protocol or notify the physician. LN H stated that if as needed medication (PRN) was given for constipation it would have been documented on the MAR.
On 09/01/21 at 03:35 PM in an interview, CNA M stated the nurse notified the CNA of who needed a daily weight and if dayshift could not get the weight, then evening shift would attempt to weigh the resident.
On 09/01/21 at 03:53 PM in an interview, Administrative Nurse D stated the CNA obtained the weekly or daily weights as ordered by the physician. Administrative Nurse D stated the physician was in the facility every day and would have documented weight changes in their progress notes. Administrative Nurse D stated bowel monitoring sheet is printed off by the nurse manager and given to the unit nurse to follow up. Administrative Nurse D stated that if a PRN was given it would be charted on the MAR. Administrative Nurse D stated if a resident refused a blood glucose test for several days the physician would have been aware, because she was at the facility almost every day and would have documented on the physician progress note.
The undated facility policy Drug Regimen Review documented: Monitoring is the ongoing collection and analysis of information (such as observations and diagnostic test results) and comparison to baseline data in order to- ascertain the individual's response to treatment and care, including progress or lack of progress toward a therapeutic goal; detect any complications or adverse consequences of the condition or of the treatments; and support decisions about modifying, discontinuing, or continuing any interventions.
The facility failed to obtain weights and blood glucose levels consistently as ordered by the physician and monitor bowel movements for R78. This deficit practice had the potential for unnecessary medication use and unwarranted side effects of constipation, hyperglycemia, hypoglycemia, and fluid volume overload for related to kidney failure.
The facility identified a census of 37 residents. The sample included 13 residents with five residents sampled for unnecessary medication review. Based on observation, record review, and interview, the facility failed to ensure that bowel monitoring was being documented daily and bowel medications administered as ordered for Resident (R)23 and R78, weights were obtained as ordered for R81, and R82, and blood sugars were obtained as ordered for R78. This deficient practice placed the residents at increased risk for complications related to unnecessary medications and adverse effects.
Findings included:
- The electronic medical record (EMR) for R23 documented diagnoses of fractures (broken bone) of lumbar spine, hemiplegia (paralysis of one side of the body) and hemiparesis (muscular weakness of one half of the body) following cerebral infarction (disrupted blood flow to the brain), constipation (difficulty passing stools), and aphasia (condition with disordered or absent language function), chronic low back pain.
The admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) was not performed and R23 was hardly ever understood. He required supervision to extensive assistance of one staff for activities of daily living (ADLs), had impairment of the lower extremity on one side, and used a walker and/or a wheelchair for mobility. R23 was continent of bowel.
The Urinary Incontinence Care Area Assessment (CAA) for R23 dated 08/16/21 documented he required limited to extensive assist with toileting. He was able to use his call light as needed for assistance. Nursing was to encourage R23 to use call light as needed for assistance with toileting and assist as needed.
The Pain Care Plan revised 8/23/21, instructed staff to monitor for adverse side effects of medication regimen; consult with physician as needed.
The Orders tab dated 08/03/21 recorded an order for the Certified Nurse Aide (CNA) to document bowel movements (BM) every shift (day 06:00 AM to 02:00 PM, evening 02:00 PM to 10:00 PM, night 10:00 PM to 06:00 AM) for constipation.
The Orders tab recorded an order dated 08/03/21 for general day three (Bowel Brigade) administer milk of magnesia (a medication used to treat constipation) 30 cubic centimeter (cc's) by mouth in the morning as needed (PRN).
The Orders tab recorded an order dated 08/03/21: Day 4 (Bowel Brigade) administer Dulcolax (a medication taken by mouth or rectally for constipation) 10 milligrams (mg) by mouth or by rectum in the am PRN for constipation.
The Orders tab recorded an order dated 08/03/21: Day 5 (Bowel Brigade) administer Fleets enema (introduction of a solution into the rectum for cleansing or therapeutic purposes).
The Orders tab recorded an order dated 08/03/21: Day 6 (Bowel Brigade), if no BM in greater than five days notify physician for further orders as needed.
The Vitals and Progress Notes tab in the EMR reviewed from 08/03/21 to 08/31/21 lacked any documentation of R23 having a bowel movement prior to 08/16/21.
Review of R23's Medication Administration Record for the month of August 2021 lacked documentation R23 received any ordered as needed bowel brigade treatment for no bowel movement for three days or more as ordered.
On 08/31/21 at 1:15 PM, R23 was upright, sitting in his wheelchair, he had his back brace on, at the bedside table was in front of him with meal tray on it, call light was within reach.
In an interview with CNA N on 09/01/21 at 2:23 PM, she stated she normally would go into each resident's room and ask them if they have had a BM. CNA N stated the facility CNAs monitor BM's to make sure that a resident is not getting constipated. BM's are charted under the outputs in the EMR and should be done each shift.
In an interview on 09/01/21 at 2:37PM Licensed Nurse (LN) H stated, BM's are monitored daily by Administrative Nurse E, she prints out a daily report of residents that have gone three days without a BM and the Bowel Brigade protocol would begin. BM's show up under vitals as output and in a progress note. The aides are supposed to ask a resident every time the vital signs are obtained if they have had a BM.
In an interview with Administrative Nurse D on 09/01/21 at 3:51PM she stated each morning a report is ran that shows who has gone three days without a BM. That list is given to the staff nurses and the Bowel Brigade protocol would be started.
