Azria Health Olathe

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 107 residents. The sample included 26 residents, with six residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 25's insulin (a hormone that lowers the level of glucose in the blood) was given before meals according to the physician-ordered parameters related to blood glucose monitoring. This deficient practice placed R25 at risk for hypoglycemia (less than normal amount of sugar in the blood), delayed treatment, and unnecessary medication complications. Findings included:- R25's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses hypertension (HTN high blood pressure), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), fracture of shaft of left tibia (the inner and typically larger of the two bones between the knee and the ankle), quadriplegia (inability to move the arms, legs, and trunk of the body below the level of an associated injury to the spinal cord), need for assistance with personal care, muscle weakness, cognitive ( relates to all the mental processes involved in knowing, thinking, learning, remembering, and understanding things), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear).The admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS documented R25 needed setup or cleanup for eating and oral hygiene. The MDS documented R25 was dependent on staff for toileting and needed substantial to maximal assistance for bathing. The MDS documented R25 had DM and received insulin during the look-back period.R25's Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) dated 07/09/25 documented R25's need for assistance with activities of daily living (ADL) and mobility. Contributing factors include displaced fracture with routine healing, quadriplegia, DM, HTN, anxiety, and depression. The CAA documented staff would anticipate R25's needs, administer medications as prescribed, prepare and serve his diet as ordered.R25's Care Plan dated 07/11/25 documented R25 had DM and he would have no complications related to diabetes through the review date. The plan of care for R25 documented staff would check his body for breaks in skin and treat promptly as ordered by the physician, and give diabetes medication as ordered. R25's care plan documented the dietician would discuss mealtimes, portion sizes, dietary restrictions, snacks allowed in the daily nutritional plan, and compliance with nutritional regimen.R25's EMR under Orders revealed the following physicians' orders:Insulin Glargine Subcutaneous (beneath the skin) solution pen injector 100 units/milliliter (ml) (insulin Glargine- long-acting insulin), inject five units subcutaneously at bedtime for diabetes, dated 07/04/25.Humalog (fast-acting insulin) Mix 75/25 Kwik Pen Subcutaneous suspension pen injector (75-25) 100 unit/ml (insulin Lispro Protamine (intermediate-acting insulin) and Lispro (fast-acting insulin)), inject three units subcutaneously with meals for diabetes hold if blood sugar < (less than) 200 ml/dl, dated 07/04/25.Insulin Glargine subcutaneous solution pen-injector 100units/ml (insulin Glargine), inject ten units subcutaneously at bedtime for diabetes, dated 07/14/25.R25's EMR under the Treatment Administration Record (TAR) recorded the following blood glucose levels under 200 milligrams per deciliter (ml/dl). R25's TAR that lacked evidence, R25's insulin was held.08:00 AM Blood glucose readings:07/08/25 113 ml/dl07/11/25 165ml/dl07/12/25 123ml/dl07/13/25 140 ml/dl07/16/25 108 ml/dl07/17/25 123 ml/dl07/21/25 132 ml/dl07/22/25 150 ml/dl07/28/25 178 ml/dl07/30/25 160 ml/dl12:00 PM Blood glucose readings:07/16/25 170 ml/dl07/21/25 196 ml/dl07/22/25 137 ml/dl07/30/25 160 ml/dl05:00 PM Blood glucose readings:07/12/25 196 ml/dl07/16/25 113 ml/dl07/17/25 135 ml/dl07/22/25 120 ml/dl08:00 AM blood glucose readings:08/03/25 106 ml/dl05:00 PM blood glucose readings:08/29/25 125 ml/dl08/30/25 152 ml/dlR25 admitted to the facility on [DATE] and discharged to the hospital on [DATE].On 09/10/25 at 12:58 PM, Licensed Nurse (LN) K stated it was the nurse's duty to ensure the nurse double checked the TAR before nurses would give insulin. He stated nurses waited until the resident had his meal tray or would give the insulin after the resident had eaten.On 09/10/25 at 01:22 PM, Administrative Nurse D stated the facility needed to do a better job at oversight of insulin given. She stated nurses should ensure they are giving the correct amount of insulin to a resident. She stated that if a resident should be given insulin with meals, the insulin should be given when the meal arrived, or while the resident was eating.The facility did not provide a policy for unnecessary medications.

The facility identified a census of 107 residents. The sample included 26 residents, with five medication carts and three medication rooms. Based on observation, record review, and interviews, the facility failed to ensure an accurate reconciliation of controlled drugs at the end of daily work shifts and maintain the staff count sheets for the controlled drugs. This placed residents at risk for misappropriation of medications and/or diversion of controlled substances. Findings included:- On 09/09/25 at 07:30 AM, a review of the September 2025 Narcotic Shift Count Sheet on the 200 hall from 09/01/25 to 09/09/25 (nine days) revealed a missing signature either for the on-coming nurse or the off-going nurse on the following dates: 09/01/25, 09/02/25, 09/03/25, 09/04/25, 09/05/25, 09/06/25, 09/07/25, 09/08/25, and 09/09/25. On 09/09/25 at 07:33 AM, Licensed Nurse (LN) K stated that each shift should count the narcotics at shift change with the oncoming nurse and the off-going nurse. LN K stated it was the expectation of the facility that reconciliation of the narcotics was expected when the shift started and ended. On 09/10/25 at 01:23 PM, Administrative Nurse D stated she expected the narcotics to be counted between the oncoming nurse and the off-going nurse. The facility's Controlled Substances policy, last revised April 2019, documented the facility complied with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications. Controlled medications were counted at the end of each shift. The nurse coming on duty and the nurse going off duty determined the count together. Any discrepancies in the controlled substance count were documented and reported to the director of nursing services.

The facility identified a census of 107 residents. The sample included 26 residents, with two reviewed for dementia (a progressive mental disorder characterized by failing memory and confusion). Based on interviews, record reviews, and observations, the facility failed to provide consistent dementia-related behavioral interventions for Resident (R) 16 to promote the resident's highest practicable level of well-being. This deficient practice placed R16 at risk for decreased quality of life, isolation, and impaired dignity.Findings Included:- The Medical Diagnosis section within R16's Electronic Medical Records (EMR) included diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), muscle weakness, repeated falls, and the need for assistance with personal care. R16's Quarterly Minimum Data Set (MDS) completed 08/02/25 indicated a Brief interview for Mental Status (BIMS) score of three (severe cognitive impairment). The MDS noted no upper or lower extremity impairments. The MDS noted he used a wheelchair for mobility. The MDS noted he had physical, verbal, and other self-directed behaviors observed for one to three days. The MDS noted he required substantial to maximal assistance from staff for toileting, transfers, bathing, bed mobility, dressing, personal hygiene, and putting on footwear. R16's Behavioral Care Area Assessment (CAA) triggered on 05/27/25. The CAA noted he had a history of physical and verbally aggressive behaviors. R16's Care Plan initiated 05/15/25 indicated he was admitted to a secured unit due to his medical diagnoses and risk for elopement. The plan noted he was monitored frequently for safety (05/15/25). The plan noted he required substantial assistance from staff for transfers, bathing, toileting, dressing, personal hygiene, and oral hygiene (05/15/25). The plan noted he had cognitive impairment or impaired thought processes (05/15/25). The plan instructed staff to cue, orient, and supervise him as needed (05/15/25). The plan instructed staff to engage in simple activities and kept his routine consistent (05/15/25). The plan noted he was dependent on staff for meeting his emotional, intellectual, physical, and social needs (06/20/25). On 09/02/25, R16's plan was updated, indicating he had behaviors related to inappropriate touching. The plan instructed staff to anticipate his needs, offer tasks to divert his attention, and provide activities that accommodated his interests (09/02/25). The plan noted he was placed on one-to-one supervision until his departure from the facility, and facility staff provided abuse education (09/02/25). The plan lacked interventions related to his inappropriate touching or boundary concerns prior to 09/02/25. R16's EMR under Progress Notes revealed a Nurse's Note completed on 07/16/25. The note indicated R16 was observed holding hands with another resident and using affectionate gestures towards other residents on the secured unit. The note indicated staff provided appropriate redirections to maintain personal boundaries in a respectful manner. R16's EMR under Progress Notes revealed a Nurse's Note completed on 07/17/25. The note indicated R16 wheeled himself around the secured unit. The note revealed R16 was observed repeatedly touching other residents. The note revealed that staff intervened promptly by redirecting him and provided verbal reminders regarding personal boundaries. The note revealed staff had to remove R16 from the immediate area and redirect to an activity table under staff supervision. R16's EMR under Progress Notes revealed a Nurse's Note completed on 07/18/25. The note revealed R16 was observed touching a resident in a sexual way and provided several redirections. The note revealed R16 became aggressive upon redirection and wanted to hit the staff. The note revealed that staff moved him back to his room and attempted to contact his resident representative. R16's EMR under Progress Notes revealed a Nurse's Note completed on 07/18/25. The note revealed R16 was sent out to an acute medical facility for evaluation. R16's EMR under Miscellaneous revealed an acute medical facility summary from 07/28/25. The summary indicated the facility report concerns of worsening promiscuity and combativeness. R16's EMR under Progress Notes revealed an admission Progress Note completed on 07/28/25. The note indicated he returned to the facility at 04:00 PM following a hospital stay for treatment of inappropriate behaviors and gout. R16's EMR under Progress Notes revealed a Social Service Note completed on 08/28/25. The note revealed R16's Resident representative was notified that R16 had been touching and being inappropriately with staff. The note indicated he was being transferred to an all-male unit. R16's EMR under Progress Notes revealed a Behavior Note completed on 08/29/25. The note revealed that staff witnessed R16's hands touching another resident's private area. The note revealed that both residents were immediately separated, and the unit supervisor was notified. A Facility Incident Report #3977 completed on 08/29/25 indicated R16 was observed by staff placing his hands between R75's (a severely cognitively impaired female resident) inner thighs. The report indicated R75 screamed out, Stop, don't touch me. The report indicated that both residents were separated and assessed. The note revealed neither resident had memory recall of the incident. The note revealed R16 was immediately placed under one-to-one supervision. A Witness Statement completed by CNA UU on 08/29/25 documented that she witnessed R16 putting R16's hands in between R75's thighs in her private region. The statement indicated she immediately separated them and moved R16 to the men's table. R16's EMR under Progress Notes revealed a Nurse's Note completed on 09/04/25. The note revealed R16 was transferred out of the facility. On 09/09/25 at 11:20 AM, R75 reported she had no memory of the incident, but reported she did not like any males touching or providing care for her. On 09/09/25 at 02:30 PM, CNA WW stated R16 had ongoing sexual impulses on the unit. She stated staff were expected to supervise R75 and provide reminders related to appropriate behaviors. She stated he would continually attempt to hold female staff members' hands and then move toward their private areas. She stated the facility provided dementia related training annually. She was not sure what specific interventions were in place for R16's behaviors. On 09/09/25 at 02:30 PM, CNA XX stated R16's sexual behaviors had been going on for a while. She stated staff would have to watch him closely and provide constant redirection due to his mobility in his wheelchair. She stated staff would sit him with male peers to prevent him from grabbing at female residents.On 09/09/25 at 03:31 PM, Administrative Nurse D stated she did not see his behaviors as sexual. She stated she did not believe he went to the acute care facility on 07/18/25 for sexual behaviors, but rather due to his hand issues. She stated all staff had training to recognize and prevent abuse. She stated the facility transferred R16 to an all-male unit due to his increased behaviors. Administrative Nurse D stated that the facility immediately placed R16 on one-to-one supervision until he transferred, and the facility provided abuse training to the staff.The facility was unable to provide a policy related to dementia or behavioral services as requested on 09/11/25.

The facility identified a census of 107 residents. The sample included 26 residents, with three residents reviewed for trauma-informed care (treatment or care directed to prevent re-experiencing or reducing the effects of traumatic events). Based on observation, record review, and interviews, the facility failed to assess and identify trauma-based triggers related to R11's post-traumatic stress disorder (PTSD- a mental disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress). The facility failed to implement individualized interventions to prevent re-traumatization to R11. These deficient practices placed R11 at risk for decreased psychosocial well-being and ineffective treatment. Findings included:- R11's Electronic Medical Record (EMR) documented diagnoses of PTSD, congestive heart failure (CHF- a condition with low heart output and the body becomes congested with fluid), bipolar disorder (a major mental illness that causes people to have episodes of severe high and low moods), and hydronephrosis (a condition where urine backs up into the kidney, causing it to swell).R11's Annual Minimum Data Set (MDS) dated 03/20/25 documented she had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. R11 required only supervision from staff for her cares. R11 had an active diagnosis of PTSD. R11's Psychotropic Drug Use Care Area Assessment (CAA) dated 03/02/25 documented the use of psychotropic meds to manage psychiatric illness/condition. A licensed nurse monitored for side effects every shift, and the physician/psychiatrist was to be notified of any abnormal findings. A pharmacist consultant would review medications monthly, and the physician would review medications with each visit. R11's CAAs lacked her PTDS being addressed.R11's Care Plan, revised on 08/05/25, directed staff that she had adjustment issues related to recent losses and changes. The Care Plan directed staff to allow R11 the opportunity to communicate her feelings. The Care Plan directed staff to encourage R11 to participate in conversations with staff and other residents daily. The Care Plan lacked staff direction on her PTSD triggers and interventions to prevent re-traumatization.On 09/10/25 at 11:15 AM, R11 sat in her wheelchair near the entrance of the building, visiting with a staff member.On 09/10/25 at 12:59 PM, Licensed Nurse (LN) K stated he knew that some residents' care plans did address a PTSD diagnosis, but was not certain R11's care plan did. LN K stated staff should be made aware of past trauma and what might be triggers.On 09/10/25 at 01:22 PM, Administrative Nurse D stated that social services did an initial evaluation on each resident at admission and then quarterly. Administrative Nurse D could not say if the evaluation addressed PTSD. Administrative Nurse D stated she would expect R11's care plan to address past traumas and have interventions to prevent re-traumatization.The Trauma-Informed and Culturally Competent Care policy, dated October 2023, documented the purpose was to guide staff in providing care that was culturally competent and trauma-informed in accordance with professional standards of practice. To address the needs of trauma survivors by minimizing triggers and/or re-traumatization. Trauma-informed care was an approach to delivering care that involved understanding, recognizing, and responding to the effects of all types of traumas. A trauma-informed approach to care delivery recognizes the widespread impact and signs and symptoms of trauma in residents, and incorporates knowledge about trauma into care plans, policies, procedures, and practices to avoid re-traumatization. The policy documented the performance of universal screening of residents, which included a brief, non-specialized identification of possible exposure to traumatic events. Utilize screening tools and methods that were facility-approved, competently delivered, culturally relevant, and sensitive. Screening may include information such as trauma history, including type, severity, and duration; depression, trauma-related or dissociative symptoms; risk for safety (self or others); concerns with sleep or intrusive experiences; behavioral, interpersonal, or developmental concerns; historical mental health diagnosis; substance use; protective factors and resources available; and physical health concerns. Utilize initial screening to identify the need for further assessment and care. Assessment involved an in-depth process of evaluating the presence of symptoms, their relationship to trauma, and the identification of triggers. Utilize licensed and trained clinicians who have been designated by the facility to conduct trauma assessments. Use assessment tools that are facility-approved and specific to the resident population. Develop individualized care plans that address past trauma in collaboration with the resident and family, as appropriate. Identify and decrease exposure to triggers that may re-traumatize the resident. Recognize the relationship between past trauma and current health concerns (e.g., substance abuse, eating disorders, anxiety, and depression). Develop individualized care plans that incorporate language needs, culture, cultural preferences, norms, and values.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 107 residents. The sample included 26 residents. Based on observation, record review, and interview, the facility failed to ensure that Resident (R) 24's dialysis (a procedure where impurities or wastes were removed from the blood) physician order was in his orders of the Electronic Medical Record (EMR). The facility failed to ensure R24's care plan provided interventions to direct staff and implement care and services according to the professional standards of practice in order to meet the resident's dialysis care needs. This deficient practice placed R24 at risk for missed dialysis visits and complications related to dialysis.Findings included:- R24's EMR documented diagnoses of osteomyelitis (local or generalized infection of the bone and bone marrow), end-stage renal disease (ESRD- a terminal disease of the kidneys), chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), and hemiplegia (paralysis of one side of the body).R24's admission Minimum Data Set (MDS) dated 08/20/25 documented he had a Brief Interview for Mental Status (BIMS) score of 13, which indicated an intact cognition. R24 had functional limitation in range of motion with impairment in both upper and lower extremities. R24 used a walker and a wheelchair to assist with mobility. R24 required substantial assistance to total dependence on staff for his functional abilities. R24 required peritoneal dialysis (procedure performed to remove toxins, drugs, or other wastes in the blood normally excreted by the kidney).R24's Functional Abilities Care Area Assessment (CAA) dated 08/25/25 documented he needed assistance with his activities of daily living (ADL) and mobility. Contributing factors include osteomyelitis (local or generalized infection of the bone and bone marrow) of the lumbar vertebra, discitis (inflammation that develops between the intervertebral discs of the spine), ESRD, COPD, and hemiplegia. Staff anticipated his needs and administered his medications as prescribed. Staff assist with his ADLs per the care plan.R24's Care Plan, revised 09/04/25, directed staff that he received hemodialysis. R24's Care Plan directed staff to check and change his dressing daily at the access site in the left upper arm. The Care Plan directed staff not to draw blood or take blood pressure in the left arm. R24's Care Plan lacked staff direction on his dialysis days, the location of his dialysis clinic, the contact information of the dialysis clinic, and how information would be communicated between the facility and the dialysis clinic.R24's EMR lacked a physician's order for dialysis.On 09/08/25 at 01:49 PM, R24 laid in his bed resting.On 09/10/25 at 12:59 PM, Licensed Nurse (LN) K stated that when a resident was admitted , the admitting nurse was responsible for entering orders in the EMR. LN K stated that the unit manager would review his order the next day to make sure everything was entered correctly. LN K stated R24's EMR should have his dialysis order entered. LN K stated R24's care plan should direct staff on which days he goes to dialysis, as well as any special care needed regarding care before and after his dialysis treatment.On 09/10/25 at 01:22 PM, Administrative Nurse D stated that R24's order for his dialysis should have been entered into the EMR at the time of his admission on [DATE]. Administrative Nurse D stated that the unit manager should have caught that during her audit that the order was not in the EMR. Administrative Nurse D stated she expected R24's care plan to reflect which days and times he went to dialysis, as well as the dialysis clinic name, and other special instructions.The End-Stage Renal Disease, Care of a Resident policy, dated February 2022, documented that staff caring for residents with ESRD, including residents receiving dialysis care outside the facility, shall be trained in the care and special needs of these residents. Agreements between this facility and the contracted ESRD facility include all aspects of how the resident's care would be managed, including: how the care plan would be developed and implemented; how information will be exchanged between the facilities; and responsibility for waste handling, sterilization, and disinfection of equipment; and the resident's comprehensive care plan would reflect the resident's needs related to ESRD/dialysis care.