The undated facility policy Drug Regimen Review documented: Monitoring is the ongoing collection and analysis of information (such as observations and diagnostic test results) and comparison to baseline data in order to- ascertain the individual's response to treatment and care, including progress or lack of progress toward a therapeutic goal; detect any complications or adverse consequences of the condition or of the treatments; and support decisions about modifying, discontinuing, or continuing any interventions.
The undated facility policy Bowel Brigade documented each patient will receive bowel care per general orders on a routine and consistent basis. The purpose of this policy is to ensure adequate bowel evacuation in order to prevent complications or discomfort that may arise related to acute constipation or fecal impaction.
The facility failed to ensure bowel monitoring was documented and as needed medications administered as ordered for R23, which had the potential for increased risk for constipation.
- The electronic medical record (EMR) for R81 documented diagnoses of congestive heart failure (CHF- a condition with low heart output and the body becomes congested with fluid), chronic kidney disease (loss of kidney function), acute respiratory failure (condition in which your blood does not have enough oxygen or has too much carbon dioxide causing shortness of breath and feeling extremely tired).
The admission Minimum Data Set (MDS) dated [DATE] for R81 documented a Brief Interview for Mental Status (BIMS) score of 14 which indicated intact cognition. R81 required supervision to limited assistance of one for activities of daily living (ADLs) and she used the assistance of a walker for ambulation. R81 received a diuretic (a medication to promote the formation and excretion of urine).
The Nutritional Status Care Area Assessment (CAA) dated 08/26/21, documented R81 was at alteration in weight due to the diagnosis of CHF. She was also on a 2000 milliliter (ml) a day fluid restriction. Staff was to continue to monitor weight weekly.
The Baseline Nutrition Care Plan dated 08/16/21 documented daily weights to be obtained and a fluid restriction of 2000 milliliters a day.
The Orders tab recorded an order dated 08/16/21 for daily weight for diagnosis CHF. The order directed staff to notify the physician of a weight gain greater than two pounds in a day or five pounds in a week.
The Treatment Administration Record (TAR) in the EMR for the month of August 2021 for R81, lacked documentation for a daily weight on five of the 16 days reviewed. A note was charted on the TAR by the nurse that the Certified nurse Aid (CNA) was unable to obtain weight with no explanation as to why.
Review of R81's weights on the TAR revealed she had a weight increase of 4.5 pounds between the dates of 08/24/21 and 08/26/21 (no weight was obtained on 08/25/21). The clinical record lacked evidence the physician was notified.
Review of the Physician Progress Notes in R81's chart noted no reference to the change in R81's weight on the above dates.
In an interview on 09/01/21 at 2:23 PM with CNA N she stated that she never had to get a weight for a resident because typically the day shift aides get weights. She would get a weight at the beginning of her shift if she needed to get one for a resident.
In an interview on 09/01/21 at 3:15PM with CNA M, she stated the only time a weight would not get done was if they got far behind. The nurse prints out a sheet that has a list of residents that need weighed that day. She would let the nurse know if a resident refused or if she was unable to get the weight done. Weights results are written on the weight sheet and then she would chart the weight under Vitals in the EMR.
In an interview on 09/01/21 at 2:37PM with Licensed Nurse (LN) H, LN H stated that daily weights are obtained for resident's that have CHF or are on a fluid restriction, or if they were on dialysis. The CNA's are who obtain the weights and they typically tried to get them done before a resident has had breakfast. The aide should try at least twice to get the weight, then tell they nurse that they were unable to get the weight or if the resident refused, then she would go in herself and ask the resident if she could get there weight. If they still refused, then she would chart a note on their TAR as well as a progress note. The weights are charted by the nurses. The nurse manager monitors the weights and reports changes to the physician. If a weight has not been obtained for more than three days, then she would call the physician to notify him if there was a change of two pound or more.
In an interview on 09/01/21 at 3:27 PM LN G stated that a resident could sign a refusal form to refuse getting their weight taken; but staff should try at least twice to obtain the weight before having the resident sign a refusal form. The physician should be notified when there is a weight change of more than two pounds in a day or five pounds in a week.
In an interview on 09/01/21 at 3:51 PM Administrative Nurse D stated that weights were done as ordered either daily or weekly by the CNA. If CNA staff were unable get the weight, the nurse should try to get a weight and if they were unable to obtain the weight, they would chart not able to obtain. Weight changes, if noticed by CP, would be noted on a physician progress note. The physician will note any weight changes in his progress notes as he was in the facility daily.
The undated facility policy Drug Regimen Review documented: Monitoring is the ongoing collection and analysis of information (such as observations and diagnostic test results) and comparison to baseline data in order to- ascertain the individual's response to treatment and care, including progress or lack of progress toward a therapeutic goal; detect any complications or adverse consequences of the condition or of the treatments; and support decisions about modifying, discontinuing, or continuing any interventions.
The undated facility policy Drug Regimen Review Policy The undated facility policy Weights documented: The clinical nurse manager will post all residents requiring charting for weight variances, please chart every shift three times daily speaking to the problem; ensure physician is notified of weight change.
The facility failed to ensure that daily weights were obtained and reported to the physician as ordered, which had the potential for unnecessary medication administration or complications related to CHF.