The facility identified a census of 107 residents. The sample included 26 residents. The facility had one oxygen storage room on the 100 hall and one oxygen storage room on the 200 hall. The facility had a total of six cognitively impaired, independently mobile residents who resided on either the 100 or the 200 hall. Based on observation, record review, and interview, the facility failed to ensure oxygen tanks were stored in a securely locked room. The facility failed to ensure that Resident (R) 28's nothing by mouth (NPO) physician's order was followed. This deficient practice placed residents at risk of possible avoidable injury.Findings included:- On 09/08/25 at 07:14 AM, during the initial tour of the facility, the oxygen storage room on 200 hall was unlocked with 21 unused full oxygen cylinders present.
On 09/08/25 at 07:15 AM, the oxygen storage room on the 100 hallway was unsecured with 32 Oxygen E-tanks stored in the room.
On 09/08/25 at 09:01 AM, a return to the 200-hall oxygen storage room continued to be unlocked.
On 09/08/25 at 07:18 AM, Certified Nurse Aide (CNA) M stated the oxygen storage room should be locked, but the lock was broken. CNA M stated the door had been broken for the past two years.
On 09/08/25 at 09:02 AM, Licensed Nurse (LN) G stated that the code for the oxygen storage room had been changed recently. LN G stated that the room should be locked all the time.
On 09/10/25 at 01:22 PM, Administrative Nurse D stated that the oxygen storage rooms should always be locked unless a staff member is replacing a used tank with a new one.
The facility lacked a policy regarding oxygen storage or accidents.
- R28's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of cerebral palsy (a progressive disorder of movement, muscle tone, or posture caused by injury or abnormal development in the immature brain, most often before birth), protein calorie malnutrition (a nutritional deficiency where the body doesn't get enough protein and calories (energy) from food), retention of urine, impulse disorder, legally blind, need for assistance with personal cares, and dysphagia (swallowing difficulty) oropharyngeal phase (the second phase of swallowing).
The admission Minimum Data Set (MDS) for R28, dated 06/10/25, recorded a Brief Interview for Mental Status (BIMS) score of zero, which indicated severely impaired cognition. The MDS documented eating was not applicable and was dependent on staff for all activities of daily living (ADL).
R28's Nutrition Status Care Area Assessment (CAA) dated 06/10/24 documented impaired nutritional status, internal tube placement, and nothing by mouth (NPO) status. Contributing factors include cerebral palsy, protein-calorie malnutrition, gastrostomy status, colostomy status, legal blindness, congenital malformation, and anemia (an inadequate number of healthy red blood cells to carry adequate oxygen to body tissues). R28's CAA documented staff would anticipate his needs, administer medications and enteral feedings per orders, and monitor for signs and symptoms of aspiration. The CAA documented that the registered dietician would do an evaluation for caloric intake/need and report to the healthcare practitioner as needed.
R28's Care Plan dated 06/05/25 documented R28 required tube feeding related to malnutrition and chronic ileus (a condition where the normal movement of food and waste through the intestines has slowed or stopped) that recently resulted in small bowel obstruction that was surgically repaired. R28's plan of care documented he would maintain adequate nutrition and hydration status and maintain a stable weight. R28's plan of care documented staff should allow R28 to have thin water, five ml of Provale (special water) cup, on a pleasure feeding basis; staff were to limit one cup of water per day. The plan of care for R28 documented he was to have 100 percent staff supervision during intake, and his cup was to be stored with nursing or in the nourishment room when not in use. The plan of care documented staff were to monitor R28 for potential aspiration. R28's plan of care, revised on 06/12/25, documented R28 was NPO, receives all nutrition through his feeding tube, but it was ok to have ice chips as requested.
R28's EMR under the Orders tab documented the following physician order:
NPO diet, Not Applicable texture, NPO consistency, dated 06/12/25.
On 09/08/25 at 11:30 AM, R28 sat in his Broda chair (specialized wheelchair with the ability to tilt and recline) outside of the day room. R28 had a cup of crushed ice in a Styrofoam cup with a spoon. There was no nursing staff to monitor R28 for aspiration.
On 09/09/25 at 12:30 PM, R28 sat in his Broda chair in hallway 200. R28 had a cup of chunked ice with a spoon; there was no staff monitoring R28 for possible aspiration.
On 09/10/25 at 12:30 PM, Certified Nurse's Aide (CNA) O stated the nurse knows how often R28 could have ice chips. She stated the nurse monitored R28 when he received ice chips.
On 09/10/25 at 12:58 PM, Licensed Nurse (LN) K stated R28 could have ice chips every hour if he wanted. He stated that the nurse gave him his ice chips, but he should be monitored while receiving the ice. LN K stated there should be an order stating R28 could have ice chips.
On 09/10/25 at 01:22 PM, Administrative Nurse D stated staff monitored R28 while he ate his ice chips. She stated there should be an order for ice chips or some documentation stating he was safe to have ice chips. Administrative Nurse D stated that speech therapy had worked with R28.
The facility did not provide an accident policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 107 residents. The sample included 26 residents with one resident was reviewed for quality of care. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 44 was provided services and treatment to prevent worsening of contractures (abnormal permanent fixation of a joint or muscle) in his left hand. This deficient practice placed R44 at risk for discomfort and decreased range of motion (ROM - the full movement potential of a joint, usually its range of flexion and extension). Findings included:- R44's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of contracture of the left elbow, contracture of the left hand, depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), cerebrovascular accident (CVA- stroke- sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), and dementia (a progressive mental disorder characterized by failing memory and confusion).The Annual Minimum Data Set (MDS) dated 05/08/25 documented a Brief Interview of Mental Status (BIMS) score of 12, which indicated moderately impaired cognition. The MDS documented R44 had bilateral lower limitation in range of motion (ROM - the full movement potential of a joint, usually its range of flexion and extension) and limited ROM on one upper extremity. The MDS documented R44 was dependent on staff's assistance for oral hygiene, transfers, toileting, bathing, dressing, personal hygiene, and bed mobility. The MDS documented R44 had not rejected care during the observation period. The MDS documented R44 had no nursing restorative program. The Quarterly MDS dated [DATE] documented a BIMS score of 10, which indicated moderately impaired cognition. The MDS documented R44 had bilateral lower limitation in range of motion (ROM - the full movement potential of a joint, usually its range of flexion and extension) and limited ROM on one upper extremity. The MDS documented R44 was dependent on staff's assistance for oral hygiene, transfers, toileting, bathing, dressing, personal hygiene, and bed mobility. The MDS documented R44 had not rejected care during the observation period. The MDS documented R44 had no nursing restorative program.R44's Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) dated 05/22/25 documented she required assistance with activities of daily living.R44's Care Plan dated 08/23/22 documented nursing staff would administer her medication as ordered by the physician. The plan of care documented the nursing staff would notify the nurse of decreased ROM, redness, pressure areas, or increased pain. The plan of care dated 10/02/22 documented R44 refused the use of a left resting splint. The plan of care dated 10/08/24 documented the nursing staff would assist her to maintain proper body position in the bed and when she was in her wheelchair.Review of R44's EMR lacked documentation of a re-evaluation of her current left hand and left elbow contracture. The EMR also lacked documentation of alternative interventions or services provided to R44 to prevent worsening of her contractures. R44's EMR lacked documentation of refusals to wear the left-hand splint. On 09/09/25 at 08:13 AM, R44 laid on the bed with the head of her bed elevated. R44's left elbow was bent and lay against her abdomen with her left hand closed with no splint or device to prevent the worsening of her contractures. On 09/10/25 at 08:01 AM, R44 laid on the bed with her left arm bent at the elbow and her left hand was tightly closed.On 09/10/25 at 12:30 PM, Certified Nurse Aide (CNA) O stated the therapy department would evaluate the residents and determine if the residents required any type of contracture care. CNA O stated the nursing staff would apply the splints if ordered by therapy. CNA O stated the nursing staff would chart the application and removal in the residents' EMR.On 09/10/25 at 12:58 PM, Licensed Nurse (LN) K stated that the therapy evaluated the residents with contractures. LN K stated the nurse would apply the splint and monitor the application of the splint. LN K stated if a resident refused to wear their splint, the nurse would refer them back to the therapy department for re-evaluation. LN K stated the nurse would document the application of the splint or their refusal on the Treatment Administration Record (TAR).On 09/10/25 at 01:23 PM, Administrative Nurse D stated that some of the residents were on therapy maintenance programs. Administrative Nurse D stated the nurse would monitor the application and removal of the splints, and that would be documented on the TAR. Administrative Nurse D stated that if a resident were to refuse to wear their hand splint, that resident would be referred to the therapy department for another assessment.The facility was unable to provide a policy related to quality of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 107 residents. The sample included 26 residents, with four residents reviewed for treatment and services to prevent and heal pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, because of pressure, or pressure in combination with shear and/or friction). Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 14's low air loss mattress was at the correct weight setting, and R48's offloading boots were applied to her heels to prevent pressure ulcers. This placed R14 and R48 at increased risk for developing pressure ulcers.Findings Included:- R14's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of paraplegia (paralysis characterized by motor or sensory loss in the lower limbs and trunk), hypertension (HTN- high blood pressure), neuromuscular dysfunction of the bladder (the muscles that control the flow of urine out of the body do not relax and prevent the bladder from fully emptying), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), anemia (an inadequate number of healthy red blood cells to carry adequate oxygen to body tissues), major depressive disorder (major mood disorder that causes persistent feelings of sadness), diabetes mellitus (DM- when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), and pressure ulcer of left buttocks Stage 3 (full-thickness pressure injury extending through the skin into the tissue below).The Annual Minimum Data Set (MDS) dated [DATE], documented a Brief Interview of Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS documented R14 had impairment on both sides of her upper body and both sides of her lower body. The MDS documented R14 was dependent on staff for toileting and bathing. The MDS documented R14 was dependent on the staff to roll right to left. The MDS documented R14 was at risk for pressure ulcers and had one stage 3 pressure ulcer. The MDS documented R14 had a pressure-reducing device in her chair and a pressure-reducing device on her bed. R14's Pressure Ulcer/ Injury Care Area Assessment (CAA) dated 07/26/25 documented impaired skin integrity, current pressure ulcers, diabetic foot ulcers, and surgical wounds. The CAA documented the contributing factors, which included osteomyelitis (local or generalized infection of the bone and bone marrow), surgery on the genitourinary system, DM, and paraplegia. R14's Care Plan dated 02/17/23 documented R14 was offered and accepted a low air loss mattress and a foam wedge for positioning; staff were to monitor to ensure proper functioning. R14's plan of care documented R14 was at risk for further alteration in skin integrity related to her medical diagnoses. The plan of care dated 07/17/25 documented R14 had a left lateral (position that was the side) foot, left posterior (back of the body) thigh, right posterior thigh wound, Stage 3 pressure ulcer, and right foot surgical wound. The plan of care for R14 documented staff was to do skin assessments with every care provided and report to the nurse any necessary findings. R14's plan of care lacked direction for staff to monitor her low-air-loss mattress.R14s EMR under the Orders tab revealed the following orders: Left posterior thigh: cleanse all open areas with hypochlorous acid (wound cleaner) or normal saline, pat dry. Apply skin prep (adhesive dressing) to peri-wound (skin surrounding the wound). Cut a collagen (protein-derived wound treatment used to promote wound healing) pad to fit the posterior and medial area and place it over the wound bed. Apply black foam to the base of a large wound and use a wound vacuum device (also known as a negative pressure wound therapy or NPWT), change every day shift on Tuesday, Thursday, and Saturday, dated 08/28/25.R14's EMR under the Weights and Vitals tab document:Weight 213.6 pounds on 09/03/25.R14's Braden Scale for Prediction Pressure Sore Risk dated 08/05/25 documented a score of 14, indicating a moderate risk for pressure ulcers.R14's Weekly Wound Assessment dated 09/02/25 documented R14 had a diabetic foot ulcer on the left foot. On 09/08/25 at 08:25 AM, R14 laid in her bed on her back. R14's low-air-loss mattress was set at 550 pounds. On 09/09/25 at 08:27 AM, R14 laid on her bed on her back. R14 was eating her breakfast. R14's low-air-loss mattress was set at 550 pounds.On 09/10/25 at 12:30 PM, Certified Nurse's Aide (CNA) O stated that CNAs did not do anything with the low air loss mattresses. CNA O stated that she would ensure the bed was working, but did not know anything about the dials. She stated the mattresses were set up by the supply person, and she didn't think the dials needed to be touched after the setup. On 09/10/25 at 12:58 PM, Licensed Nurse (LN) K set the low air loss mattresses according to weight. He stated the mattress should be set close to the resident's weight. He stated that the medical supply set the beds up. He stated there was no place on the Treatment Administration Record (TAR) for the nurse to mark to ensure the bed was set at the correct weight. He stated he was unsure who was monitoring the residents' mattresses. On 09/10/24 at 01:22 PM, Administrative Nurse D stated all mattresses were rented. She stated that medical supplies and maintenance set the mattress up. She stated the mattresses were set by weight and should be close to the resident's weight. She stated she was unsure of who was monitoring the mattress daily. The facility's Prevention of Pressure Injuries policy dated 03/20 documented the purpose of the procedure was to provide information regarding the identification of pressure injury risk factors and interventions for specific risk factors. Review the residents' care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable. Assess the resident on admission for existing pressure injury risk factors and use a standardized injury screening tool to determine and document risk factors. Inspect skin every seven days and document results.- R48's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of quadriplegia (inability to move the arms, legs, and trunk of the body below the level of an associated injury to the spinal cord), diabetes mellitus (DM- when the body cannot use glucose, not enough insulin was made, or the body cannot respond to the insulin), dysfunction of the bladder, hypotension (low blood pressure), major depressive disorder (major mood disorder that causes persistent feelings of sadness), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), pressure ulcer of sacral (back and buttocks) region, and pressure ulcer of left buttocks Stage 3 (full-thickness pressure injury extending through the skin into the tissue below).The Quarterly Minimum Data Set (MDS) for R48 dated 06/12/25 recorded a Brief Interview for Mental Status (BIMS) score of 13, which indicated intact cognition. The MDS documented R48 had an impairment of both sides of his upper and lower body. The MDS documented R48 was dependent on staff assistance for all activities of daily living (ADL). The MDS documented R48 was at risk for pressure ulcers and had a pressure-reducing device in his wheelchair and on his bed. R48's Pressure Ulcer/ Injury Care Area Assessment (CAA) dated 12/12/24 documented R48 pressure ulcers CAA triggered secondary to R48 having an actual pressure ulcer. R48's contributing factors include ADL/functional/mobility impairment, history of pressure ulcers, actual pressure ulcers, and use of medications that can contribute to skin breakdown, incontinence, and pain. The CAA documented R48's risk factors include pain, the development of pressure ulcer condition, and fluid deficit risk. A licensed nurse assesses skin each week and puts proper interventions in place to prevent skin breakdown. Skin was also assessed by caregivers with each bath and each time R48 was dressed. The physician was to be notified of any abnormal findings, and treatment orders were to be obtained. The dietitian monitored food and fluid intake and implemented dietary interventions as necessary. R48's Care Plan dated 03/12/24 documented R48 was at risk for altered skin integrity related to ADL self-care deficit, immobility, impaired sensation, incontinence of bowel, and a history of skin alterations. R48's plan of care documented that nursing was to complete treatments as ordered by the provider, notify the provider of any abnormal changes or worsening in condition. The plan of care documented R48 was often non-compliant with skin and wound care. This often occurred when R48 was up in a wheelchair and did not want to get back in bed. The plan of care for R48 documented staff were to encourage and assist R48 to offload pressure between lunch and dinner for pressure reduction. R48's plan of care documented he had a low-air-loss mattress in place, and staff were to monitor for changes in skin integrity, assist with ADLs, and report to the charge nurse. The plan of care for R48 documented staff was to offload bilateral heels using multiple pillows or soft heel lift boots when in bed, as R48 would allow or tolerate. R48's Braden Scale for Prediction Pressure Sore Risk dated 09/04/2025 documented a score of 13, indicating a high risk for pressure ulcers. R48's physician orders under the Orders tab revealed the following orders: Weekly skin assessment every Saturday, day shift, dated 09/13/25.R48's Nursing Progress Notes lacked documentation R48 was offered his heels floated or refused to have his heels floated.On 09/08/25 at 08:10 AM, R48 laid on his bed, R48's heels lay directly on his mattress. On 09/08/25 at 09:11 AM, R48 laid on his bed, R48's heels lay directly on his mattress.On 09/10/25 at 12:30 PM, Certified Nurse's Aide (CNA) O stated if a resident needed their heels floated, the nurse would let the CNAs know. She stated the nursing staff would help her float the residents' heels. She stated that floating of a resident's heels would be a nursing duty, but that would probably show up on her Kardex (a nursing tool that gives a brief overview of the care needs of each resident).On 09/10/25 at 12:58 PM, Licensed Nurse (LN) K stated that if a resident was to have their heels offloaded, whether with boots or pillows, that order would show on the nursing Treatment Administration Record and the resident's care plan. He stated that any nursing staff member was able to float a resident's heels.On 09/10/25 at 01:22 PM, Administrative Nurse D stated that floating of a resident's heels would show on the Treatment Administration Record (TAR) Kardex and the resident's care plan. She stated nurses would check to ensure the task was done.The facility's Prevention of Pressure Injuries policy dated 03/20 documented the purpose of the procedure was to provide information regarding the identification of pressure injury risk factors and interventions for specific risk factors. Review the residents' care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable. Assess the resident on admission for existing pressure injury risk factors and use a standardized injury screening tool to determine and document risk factors. Inspect skin every seven days and document results.

The facility identified a census of 107 residents. The sample included 26 residents, with 26 residents reviewed for baseline care plans. Based on observation, record review, and interviews, the facility failed to develop a person-centered baseline care plan for Resident (R) 121 to include her chronic pain. This deficient practice placed R121 at risk of impaired care related to uncommunicated care needs.Findings included:- R121's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of Guillain-Barre syndrome (a disorder in which the body's immune system attacks the nerves), fractured toe, fibromyalgia (condition of musculoskeletal pain, spasms, stiffness, fatigue, and severe sleep disturbance), and diabetes mellitus (DM- when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin).The admission Minimum Data Set (MDS) was in progress. R121's Care Area Assessment (CAA) was in progress. R121's Baseline Care Plan dated 09/05/25 documented nursing staff would administer all medication as ordered by the physician. The care plan lacked direction for R121's chronic pain related to a fractured toe, Guillain-Barre syndrome, and fibromyalgia.Review of R121's EMR under the Evaluation tab revealed the Baseline Care Plan e-signed on 09/05/25 lacked documentation related to R121's chronic pain.On 09/10/2025 at 08:01 AM, R121 sat in her electric wheelchair at the dining room table. R121 stated she had to wait for her pain medication after she was admitted to the facility. R121 stated her chronic pain was horrible at times. On 09/10/25 at 12:30 PM, Certified Nurse Aide (CNA) O stated the resident's information for their care and what assistance the resident required for care could be found on their care plan or the Kardex (nursing tool that gives a brief overview of the care needs of each resident). On 09/10/25 at 12:58 PM, Licensed Nurse (LN) K stated the baseline care plan was an under-defined assessment (UDA) in the EMR under the Evaluation tab. LN K stated the admission nurse would answer all the nursing questions on the assessment. LN K stated that for a resident with a diagnosis of chronic pain the information should be included in their baseline care plan.On 09/10/25 at 01:23 PM, Administrative Nurse D stated she expected the baseline care plan to be completed within 24 hours after the resident's admission. Administrative Nurse D stated that chronic pain should be addressed on the resident's baseline care plan with person-centered interventions.The facility's Baseline Care Plans policy, last revised 03/2022, documented the baseline plan of care was to meet the resident's immediate health and safety needs, and was developed for each resident within forty-eight (48) hours of admission. The baseline care plan included instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality care and must include the minimum healthcare information necessary to properly care for the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 107 residents. The sample included 26 residents, with two sampled residents reviewed for hospitalization and one resident reviewed for discharge. Based on observation, record review, and interview, the facility failed to ensure that Resident (R) 1 and their representative were provided, as soon as practicable, a written notification of transfer upon their transfer to the hospital. The facility failed to ensure a discharge summary, and a recapitulation of R120's stay was completed upon discharge from the facility. This placed R1 and R120 at risk of miscommunication between the facility and the resident's representative, and the possible missed opportunity for healthcare services.Findings included:- R1's Electronic Medical Record (EMR) documented diagnoses of chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), congestive heart failure (CHF- a condition with low heart output and the body becomes congested with fluid), hypertension (HTN- elevated blood pressure), major depressive disorder (major mood disorder that causes persistent feelings of sadness), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear).
R1's Discharge Minimum Data Set (MDS) dated 11/15/24 documented an unplanned discharge to an acute hospital with a return anticipated.
R1's Entry MDS dated 11/15/24 documented a re-entry to the facility from an acute hospital.
R1's Discharge MDS dated 12/07/24 documented an unplanned discharge to an acute hospital with a return anticipated.
R1's Entry MDS dated 12/09/24 documented a re-entry to the facility from an acute hospital.
R1's Annual MDS dated 12/19/24 documented she had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. R1 required substantial assistance, being dependent on staff for her cares. The overall goal for R1 was to remain in the facility. No active discharge planning was occurring.
R1's Discharge MDS dated 05/01/25 documented an unplanned discharge to an acute hospital with a return anticipated.
R1's Entry MDS dated 05/03/25 documented a re-entry to the facility from an acute hospital.
R1's Functional Abilities Care Area Assessment (CAA) dated 12/30/25 documented she required assistance with her activities of daily living (ADL) and had impaired balance and impaired transition during transfers, and functional impairment in activity. Contributing factors included R1's generalized weakness and decreased safety awareness. R1's risk factors included further ADL decline, falls, incontinence, skin breakdown, and pain.
R1's Care Plan, revised 06/09/25, directed staff that due to her daily care needs, R1 wished to remain in long-term care. The Care Plan directed staff to encourage her to express her concerns and feelings. The Care Plan directed staff that R1 would have all her spiritual needs met.
On 09/09/25 at 09:15 AM, R1 lay in bed with her supplemental oxygen on; R1 voiced no complaints.
On 09/10/25 at 01:22 PM, Administrative Nurse D stated that social services typically completed the bed hold and notification of transfers when a resident was sent to the hospital. Administrative Nurse D stated all of R1's bed holds, and notification of transfer should be in her scanned chart.
The facility lacked a policy regarding written notification of transfer.
- R120's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of traumatic brain injury (TBI- an injury to the brain caused by external forces), insomnia (inability to sleep), and hemiplegia (paralysis of one side of the body).
The Entry Minimum Data Set (MDS) dated 07/09/25 documented R120 admitted to the facility.
The admission MDS dated 07/14/25 documented a Brief Interview of Mental Status (BIMS) score of 12, which indicated moderately impaired cognition. The MDS documented R120 was independent with bed mobility and toileting. The MDS documented R120 required partial to moderate staff assistance with dressing.
R120's Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA), dated 07/24/25, documented R120 required staff assistance with activities of daily living.
R120's Care Plan, dated 07/16/25, documented he required staff supervision during bathing.
The Nurses Note on 07/14/25 at 03:52 PM documented R120 discharged to home at 01:30 PM with his personal belongings.
The facility was unable to provide a discharge summary, which included a recapitulation of his stay, a final summary of the resident's status, and reconciliation of all pre- and post-discharge medications.
R120 was admitted on [DATE] and discharged home on [DATE].
On 09/09/25 at 01:45 PM, Administrative Staff A stated R120 was a respite care resident, and his discharge summary was overlooked at the time of discharge.
The facility's Discharge Summary and Plan policy, revised 10/2022, documented that when a resident's discharge was anticipated, a discharge summary and post-discharge plan would be developed to assist the resident with discharge. The discharge summary included a recapitulation of the resident's stay at the facility and a final summary of the resident's status at the time of the discharge in accordance with established regulations governing release of resident information and as permitted by the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 107 residents. The sample included 26 residents, with three reviewed for abuse and neglect. Based on observation, interview, and record review, the facility failed to ensure residents remained free from sexual abuse when cognitively impaired Resident (R) 16, a resident with a history of inappropriate touching, touched R75's genital area against R75's wishes. On 07/18/25, R16 touched a lady in a sexual way, and the facility sent R16 to the hospital for inappropriate behavior. R16 returned to the facility on [DATE], but the facility did not implement interventions to address R16's inappropriate touching. On 08/28/25, R16 exhibited sexual behaviors towards staff, but the facility did not address these behaviors with new interventions. On 08/29/25, R16 touched cognitively impaired R75, a resident unable to consent, in her genital area. R75 screamed at R16 to stop touching her. Staff separated R16 and R75 and placed R16 under one-to-one staff supervision until R16 transferred to an all-male unit in another facility. The facility's failure to identify and implement interventions in response to R16's inappropriate touching and behaviors to prevent sexual abuse placed R75 in immediate jeopardy. Findings Included:- The Medical Diagnosis section within R16's Electronic Medical Records (EMR) included diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), muscle weakness, repeated falls, and the need for assistance with personal care. R16's 08/02/25 Quarterly Minimum Data Set (MDS) revealed a Brief Interview for Mental Status (BIMS) score of three, indicating severe cognitive impairment. The MDS noted R16 with no upper or lower extremity impairments, and he used a wheelchair for mobility. The MDS noted R16 had physical, verbal, and other self-directed behaviors observed for one to three days. R16's Behavioral Care Area Assessment (CAA) triggered on 05/27/25. The CAA noted he had a history of physical and verbally aggressive behaviors. R16's Care Plan initiated 05/15/25 indicated he was admitted to the secured unit due to his medical diagnoses and risk for elopement. The plan noted staff monitored R16 frequently for safety (05/15/25). The plan noted he had cognitive impairment or impaired thought processes (05/15/25). The plan instructed staff to cue, orient, and supervise him as needed, engage the resident in simple activities, and keep his routine consistent (05/15/25). The plan noted he was dependent on staff for meeting his emotional, intellectual, physical, and social needs (06/20/25). The 09/02/25 care plan update indicated R16 had behaviors related to inappropriate touching. The plan instructed staff to anticipate his needs, offer tasks to divert his attention, and provide activities that accommodated his interests (09/02/25). The plan noted staff provided R16 with one-to-one supervision until his departure from the facility, and the facility provided abuse education (09/02/25). R16's EMR under Progress Notes revealed a Nurse's Note completed on 07/16/25. The note indicated R16 was observed holding hands with another resident and using affectionate gestures towards other residents on the secured unit. The note indicated staff provided appropriate redirections to maintain personal boundaries in a respectful manner. The 07/17/25 Nurse's Note indicated R16 wheeled himself around the secured unit and was observed repeatedly touching other residents. The note revealed staff intervened promptly by redirecting him and provided verbal reminders regarding personal boundaries. The note revealed staff had to remove R16 from the immediate area and redirect to an activity table under staff supervision. The 07/18/25 Nurse's Note revealed R16 was observed touching a resident in a sexual way and staff provided several redirections. The note revealed R16 became aggressive upon redirection and wanted to hit the staff. The note revealed staff moved him back to his room and attempted to contact his resident representative. The 07/18/25 Nurse's Note revealed R16 was sent out to an acute medical facility for evaluation. The 07/28/25 acute medical facility summary indicated the facility reported concerns of worsening promiscuity and combativeness. The admission Progress Note completed on 07/28/25 revealed R16 returned to the facility at 04:00 PM following a hospital stay for treatment of inappropriate behaviors and gout. The Social Service Note completed on 08/28/25 revealed the facility notified R16's representative of R16's inappropriate touching. The note indicated he transferred to an all-male unit. The Behavior Note completed on 08/29/25 revealed staff witnessed R16's hands touching another resident's private area. The note documented both residents were immediately separated, and notification of the unit supervisor. The Facility Incident Report #3977 completed on 08/29/25 indicated staff observed R16 placing his hands between R75's (a severely cognitively impaired female resident) inner thighs. The report indicated R75 screamed out, Stop, don't touch me. The report indicated both residents were separated and assessed. The note revealed neither resident had memory recall of the incident, and the facility immediately placed R16 under one-to-one supervision. A Witness Statement completed by CNA UU on 08/29/25 documented she witnessed R16's hands in between R75's thighs in her private region. The statement indicated she immediately separated them and moved R16 to the men's table. The 09/04/25 Nurse's Note revealed R16 transferred out of the facility. On 09/09/25 at 11:20 AM, R75 reported she had no memory of the incident, but reported she did not like any males touching or providing care for her. On 09/09/25 at 02:30 PM, CNA WW stated R16 had ongoing sexual impulses on the unit. She stated staff were expected to supervise R75 and provide reminders related to appropriate behaviors. She stated he would continually attempt to hold female staff members' hands and then move toward their private areas.On 09/09/25 at 02:30 PM, CNA XX stated R16's sexual behaviors had been going on for a while. She stated staff had to watch him closely and provide constant redirection due to his mobility in his wheelchair. She stated staff would sit him with male peers to prevent him from grabbing at female residents.On 09/09/25 at 03:31 PM, Administrative Nurse D stated she did not see his behaviors as sexual. She stated she did not believe he went to the acute care facility on 07/18/25 for sexual behaviors, but rather due to his hand issues. She stated all staff had training to recognize and prevent abuse. She stated the facility transferred R16 to an all-male unit due to his increased behaviors. Administrative Nurse D stated the facility immediately placed R16 on one-to-one supervision until he transferred, and the facility provided abuse training to the staff.The facility's Abuse, Neglect, and Exploitation policy, revised 10/2023, documented that the resident has a right to be free from verbal, sexual, physical, and mental abuse and involuntary seclusion. The policy indicated it was the responsibility of the facility to treat each resident with respect, kindness, dignity, and care, to keep them free from abuse and neglect, and to take swift action to investigate and adjudicate alleged resident abuse and neglect. Mental abuse includes, but is not limited to, verbal or non-verbal conduct which causes or has the potential to cause humiliation, intimidation, fear, shame, agitation, degradation, harassment, or threats of punishment or deprivation. The policy indicated that all staff were to be educated to identify, prevent, and intervene when potential abuse was identified. On 09/09/25 at 05:55 PM, Administrative Staff A was provided the IJ template and notified of the facility's failure to ensure R75 remained free from sexual abuse placed R75 in immediate jeopardy.The facility identified, implemented, and completed the following corrective actions related to the incident:1. The facility screened all residents on the secured unit on 09/01/25.2. The facility assessed both R16 and R75 for psychosocial trauma from the incident. 3. The facility will monitor and provide ongoing education through the Quality Assurance and Performance Improvement program (QAPI) team. 4. All staff were educated on Abuse, Neglect, and Exploitation on 08/30/25.5. R16 was immediately placed under one-to-one staff supervision on 08/29/25 until his transfer from the facility on 09/04/25. This deficient practice was deemed past non-compliance when the facility completed the corrective actions on 08/30/25, prior to the surveyor entering the facility. The deficient practice remained at a scope and severity of a G to represent actual harm determined by the visual agitation of the resident during the event, as well as using the reasonable person concept based on the fact that R75 was unable to verbalize or express the psychosocial impact of the abuse.

The facility identified a census of 107 residents. The sample included 26 residents, with five reviewed for dignity. Based on observation, record review, and interviews, the facility failed to provide a dignified care environment for Residents (R) 43 and R20. This deficient practice placed both residents at risk for impaired dignity and unmet care needs.Findings Included:- The Medical Diagnosis section within R43's Electronic Medical Records (EMR) included diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), muscle weakness, repeated falls, and the need for assistance with personal care. R43's Annual Minimum Data Set (MDS) completed 07/01/25 indicated a Brief interview for Mental Status (BIMS) score of zero (severe cognitive impairment). The MDS noted no upper or lower extremity impairments. The MDS noted she used a wheelchair for mobility. The MDS noted she required substantial to maximal assistance for her activities of daily living (ADL) and supervision during meals. The MDS noted no weight loss. R43's Cognitive Loss Care Area Assessment (CAA) triggered on 05/27/25, indicating she was at risk for a decline in her ADLs related to her memory loss, impaired decision making, and need for assistance. The CAA noted she was at risk for nutritional impairment due to her medical diagnoses and cognitive impairment. R43's Communication CAA triggered on 05/27/25, indicating she was at risk for impaired communication related to her hearing and communication deficits. The CAA noted that a care plan was implemented to minimize the risks associated with her impairments, and staff were to anticipate her needs. R43's Care Plan initiated 07/11/24 indicated she was dependent on staff for meeting her emotional, intellectual, physical, and social needs due to her cognitive impairments. The plan instructed staff to provide a consistent routine and use approaches to ensure her involvement in decision-making. The plan instructed staff to anticipate and meet her needs. On 09/09/25 at 07:50 AM, R43 was wheeled to the dining room area. Her wheelchair lacked foot pedals, and her feet slid on the floor as she was pushed. R43 told staff, I'm hungry, and staff moved her to the table. At 07:55 AM, staff started serving trays two at a time from the kitchen. At 08:00 AM, R43 again informed staff she was hungry as she sat at the table. At 08:10 AM, two other residents had their food at the table she sat at and they ate their food. At 08:15 AM, staff placed a plate of food in the empty seat next to her. At 08:20 AM, the majority of the room had already served their meals except R43. R43 again complained she was hungry and began looking at the meal ticket for the empty seat next to hers. At 08:30 AM, R43 finally received her meal and began eating. The majority of the room had completed their meals before R43 received her plate. On 09/09/25 at 08:45 AM, Administrative Staff B stated the kitchen had to serve the meals two at a time to ensure the food stayed hot. She stated the dishwasher had been down for a week, and the kitchen had to serve the meals on Styrofoam plates. On 09/10/25 at 11:20 AM, Dietary Staff BB stated the dishwasher had been broken for the last week and a half. He stated the facility was waiting for a part and had to use Styrofoam plates. He stated the meals were to be served on the units to ensure they come out at the same time for each resident to enjoy their meals together. On 09/10/25 at 12:32 PM, Certified Nurses Aide (CNA) O stated the residents were to be served their meals around the same time so they could enjoy their meals together. She stated residents should not wait more than five minutes to receive their meals during breakfast. She stated the residents should never be allowed to watch other residents eat while they wait. The facility's Resident Rights policy, revised 12/2018, indicated the facility was to ensure all residents were treated in a dignified manner. The policy indicated the facility was to provide ongoing education and In-service.- The Medical Diagnosis section within R20's Electronic Medical Records (EMR) included diagnoses of anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), cognitive communication disorder (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness), major depressive disorder (major mood disorder), and need for assistance for personal cares. R20's Quarterly Minimum Data Set (MDS) completed 06/19/25 indicated a Brief interview for Mental Status (BIMS) score of 15 (intact cognition). The MDS noted no upper or lower extremity impairments. The MDS noted he used a wheelchair for mobility. The MDS noted he had physical, verbal, and other self-directed behaviors observed for one to three days. The MDS noted he was independent for toileting, transfers, bathing, bed mobility, dressing, personal hygiene, and putting on footwear. The MDS noted no behaviors or rejection of care. R20's Functional Ability Care Area Assessment (CAA) was triggered on 09/11/25. The CAA noted he required assistance from staff related to medical diagnoses. The CAA noted that a care plan was implemented to minimize the risks related to his potential decline in activities of daily living. R20's Care Plan initiated 05/10/18 indicated he was at risk for falls, nutritional deficit, and ADL decline related to his medical diagnoses. The plan indicated he could complete bathing, toileting, transfers, dressing, bed mobility, and personal hygiene with minimal staff assistance. The plan noted he was at risk for a psycho-social decline related to his history of anxiety. The plan instructed staff to move R20 to a calmer environment when conflict arose and allow him to share his feelings. A Facility Incident Report #2381 completed on 08/27/25 reported that an incident occurred between Dietary Staff CC and R20. The report indicated on 08/27/25, Dietary Staff CC got into a verbally aggressive argument with R20 in the dining area during dinner meal service. The report indicated R20 asked Dietary Staff CC for some milk. The report indicated that Dietary Staff CC informed R20 that he could not have milk. The report indicated that Dietary Staff CC became verbally aggressive with R20 upon being asked why he could not have milk. The report indicated that Dietary Staff CC was removed from the facility and immediately suspended. A Witness Statement was completed by Certified Nurse Aide (CNA) XX on 08/27/25. The statement indicated CNA XX witnessed R20 in the dining room, upset that he could not get milk with his meal. CNA XX noted in the statement that she witnessed Dietary Staff CC throw his hands in the air and run at R20. CNA XX noted in her statement that Dietary Staff CC continued to yell at R20, and she stood in front of Dietary Staff CC and told him to return to the kitchen. The statement indicated that Dietary Staff CC returned to the kitchen after multiple staff members requested him to leave. A Witness Statement was completed by Certified Nurse Aide (CNA) YY on 08/27/25. The statement indicated she witnessed Dietary staff CC aggressively approach R20 during the altercation and get into R20's face. She stated CNA XX got in between the two and told Dietary Staff CC to leave the dining room. On 09/09/25 at 11:32 AM, R20 sat in his room. R20 reported he remembered the incident on 08/27/25. He stated he felt threatened that staff would assault him over a carton of milk. He stated the kitchen staff aggressively yelled at him and got in his face until another staff member intervened. He stated the other staff was able to get him milk without issue. He stated he never he issues with staff until that day. He stated he felt humiliated and dehumanized that staff would treat him in such a rude manner over milk. On 09/09/25 at 02:30 PM, CNA WW stated all staff received training related to abuse, dementia care, and communication at least every quarter. She stated the previous abuse training was held in July 2025. She stated that staff were to always talk to the residents in a respectful manner. She stated milk and condiments were always available to the residents. On 09/10/25 at 12:23 PM, Administrative Nurse D stated the facility holds abuse training annually and after any incidents occur. She stated staff were expected to treat all residents in a dignified manner and protect the residents from abuse. She stated staff were expected to accommodate the residents' needs and asked the department managers if items were not immediately available. The facility's Resident Rights policy, revised 12/2018, indicated the facility was to ensure all residents were treated in a dignified manner. The policy indicated the facility was to provide ongoing education and In-service.

The facility had a census of 107 residents. The sample included 26 residents, with four reviewed for accommodation of needs for assistive device. Based on observation, record review, and interview the facility failed to utilize foot pedals during wheelchair transports for Resident (R) 37, R43, R104, and R122. This placed the residents at risk for preventable accidents. Findings Included: - On 09/09/25 at 07:40 AM, R37 (a severely cognitively impaired resident on the secured unit) was wheeled from her room to the dining room table. R37's wheelchair lacked foot pedals, and her feet slid on the ground as she was pushed. On 09/09/25 at 07:50 AM, R43 (a severely cognitively impaired resident on the secured unit) was wheeled to the dining room area from her room. Her wheelchair lacked foot pedals, and her feet slid on the floor as she was pushed.On 09/09/25 at 08:42 AM, R104 (a severely cognitively impaired resident on the secured unit) was pushed from the hallway to the dining room table. R104's wheelchair lacked foot pedals. Her feet touched the floor as she was pushed to the table. On 09/09/25 at 08:15 AM, R122 wheeled to her room from the main dining hall by staff. R122's wheelchair lacked foot pedals, and her feet slid on the ground as she was pushed.On 09/10/25 at 12:22 PM, Certified Nurse's Aide (CNA) O stated foot pedals were to be used on all residents while being pushed in their wheelchairs. She stated that all the wheelchairs had foot pedals available to use. She stated that pushing residents in their wheelchairs without them could cause an injury or fall. On 09/10/25 at 12:34 PM, Administrative Nurse D stated that staff were expected to use foot pedals while pushing the resident's wheelchair. The facility was unable to provide a policy related to assistive devices or accidents as requested on 09/10/25.

The facility had a census of 107 residents. Five Certified Nurse Aides (CNA) were sampled for required in-service training. Based on record review and interview, the facility failed to ensure five of the five CNA staff reviewed had the required 12 hours of in-service education. This placed the residents at risk for decreased quality of life and/or inadequate care. Findings included:- Review of the information facility's in-service records revealed the following CNAs were employed with the facility for more than 12 months: CNA MM, hired on 06/26/24, had not completed the required in-services in the past 12 months. CNA NN, hired on 09/29/24, had not completed the required in-services in the past 12 months. CNA OO, hired on 09/22/22, had not completed the required in-services in the past 12 months. CNA PP, hired on 11/22/23, had not completed the required in-services in the past 12 months. CNA QQ, hired on 10/25/23, had not completed the required in-services in the past 12 months. On 09/10/25 at 12:30 PM, Certified Nurse Aide (CNA) O stated the facility did have monthly meetings. CNA O stated she could not remember the last time she had a dementia (a progressive mental disorder characterized by failing memory and confusion) in-service. On 09/10/25 at 12:58 PM, Licensed Nurse (LN) K stated the facility did provide monthly in-services. LN K stated he could not remember the last dementia care in-service. LN K stated we are provided abuse and neglect in-services often. On 09/10/25 at 01:23 PM, Administrative Nurse D stated the facility human resource department, and the administrative staff were responsible for ensuring the direct care staff received the required 12 hours of in-services. The facility's In-Service Training, All Staff policy, last revised 08/2022, documented all staff must participate in initial orientation and annual in-service training.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 107 residents. The sample included 26 residents, with two residents reviewed for hospice (a type of health care that focuses on the terminally ill patient's pain and symptoms and attending to their emotional and spiritual needs at the end of life) services. Based on observation, record review, and interview, the facility failed to ensure a coordinated plan of care, which coordinated care and services provided by the facility with the care and services provided by hospice, was developed and available for Residents (R) 4 and R5. This placed the resident at risk for inadequate end-of-life care. Finding Included:- R4's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of hypertension (HTN- elevated blood pressure), anemia (an inadequate number of healthy red blood cells to carry adequate oxygen to body tissues), epilepsy (brain disorder characterized by repeated seizures), psychosis (any major mental disorder characterized by a gross impairment in reality perception), dementia (a progressive mental disorder characterized by failing memory and confusion), schizoaffective (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought), bipolar disorder (a major mental illness that causes people to have episodes of severe high and low moods), repeated falls, need with assistance with personal cares, muscle weakness, encounter for palliative care, and major depressive disorder (major mood disorder that causes persistent feelings of sadness).
The Annual Minimum Data Set (MDS) dated [DATE], documented a Brief Interview of Mental Status (BIMS) score of 99, which indicated severely impaired cognition. The MDS documented R4 was dependent on staff for toileting, bathing, dressing, and eating. The MDS documented R4 received hospice services.
R4's The Functional Abilities Self-Care and Mobility Care Area Assessment (CAA), dated 08/12/25, documented R4's activities of daily living (ADL) function CAA triggered secondary to assistance required in ADLs, impaired balance, transitions during transfers, and functional impairment in activity. R4's contributing factors include generalized weakness and decreased safety awareness. R4's risk factors included further ADL decline, falls, incontinence, skin breakdown, and pain. The CAA documented R4's care plan would be initiated/reviewed to improve/maintain current ADL status and functional ability, maintain continence status, decrease pain, and decrease fall and pressure ulcer risk.
R4's Care Plan dated 09/05/24 documented R4 was admitted to hospice due to a terminal diagnosis, cerebral atherosclerosis (a condition where fatty deposits build up in the arteries that supply blood to the brain). R4's plan of care documented comfort would be maintained, and staff would adjust the provision of ADLs to compensate for the resident's changing abilities. R4's plan of care documented that staff were to encourage participation to the extent the resident wished to participate and encourage the support system of family and friends. R4's plan of care documented to keep the environment quiet and calm, keep linens clean, dry, and wrinkle-free. R4's plan of care documented staff were to keep the lighting low and familiar objects nearby. The plan of care for R4 documented the hospice provider would review the resident's living will and ensure it was followed. The plan of care for R4 documented staff were to involve the family in the discussion. R4's plan of care documented Vitas hospice would provide durable medical equipment (DME), and staff would work cooperatively with hospice team to ensure R4's spiritual, emotional, intellectual, physical, and social needs were met.
A review of the hospice-provided communication binder revealed R4 was admitted to hospice services on 09/05/24.
On 09/09/25 at 08:35 AM, R4 sat in the dining area waiting for her breakfast, holding her doll.
On 09/09/25 at 08:50 AM, R4 sat in the dining room with staff assisting her with breakfast.
On 09/10/25 at 12:30 PM, Certified Nursing Aide (CNA) O stated she was unsure what hospice provided for the residents. She stated the hospice aides would let the staff know if the hospice provider left any supplies or gave a shower. CNA O stated she didn't think that what hospice provided, the CNAs could see.
On 09/10/25 at 12:58 PM, Licensed Nurse (LN) K stated he was unsure what hospice provided. He stated he did not do the care plans; the MDS coordinator did the care plan. LN G stated he did not think what hospice provided would need to be on the facility's care plan. LN G stated that hospice aides and nurses were good at letting the facility know what equipment and supplies they brought to the resident. He stated if there was something specific the facility needed to know, they could look in the hospice binder specific to each resident.
On 09/10/25 at 01:22 PM, Administrative Nurse D said she knew the hospice providers had detailed care plans and staff would know specific services by those. She stated she thought everything hospice provided should be on the care plan.
The facility's Hospice Program policy, dated 07/17, documented hospice services were available to residents at the end of life. The facility had an agreement in place with at least one Medicare-certified hospice to ensure that residents who wish to participate in a hospice program may do so. Upon admission and periodically during their stay, residents were informed of the availability of hospice services coordinated through the facility.
- R5's Electronic Medical Record (EMR) documented diagnoses of malignant neoplasm (cancer- an abnormal growth of cells that can invade and spread to other parts of the body) of lung, chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), and hemiplegia/paresis (weakness and paralysis on one side of the body).
R5's admission Minimum Data Set (MDS) dated 08/25/25 documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. R5 required substantial/maximal assistance to being dependent on staff for his activities of daily living (ADL) care. R5 was on hospice care.
R5's Functional Abilities Care Area Assessment (CAA) dated 08/27/25 documented his need for assistance with his ADLs and mobility due to his lung cancer, need for palliative care, and failure to thrive.
R5's Care Plan initiated on 08/19/25 directed staff that he had a terminal prognosis and elected hospice care. The Care Plan directed staff to adjust provisions of his ADLs to compensate for his changing abilities. The Care Plan directed staff to encourage participation to the extent the resident wished to participate. The Care Plan directed staff to encourage the resident to express his feelings and listen with non-judgmental acceptance and compassion. The Care Plan directed staff to encourage a support system of family and friends. The Care Plan directed staff to keep the environment quiet and calm, keep linens clean, dry, and wrinkle-free, keep the lighting low, and keep familiar objects nearby. The Care Plan directed staff to observe R5 closely for signs of pain and administer pain medications as ordered and notify the physician immediately if there was breakthrough pain. The Care Plan directed staff to work cooperatively with the hospice team to ensure the resident's spiritual, emotional, intellectual, physical, and social needs were met. R5's Care Plan lacked staff direction on who the hospice provider was and the contact information. R5's Care Plan lacked staff direction on what hospice provided for the resident as far as supplies, durable medical equipment (DME), medications, and hospice staff information (who would visit and the frequency of the visits).
On 09/09/25 at 01:15 PM, R5 lay resting on his low air loss mattress, the bed in low position, and the call light within reach.
On 09/10/25 at 12:30 PM, Certified Nurse Aide (CNA) O stated that the nurses would usually tell staff when a resident was on hospice. CNA O stated that the hospice aide would come a couple of times a week, and the hospice nurse came to the facility weekly and would usually ask if a resident needed any supplies. CNA O stated that the items/equipment supplied had the hospice name on them. CNA O stated she was not certain if R5's care plan had all that information in it or not.
On 09/10/25 at 12:59 PM, Licensed Nurse (LN) K stated the hospice information was at the nurse's station and the hospice plan of care was in the resident's hospice books. LN K could not say for certain if R5's care plan had all the information about hospice in it as far as the contact information and what hospice supplied, but would expect that the care plan should have that information on it.
On 09/10/25 at 01:22 PM, Administrative Nurse D stated they had been working on improving the resident care plans. Administrative Nurse D stated R5's care plan should document the hospice provider and contact information as well as what hospice provided and when hospice staff would visit. Administrative Nurse D stated she would ensure R5's care plan was revised to reflect that information.
The Hospice Program policy, dated January 2024, documented coordinated care plans for residents receiving hospice services would include the most recent hospice plan of care as well as the care and services provided by our facility (including the responsible provider and discipline assigned to specific tasks) to maintain the resident's highest practicable physical, mental, and psychosocial well-being. The coordinated care plan would reflect the resident's goals and wishes, as stated in his or her advance directives and during ongoing communication with the resident or representative, including palliative goals and objectives, palliative interventions, and medical treatment and diagnostic tests.

The facility identified a census of 107 residents, with one kitchen and two dining rooms. Based on observation, record review, and interviews, the facility failed to follow sanitary dietary standards related to storage, preparation, and meal service. This deficient practice placed the residents at risk of food-borne illnesses and food safety concerns. Findings Included: - On 09/08/25 at 07:05 AM, a walkthrough of the facility's kitchen was completed. An inspection of the main kitchen area revealed:The floor was heavily dirty with old food debris and trash in the food prep and stove area. A soiled towel was on the floor next to the stove top ovens. Dessert saucers and plates were stored upwards in the dishware storage rack. An inspection of the dry food storage area revealed dirty floors and a soiled Band-Aid in the center of the dry food storage room floor. A dented 6.56-pound (lb.) can of fruit cocktail was on the canned storage rack. An inspection of the walk-in refrigerator revealed a metal tray of five packaged turkey cold cut meat underneath the walk-in refrigerator's air blower. The tray had liquid dripping on the turkey packages and pooling in the tray, dripping from a pipe coming from the air conditioner. On 09/11/25 at 12:01 PM, Dietary Staff BB stated that food was not to be placed underneath the air conditioner in the walk-in units. He stated the food was moved and thrown out. He stated that staff were expected to clean after every meal service.A review of the facility's Food Services and Nutrition policy, dated 10/2017, indicated the facility would promote a system that identified proper service, cleaning, and food storage. The policy noted that all surfaces within the dining room and kitchen were to be cleaned and sanitized per professional standards. The policy indicated food would be labeled/dated and stored in a manner that is safe and maintains nutritional value. The policy indicated staff were to ensure safe food handling practices to prevent cross-contamination and food-borne illness. The policy indicated staff should complete hand hygiene in between touching surfaces related to direct food preparation, handling, and serving. The policy noted that all kitchen and dining equipment be stored in a manner that prevents soiling or contamination of clean items.

The facility identified a census of 107 residents. The facility had three medication rooms and five medication carts. Based on observation, record review, and interview, the facility failed to ensure the medication cart was kept locked and secured with cognitively impaired and independently mobile residents on the hall. This placed the residents at risk of accidental ingestion of medication and adverse reactions.Findings included:- On 09/08/25 at 07:14 AM, the nurse's medication cart on the 200 hall was left unlocked and unattended by staff. The medication cart contained two insulin pens and two vials of insulin.On 09/08/25 at 07:18 AM, Licensed Nurse (LN) H stated that she had stepped away from the cart briefly to assist another nurse, but the cart should always be locked when she was away from it. On 09/10/25 at 01:22 PM, Administrative Nurse D stated that the medication carts should not ever be left unlocked when staff are away from the cart. The facility's Security of Medication Cart policy, dated January 2023, documented that the medication cart shall be secured during medication passes. The nurse or certified medication aide must secure the medication cart during the medication pass to prevent unauthorized entry. The medication cart should be parked in the doorway of the resident's room during the medication pass. The cart doors and drawers should be facing the resident's room. When it's not possible to park the medication cart in the doorway, the cart should be parked in the hallway against the wall with doors and drawers facing the wall. The cart must be locked before the nurse enters the resident's room. Medication carts must be securely locked at all times when out of the nurse's view. When the medication cart is not being used, it must be locked and parked at the nurses' station or inside the medication room.

The facility identified a census of 102 residents with six residents on puree textured diets. Based on observations, interviews, and record review, the facility failed to follow nutritionally approved recipes during the preparation of the facility's pureed meals. This deficient practice placed six residents at risk for complications related to nutritional impairment.
Findings Included-
- On 01/22/23 at 10:15 AM Dietary Staff BB placed a tin of cooked beef and another of beef stock in the preparation area. The food processor machine had previously been used for food and had not been washed before puree use. Dietary Staff BB placed the contents of the cooked beef in the food processor and started to puree the meat. Dietary Staff BB then added beef stock to the processor without measuring to amount of liquid stock to be added. Dietary Staff then prepared a tin serving pan with non-stick spray and removed the textured mixer from the processor to the serving tray. An inspection of the mixer revealed a wet pudding-like consistency for the prepared meat. Dietary Staff BB did not review the pureed beef recipe throughout the preparation of the pureed meal. Dietary Staff BB explained the recipes were available for review and pointed to the recipe book on a table.
On 01/23/23 at 11:23 PM Dietary Staff BB stated recipes must be followed by staff during meal preparation and staff were to review them during preparation.
The facility's provided Food Preparation and Service 04/2019 indicated food will be prepared and maintained to ensure proper nutritional values are maintained and to meet the dietary requirements of each resident.
The facility failed to follow a nutritionally approved recipe during the preparation of the facility's pureed meals. This deficient practice placed six residents at risk for complications related to nutritional impairment.

The facility identified a census of 102 residents. The sample included 22 residents with three reviewed for abuse and/or neglect. Based on record review, observations, and interviews, the facility failed to identify a preventable accident for Resident (R) 18, who was dependent on staff for transfers with a Hoyer (full body mechanical lift), as an allegation of potential neglect and failed to report to the State Agency (SA) as required within the required timeframe. This placed the resident at risk for unidentified and ongoing neglect.
Findings included:
- The Electronic Medical Record (EMR) for R18 documented a diagnosis of cerebral palsy (a progressive disorder of movement, muscle tone, or posture caused by injury or abnormal development in the immature brain, most often before birth), and obstructive and reflux uropathy (a disorder of the urinary tract that occurs due to obstructed urinary flow that can be either structural or functional and allows urine to flow back into the kidneys).
The admission Minimum Data Set (MDS) dated 07/21/23, documented a Brief Interview for Mental Status (BIMS) score of 12 which indicated moderate cognitive impairment. The MDS documented R18 used a wheelchair and was dependent on staff for bathing, dressing, mobility, and transfers.
The Falls Care Area Assessment (CAA) dated 07/21/23, documented R18 was at risk for falls related to cerebral palsy. The MDS further documented R18 had a history of falls, weakness, and physical performance limitations that affected his balance, gait, strength, and muscle endurance.
R18's Care Plan with an initiated date of 07/24/23, documented R18 had an activity of daily living (ADL) self-care performance deficit and impaired mobility related to cerebral palsy. An intervention with an initiated date of 07/24/23 documented R18 required the use of a Hoyer lift for transfers. An intervention with an initiated date of 07/24/23 documented R18 admitted to the facility with his wheelchair and that R18 was dependent on staff for locomotion. The intervention directed staff to assist as appropriate.
A Witnessed Fall 3110 report dated 01/04/24, documented Licensed Nurse (LN) H was called to R18's room and found him on the floor facing up with a pillow under his head. The document further recorded the staff present at the time of the incident reported they transferred R18 from a chair to his bed with a Hoyer lift when one of the loops on the right side came loose and caused R18 to fall. The document further recorded R18 had a hard bump to the back of his head. The document recorded R18 was assessed by the advanced practice registered nurse (APRN) who was in the facility and sent to a local emergency room for evaluation and treatment.
Certified Nurse Aide (CNA) M's undated Witness Statement documented CNA M and CNA N took R18 to his room. CNA N hooked the Hoyer pad to the Hoyer lift. The witness statement documented CNA M walked behind R18's wheelchair to move it as CNA N began lifting R18 with the Hoyer lift. The witness statement further documented CNA N yelled as CNA M came around the wheelchair to move it, and R18 fell on the floor.
CNA N's undated Witness Statement documented CNA M and CNA N took R18 into his room so he could go to bed. The witness statement documented CNA N hooked the R18's sling to the Hoyer lift while CNA M unhooked R18's urine collection bag from the bottom of his wheelchair. The statement further documented CNA N raised R18 in the Hoyer sling and CNA M went to move R18's wheelchair. CNA N documented as R18 was raised in the sling, the back, left hoop on the Hoyer sling came off and R18 fell backward out of the sling onto the floor.
On 01/22/24 at 09:22 AM CNA M and CNA O used a Hoyer lift to transfer R18 from a wheelchair to his bed.
On 01/23/24 at 12:55 PM Administrative Nurse D stated the expected staff to ensure sling hoops were correctly placed on the Hoyer lift before transfers. Administrative Nurse D stated it was not a normal occurrence for a Hoyer sling to come off a Hoyer lift unless the equipment was faulty. Administrative Nurse D further stated the fall was most likely a result of human error as the lift and sling used to transfer R18 were inspected and found to be functioning correctly. Administrative Nurse D stated the fall was not reported to the SA as it was his understanding that a fall from a Hoyer was only reportable if the resident sustained a significant injury, since the facility did not report every resident that was sent to the emergency room due to a fall. Administrative Nurse D verified the facility reported outright allegations of abuse but went on to say there was not a suspicion of neglect and the facility believed it was premature to assume there was until after an investigation was conducted. Administrative Nurse D stated the fall would have been reported immediately if R18 had a significant injury or if the investigation showed abuse. Administrative Nurse D stated he did see human error as a potential neglect situation.
The facility provided the Abuse, Neglect, Exploitation, and Misappropriation Preventions Program policy with a revised date of April 2021 documented that residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. The policy further documented that the program supported identifying and investigating all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property and investigating and reporting allegations within the timeframes required by federal requirements.
The facility failed to identify a preventable accident for R18, who was totally dependent on staff for transfers with a Hoyer, as an allegation of potential neglect and failed to report to the SA as required within the required timeframe. This placed R18 at risk for unidentified and ongoing neglect.

The facility identified a census of 102 residents. The sample included 22 residents with six residents reviewed for dignity. Based on observation, interview, and record review, the facility failed to ensure a dignified care environment for Resident (R)33, R62, R75, R88, and R89. The facility additionally failed to provide dignity while dining when the facility used disposable silverware and dishware during meals. This deficient practice placed the residents at risk of unnecessary embarrassment and decreased psychosocial well-being.
Findings Included:
- The Facility Reported Incident 2181 documented that on 08/13/23, R33 assisted emergency medical services (EMS) by holding open a door so EMS could enter the facility. The report indicated Administrative Staff B approached R33 and told R33 to move out of the way. The report indicated R33 refused to move, and Administrative Staff B used profanity towards R33.
On 01/17/24 at 08:05 AM an inspection of the main dining area revealed residents ate breakfast with Styrofoam plates/cups and disposable plastic silverware. At 08:05 AM Dietary Staff BB stated the facility had enough silverware for all three meal services, but staff did not return the silverware to the kitchen in time for the next service.
On 01/17/24 at 08:30 AM an inspection of the Abbey Hall dining service revealed residents ate breakfast with Styrofoam plates/cups and disposable plastic silverware.
On 01/17/24 at 12:14 PM R75 (a severely cognitively impaired resident) rested in the dining area in her Broda chair (specialized wheelchair with the ability to tilt and recline). R75 sat at the table with her head and arms resting on the table. An unidentified staff member walked up to R75 and informed her it was lunchtime. R75 stated she preferred to rest with her head on the table. Staff then repositioned her upright in her wheelchair without notifying her or asking her if she wanted to sit up. R75 agreed to eat lunch. The unidentified staff member yelled out I'll feed her to another staff across the room.
On 01/22/24 at 09:56 AM Licensed Nurse (LN) G administered R88's morning medications through her gastrotomy tube (G-tube: tube surgically placed through an artificial opening into the stomach) and completed a dressing change. LN G failed to close the door or pull the privacy curtain during the provided care with multiple people walking past the room within sight of the provided care. During the dressing change, Administrative Nurse D walked by R88's room, then stopped and closed the door. LN G stated she usually would close the door when she provided wound care but not while working with G-tubes.
On 01/22/24 at 11:50 AM R89 (a severely cognitively impaired resident) sat at the dining table closest to the television and awaited her lunch. Certified Nurses Aid (CNA) NN brought R89's meal to her and prepped her for lunch. CNA NN provided assistive feeding for R89 while standing next to the resident. At 11:56 AM, LN J approached CNA NN and instructed her to sit down next to R89 while providing assisted feeding. CNA NN sat down and remained seated during the meal assist.
On 01/22/24 at 11:58 AM R62 was assisted to the dining room by CNA LL. R62 sat at the table next to the window and CNA LL adjusted her seat. CNA LL completed hand hygiene and retrieved R62's meal and drink from the food cart. CNA LL stood next to R62 and began spoon-feeding her mechanically soft beef and mashed potatoes. At 12:01 PM CNA LL continued to provide assistive feeding to R62 without offering or alternating drinks with her solid food. At 12:09 PM CNA LL picked up R62's red beverage and offered it to her. R62 took a large drink and continued her meal while CNA LL stood next to her to assist.
On 01/23/24 at 11:20 AM CNA M stated staff were expected to always be seated with the residents during assistive feedings. She stated it would be disrespectful to stand over someone else while trying to feed them.
On 01/23/24 at 11:55 AM LN I stated staff should always communicate before repositioning residents and always sit with them while assisting them with meals. She stated staff should always ensure privacy while providing personal care assistance and dressing changes.
On 01/23/24 at 12:50 PM Administrative Nurse D stated staff was expected to ensure the residents had privacy during care. He stated staff should always sit while providing assisted meals and be at eye level to ensure effective communication. He stated staff should always communicate with the residents before repositioning them and ask for their opinion or input.
A review of the facility's Resident Rights policy revised 12/2016 indicated all residents had the right to be treated with dignity, respect, and kindness. The policy indicated the facility would provide care in a manner that communicates understanding and preferred choices related to each resident's needs, wants, and preferences.
The facility failed to ensure a dignified care environment for R33, R62, R75, R88, and R89. The facility additionally failed to provide dignity while dining related to using disposable silverware and dishware during meals. This deficient practice placed the residents at risk of unnecessary embarrassment and decreased psychosocial well-being.

The facility identified a census of 102 residents with 22 residents included in the sample. The facility identified two residents who were discharged from Medicare Part A services. Based on interview and record review the facility failed to issue CMS (Center for Medicare/Medicaid Services) Skilled Nursing Facility Advance Beneficiary Notification (SNF ABN) form 10055 (the form used to notify Medicare A participants of potential financial liability when a Medicare Part A episode ends) with the required information for Resident (R) 81 and R 28. This failure placed the residents at risk for impaired decision-making.
Findings included:
- A review of R81's Electronic Medical Record (EMR) documented that the Medicare Part A episode began on 08/17/23 and ended on 08/21/23. R81 remained in the facility for custodial care. The facility-issued SNF ABN 10055 lacked an estimated cost for continued services.
A review of R28's Electronic Medical Record (EMR) documented that the Medicare Part A episode began on 07/12/23 and ended on 09/01/23. R28 remained in the facility for custodial care. The facility-issued SNF ABN 10055 lacked an estimated cost for continued services.
On 01/23/23 at 11:25 PM Social Services X stated that she was unaware the form CMS-10055 needed an estimated cost for continued services.
The facility's Advance Beneficiary Notices policy, dated 04/2021, documented that the current CMS-approved version of the forms shall be used at the time of issuance to the beneficiary and the contents of the form shall comply with related instructions and regulations regarding the use of the form.
The facility failed to ensure the forms provided at the end of skilled services contained the required information for the residents to make informed choices. This failure placed the residents at risk for impaired decision-making.

The facility identified a census of 102 residents. The sample included 22 residents. Based on record review and interview, the facility failed to provide written notification as soon as practicable to Resident (R) 58. This deficient practice had the risk of miscommunication between the facility and the resident.
Findings included:
- The electronic medical record (EMR) for R58 documented diagnosis of quadriplegia (inability to move the arms, legs, and trunk of the body below the level of an associated injury to the spinal cord), and neuralgia (intense pain along a nerve).
The Significant Change Minimum Data Set (MDS) dated 11/30/23 documented R58 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. R58 had impairment on both sides of his body and was dependent on staff for all functional activities.
The Functional Abilities Care Area Assessment (CAA) dated 12/07/23 documented R58 was dependent on staff for activities of daily living (ADLs) care needs including eating, oral and personal hygiene, toileting, and mobility issues.
R58's Psychosocial Well-Being Care Plan revised 12/29/23 directed staff to allow R58 the opportunity to communicate his feelings. R58 was to meet with social services weekly to discuss feelings and develop coping strategies.
A Bed Hold Authorization dated 09/21/23 with a transfer date of 09/20/23 was completed and verbally authorized by R58's representative.
A Bed Hold Authorization dated 10/20/23 with a transfer date of 10/19/23 was completed and verbally authorized by R58's representative.
A Bed Hold Authorization dated 12/01/23 with a transfer date of 12/01/23 was completed and verbally authorized by R58's representative.
A Bed Hold Authorization dated 12/15/23 with a transfer date of 12/14/22 was completed and verbally authorized by R58's representative.
R58's clinical record lacked evidence a written notification of transfer was provided to R58 and/or their representative for the facility-initiated transfer dates noted above (09/21/23, 10/19/23, 12/01/23, and 12/14/23).
On 01/22/24 at 01:05 PM Administrative Staff A stated that staff notified the family representative by phone of the transfer. Administrative Staff A said she was not aware if written notification was provided to R58 or his representative.
The Transfer or Discharge, Facility-Initiated policy dated October 2022 documented facility-initiated transfers and discharges, when necessary, must meet specific criteria and require resident/representative notification, orientation, and documentation as specified in this policy. The resident and representative were to be notified in writing of a specific reason for the transfer or discharge. The effective date of the transfer or discharge. The specific location to which the resident was being transferred or discharged . An explanation of the resident's rights to appeal the transfer or discharge to the state.
The facility failed to provide written notification of facility-initiated transfers with the required information to R58 and/or his representative in a practicable amount of time. This deficient practice had the risk of miscommunication between the facility and R58.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 102 residents. The sample included 22 residents with three residents reviewed for activities of daily living (ADLs). Based on record review, interviews, and observations, the facility failed to provide the necessary assistance to Resident (R)62 for eating and drinking. These deficient practices placed R62 at risk of increased complications due to impaired ADL ability.
Findings included:
- The Medical Diagnosis section within R62's Electronic Medical Records (EMR) included diagnoses of dementia (progressive mental disorder characterized by failing memory, and confusion), aphasia (condition with disordered or absent language function), major depressive disorder (major mood disorder), and type two diabetes mellitus (when the body cannot use glucose, not enough insulin or the body cannot respond to the insulin).
R62's Quarterly Minimum Data Set (MDS) completed 01/03/24 indicated a Brief Interview for Mental Status (BIMS) score of zero indicating severe cognitive impairment. The MDS indicated she was dependent on staff assistance for eating, oral hygiene, toileting, dressing, bed mobility, transfers, and bathing. The MDS indicated no dental or oral issues.
R62's Nutrition Care Area Assessment (CAA) completed 04/14/23 indicated she was at risk for impaired nutrition related to her advanced dementia. The CAA noted she required a mechanically soft diet and had forgotten how to use eating utensils for self-feeding. The CAA noted she required assistance with eating. The CAA noted she was unable to eat meals without extensive physical assistance. The CAA indicated she had issues with swallowing her meals.
R62's Care Plan initiated 06/09/22 indicated she had nutritional deficits related to her medical diagnoses. The plan indicated she required extensive to total assistance with meals. The plan instructed staff to provide her meals as ordered and monitor her intake. The plan instructed staff to offer meal substitutions and snacks as appropriate. The plan indicated she had dementia-focused nutritional interventions due to R62's inability to use utensils. The plan implemented safe swallow strategies instructing staff to alternate between two bites of solid food to one drink ratio.
On 01/22/24 at 11:58 PM, R62 was assisted to the dining room by Certified Nurses Aid (CNA) LL. R62 sat at the table next to the window and CNA LL adjusted her seat. CNA LL completed hand hygiene and retrieved R62's meal and drink from the food cart. CNA LL stood next to her R62 and began spoon-feeding her mechanically soft beef and mashed potatoes. At 12:01 PM CNA LL continued to provide assistive feeding to R62 without offering or alternating drinks with her solid food. At 12:09 PM CNA LL picked up R62's red beverage and offered it to her. R62 took a large drink and continued her meal. R62's solid-to-liquid meal intake was not alternated throughout the meal per her care plan.
On 01/23/24 at 11:20 AM Certified Nurse's Aide (CNA) M stated each resident's diet and care requirements were reflected on the [NAME]. She stated staff should actively engage with the residents while feeding them and anticipate their needs if a resident could not communicate with them. She stated staff should offer drinks to residents frequently who were unable to get a drink on their own.
On 01/23/24 at 11:55 AM Licensed Nurse (LN) I stated direct staff were expected to review each [NAME] to ensure the correct level of care was given to each resident. She stated staff were expected to sit next to each resident while assisting them and ask the resident frequently if they required drinks. She stated R62 required total assistance during meals due to her dementia and difficulty communicating her needs.
On 01/23/24 at 12:54 PM Administrative Nurse D stated all staff had access to review the care plans and [NAME] information for each resident. He stated staff were expected to sit next to the residents during meals and provide the level of assistance identified in the care plan.
The facility's provided Activities of Daily Living 03/2018 indicated residents unable to carry out activities of facility living independently will receive the services necessary to maintain good nutrition, grooming, and personal care.
The facility failed to provide R62 with the necessary assistance during staff-assisted meals. These deficient practices placed R62 at risk for complications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 102 residents. The sample included 22 residents with one resident reviewed for hydration. Based on observation, record review, and interviews, the facility failed to follow a physician's order for daily weights to monitor for fluid overload for Resident (R) 38. This deficient practice placed R38 at risk for delay in treatment related to fluid overload and untreated illness.
Findings included:
- R38'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), edema (swelling resulting from an excessive accumulation of fluid in the body tissues), and paraplegia (paralysis characterized by motor or sensory loss in the lower limbs and trunk).
The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS documented that R38 was dependent on staff assistance for transfers. The MDS documented R38 received diuretic (medication to promote the formation and excretion of urine) medication during the observation period.
R38's Functional Abilities Care Area Assessment (CAA) dated 12/28/23 documented R38 preferred to stay in bed.
R38's Care Plan dated 05/26/22 documented that a daily weight would be obtained as ordered by the physician and staff would notify the physician of a weight gain greater than three pounds.
A review of the EMR under the Orders tab revealed the following physician orders:
Lasix (diuretic) oral tablet 20 milligrams (mg) give 60 mg by mouth two times a day for CHF dated 05/23/23.
Daily weight in the morning, notify physician of weight gain of three pounds or greater related to edema dated 05/23/23.
Review of R38's Treatment Administration Record (TAR) from 10/01/23 to 01/21/24 (113 days) lacked evidence staff measured and recorded R38's weight) on following dates 10/28/23, 10/31/23, 11/04/23, 11/11/23, 11/13/23, 11/16/23, 11/28/23, 12/08/23, 12/14/23, 12/17/23, 01/03/24, and 01/15/24. The clinical record lacked evidence of physician notification the daily weight was not obtained.
Observation on 01/22/24 at 12:16 PM R38 reclined in his Broda chair (specialized wheelchair with the ability to tilt and recline). He wore foam boots on both lower extremities as he watched TV in his room.
On 01/23/24 at 11:55 AM Certified Nurse Aide (CNA) M stated the CNAs obtained the daily weights as assigned by the charge nurse. CNA M stated R38's weight was obtained early each morning per his preference. CNA M stated R38 always wanted to know what his weight was to ensure he had not gained any weight. CNA M stated that per her knowledge, R38 had never refused to be weighed.
On 01/23/24 at 12:20 PM Licensed Nurse (LN) H stated R38 wanted to be weighed at 06:00 AM every day. LN H stated R38 refused to be weighed occasionally and the refusal would be documented on the TAR. LN H said the physician should have been notified of any refusals and documented in the clinical record.
On 01/23/24 at 12:54 PM Administrative Nurse D stated R38's daily weight should be obtained as ordered by the physician and the physician should be notified of any changes and refusals. Administrative Nurse D stated communication with the physician should be documented in the clinical record.
The facility's Accommodation of Needs policy last revised 03/2021 documented the resident's individual needs and preferences were accommodated to the extent possible.
The facility failed to follow the physician's order for daily weights to monitor weight gain for fluid overload for R38, who had CHF. This deficient practice placed R38 at risk of adverse side effects from unnecessary medication or complications related to fluid overload.

- The Medical Diagnosis section within R75's Electronic Medical Records (EMR) included diagnoses of Alzheimer's Disease (progressive mental deterioration characterized by confusion and memory failure), visual loss, anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), and repeated falls.
R75's Quarterly Minimum Data Set (MDS) completed 12/28/23 indicated a Brief Interview for Mental Status (BIMS) was not completed due to severe impairment. The MDS indicated she was dependent on staff assistance for eating, oral hygiene, toileting, dressing, bed mobility, transfers, and bathing. The MDS indicated she had two non-injury falls since her admission.
R75's Fall Care Area Assessment (CAA) completed 04/27/23 indicated she was at risk for falls related to her medical diagnoses. The CAA indicated she had difficulty with balance and transitions. The CAA noted she had a history of falls prior to her admission. The CAA noted a care plan would be completed to provide interventions to prevent further accidents/injuries.
R75's Care Plan initiated 06/03/22 indicated she had deficits with her activities of daily living (ADLs). The plan indicated she required extensive staff assistance for toileting, bed mobility, transfers, dressing, meals, personal hygiene, and bathing. The plan noted she was at risk for falls related to her visual impairment, ataxia (loss of coordination with muscle movements), and medical diagnoses. The plan indicated R75 had a non-injury fall on 12/01/23. The plan indicated R75's Dycem (non-skid mat) pad was not appropriately placed in her chair during repositioning resulting in her fall. The plan indicated she used a Broda chair (specialized wheelchair with the ability to tilt and recline) and required staff for mobility.
A Fall Investigation dated 12/01/23 indicated R75 had a non-injury fall while awaiting lunch. The report noted R60 slid out of her wheelchair and landed on the floor. The report indicated the responding nurse found R75's Dycem pad was bunched up in the back of the wheelchair and was not properly placed when staff repositioned her prior to her fall. The report indicated R75 was assessed and returned to her wheelchair for lunch.
On 01/18/24 at 08:25AM R75 sat reclined in her Broda chair. R75 had a skid-proof pad and Dycem in place. An inspection of R75's room revealed her bed was in the lowest position. Her call light rested on her bed and a fall mat was on the floor to the right of her bed.
On 01/23/24 at 11:20AM Certified Nurse's Aide (CNA) M stated staff reviewed each resident's fall interventions before care was provided. She stated staff had frequent training related to completing lift transfers, repositioning, and safely moving residents. She stated staff should ensure placement of the residents in bed and chairs to prevent accidents and falls during transferring and repositioning. She stated direct care staff had access to each resident's Kardex (nursing tool that gives a brief overview of the care needs of each resident) to see safety interventions and transfer requirements.
On 01/23/24 at 11:55AM Licensed Nurse (LN) I stated R75 had two non-injury falls. She stated staff were to ensure her non-slip pads were in place after moving or repositioning her. She stated all staff had access to the care plans or the Kardex.
On 01/23/24 at 01:20PM Administrative Nurse D staff received frequent training related to positioning, transfers, and lifts. He stated all staff had access to review each resident's care interventions and he expected staff to ensure the proper care was provided.
The facility's provided Activities of Daily Living (ADLs) policy revised 03/2018 indicated the facility will ensure each resident will be provided with the appropriate care, treatment, and services to maintain or improve their ADLs. The policy noted resident's dependent on staff for assistance will be provide care, treatment, and services in a manner that is supportive, safe, and therapeutic towards the resident's treatment goals.
The facility failed to ensure proper placement of R75's Dycem in her wheelchair resulting in a non-injury fall. This deficient practice placed R75 at risk for preventable accidents and injuries.
The facility documented a census of 102 residents. The sample included 22 residents, with 10 reviewed for falls. Based on observation, record review, and interview, the facility failed to ensure an environment free from preventable accidents when staff failed to correctly place the loop of the sling during a Hoyer lift (total body mechanical lift used to transfer residents) transfer which resulted in resident (R)18's fall to the floor from the lift. The facility further failed to ensure Dycem (non-slip mat used for stabilization and gripping to prevent slipping) was placed correctly in R75's wheelchair. These deficient practices placed R18 and R75 at risk for avoidable injuries.
Findings included:
- The Electronic Medical Record (EMR) for R18 documented a diagnosis of cerebral palsy (a progressive disorder of movement, muscle tone, or posture caused by injury or abnormal development in the immature brain, most often before birth), and obstructive and reflux uropathy (a disorder of the urinary tract that occurs due to obstructed urinary flow that can be either structural or functional and allows urine to flow back into the kidneys).
The admission Minimum Data Set (MDS) dated 07/21/23, documented a Brief Interview for Mental Status (BIMS) score of 12 which indicated moderate cognitive impairment. The MDS documented R18 used a wheelchair and was dependent on staff for bathing, dressing, mobility, and transfers.
The Falls Care Area Assessment (CAA) dated 07/21/23, documented R18 was at risk for falls related to cerebral palsy. The MDS further documented R18 had a history of falls, weakness, and physical performance limitations that affected his balance, gait, strength, and muscle endurance.
R18's Care Plan with an initiated date of 07/24/23, documented R18 had an activity of daily living (ADL) self-care performance deficit and impaired mobility related to cerebral palsy. An intervention with an initiated date of 07/24/23 documented R18 required the use of a Hoyer lift for transfers. An intervention with an initiated date of 07/24/23 documented R18 admitted to the facility with his wheelchair and that R18 was dependent on staff for locomotion. The intervention directed staff to assist as appropriate.
A Witnessed Fall 3110 report dated 01/04/24, documented Licensed Nurse (LN) H was called to R18's room and found him on the floor facing up with a pillow under his head. The document further recorded the staff present at the time of the incident reported they transferred R18 from a chair to his bed with a Hoyer lift when one of the loops on the right side came loose and caused R18 to fall. The document further recorded R18 had a hard bump to the back of his head. The document recorded R18 was assessed by the advanced practice registered nurse (APRN) who was in the facility and sent to a local emergency room for evaluation and treatment.
Certified Nurse Aide (CNA) M's undated Witness Statement documented CNA M and CNA N took R18 to his room. CNA N hooked the Hoyer pad to the Hoyer lift. The witness statement documented CNA M walked behind R18's wheelchair to move it as CNA N began lifting R18 with the Hoyer lift. The witness statement further documented CNA N yelled as CNA M came around the wheelchair to move it, and R18 fell on the floor.
CNA N's undated Witness Statement documented CNA M and CNA N took R18 into his room so he could go to bed. The witness statement documented CNA N hooked the R18's sling to the Hoyer lift while CNA M unhooked R18's urine collection bag from the bottom of his wheelchair. The statement further documented CNA N raised R18 in the Hoyer sling and CNA M went to move R18's wheelchair. CNA N documented as R18 was raised in the sling, the back, left hoop on the Hoyer sling came off and R18 fell backward out of the sling onto the floor.
On 01/22/24 at 09:22 AM CNA M and CNA O used a Hoyer lift to transfer R18 from a wheelchair to his bed.
On 01/23/24 at 11:55 AM, CNA M stated she would check the size of the sling and ensure the sling hoops were the correct size for the Hoyer being used before attempting to transfer a resident. CNA M stated once the sling hoops were attached, many of the Hoyer lifts would have an arm or lever to keep the hoops from coming off during a transfer. CNA M stated if the hoops were placed properly, they should not come off the Hoyer lift, and if the hoops were to come off of the Hoyer lift during a transfer, it would likely be due to the hoops not being placed properly.
On 01/23/24 at 12:20 PM, LN H stated staff should correctly secure the Hoyer sling to the lift and double check the sling hoops to ensure they were securely in place before transferring a resident with the Hoyer lift. LN H stated if the sling hoops were correctly placed, and the Hoyer was not broken, then there was no way for them to fall off of the Hoyer lift during a transfer.
On 01/23/24 at 12:55 PM Administrative Nurse D stated he expected staff to ensure sling hoops were correctly placed on the Hoyer lift before transfers. Administrative Nurse D stated it was not a normal occurrence for a Hoyer sling to come off a Hoyer lift unless the equipment was faulty. Administrative Nurse D further stated the fall was most likely a result of human error as the lift and sling used to transfer R18 were inspected and found to be functioning correctly.
The facility provided a Lifting Machine, Using a Mechanical Lift policy with a revised date of July 2017, documented in the steps in the procedure section ensure the resident is utilizing the proper sling size and purpose according to the manufacturer's instructions, select a sling bar that is appropriate for the residents' size and the task, make sure the lift is stable and locked, make sure that all necessary equipment (slings, hooks, chains, straps and supports) are on hand and in good condition.
The facility failed to ensure an environment free from preventable accidents when staff failed to correctly place the loop of the sling during a Hoyer lift transfer which resulted in R18 falling to the floor from the lift. This deficient practice placed R18 at risk for avoidable injuries.

The facility identified a census of 102 residents. The sample included 22 residents with four reviewed for catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) care. Based on record review, observations, and interviews, the facility failed to ensure Resident (R) 18's catheter bag (urine collection bag) was kept below his bladder during a Hoyer (full body mechanical lift) transfer. This deficient practice placed R18 at increased risk for infection and other catheter-associated complications.
Findings included:
- The Electronic Medical Record (EMR) for R18 documented a diagnosis of cerebral palsy (a progressive disorder of movement, muscle tone, or posture caused by injury or abnormal development in the immature brain, most often before birth), and obstructive and reflux uropathy (a disorder of the urinary tract that occurs due to obstructed urinary flow that can be either structural or functional and allows urine to flow back into the kidneys).
The admission Minimum Data Set (MDS) dated 07/21/23, documented a Brief Interview for Mental Status (BIMS) score of 12 which indicated moderate cognitive impairment. The MDS documented R18 used a wheelchair and was dependent on staff for bathing, dressing, mobility, and transfers.
The Falls Care Area Assessment (CAA) dated 07/21/23, documented R18 was at risk for falls related to cerebral palsy. The MDS further documented R18 had a history of falls, weakness, and physical performance limitations that affected his balance, gait, strength, and muscle endurance.
The Urinary Incontinence and Indwelling Catheter CAA dated 07/21/23, documented R18 was at risk for impaired urinary elimination pattern related to his medical condition which resulted in a need for a suprapubic catheter (urinary bladder catheter inserted through the abdomen into the bladder).
R18's Care Plan with an initiated date of 07/17/23, documented R18 had a suprapubic catheter related to obstructive uropathy. An intervention with an initiated date of 07/17/23 directed staff to position R18's catheter bag and tubing below the level of his bladder.
R18's Care Plan with an initiated date of 07/24/23, documented R18 had an Activities of Daily Living (ADL) self-care performance deficit and impaired mobility related to cerebral palsy. An intervention with an initiated date of 07/24/23 documented R18 required the use of a Hoyer lift for transfers. The intervention directed staff to assist as appropriate.
On 01/22/24 at 09:22 AM R18 Certified Nurse Aide (CNA) M and CNA O transferred R18 from a wheelchair to his bed with a Hoyer lift. During the transfer, CNA M removed R18's catheter bag from the side of his wheelchair and hung it on the Hoyer lift, near where the sling attached to the lift, above R18's bladder. There was urine observed in R18's catheter tubing during the transfer.
On 01/23/24 at 11:55 AM CNA M stated she would hang the catheter bag on the side of the sling during a Hoyer transfer on a lower loop. CNA M stated the catheter bag should not be hung on the bar of the lift or above the resident's bladder.
On 01/23/24 at 12:20 PM Licensed Nurse (LN) H stated catheter bags should not be hung on the Hoyer lift or in a position that would be above the resident's bladder. LN H stated the catheter bag should always be hung in a position that is below a resident's bladder.
On 01/23/24 at 12:55 PM Administrative Nurse D stated a resident's catheter bag should be placed by their hip or in another area that is below the resident's bladder. Administrative Nurse D stated catheter bags should not be hung on the sling arm/bar of a Hoyer lift as it is above the resident's bladder.
The facility provided a Catheter Care, Urinary policy revised in August 2022, documented purpose of the procedure was to prevent urinary catheter-associated complications, including urinary tract infections.
The facility failed to ensure R18's catheter bag was kept below his bladder during a Hoyer transfer. This deficient practice placed R18 at increased risk for infection and other catheter-associated complications.

The facility identified a census of 102 residents. The sample included 22 with three reviewed for dementia (a progressive mental disorder characterized by failing memory, and confusion) care. Based on interviews, record review, and observations, the facility failed to provide appropriate dementia care and services to address Resident (R)60's wandering behavior. This deficient practice placed R60 at risk for decreased quality of life due to the inability to maintain her highest practicable level of functioning.
Findings included:
- The Medical Diagnosis section within R60's Electronic Medical Records (EMR) included diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), insomnia, cognitive-communication disorder, dysphagia (difficulty swallowing), and major depressive disorder (major mood disorder).
R60's Annual Minimum Data Set (MDS) completed 10/09/23 noted a Brief Interview for Mental Status (BIMS) score of two indicating severe cognitive impairment. The MDS indicated no wandering behaviors.
R60's Cognitive Loss Care Area Assessment (CAA) completed 11/02/23 noted she was at risk for impairment related to orientation, memory, and recall deficits related to her BIMS. The CAA indicated her care plan will be developed to maintain her current cognitive status, continence, mobility, activities of daily living (ADLs), and communication.
R60's Falls CAA completed 11/02/23 indicated she was at risk for falls related to impaired gait and mobility, physical limitations, and weakness. The CAA indicated she required supervision while walking.
R60's Care Plan initiated 10/16/20 noted she was at risk for alterations in self-care/mobility and required assistance with her ADLs. The plan noted she required touch assistance while walking. The plan instructed staff to provide consistency in care to promote comfort with ADLs. The plan indicated R60 had a history of sleeping in other resident's beds. The plan instructed staff to show her to her bed and provide activities. The plan instructed staff to monitor and record occurrences for behaviors related to pacing, wandering, and aggressive behaviors (01/06/22). The plan indicated she preferred one-to-one interaction with staff including walking, music, painting nails, and social events.
On 01/17/24 at 12:02 PM R60 was found in R75's room asleep in R75's bed. At 12:10 PM R60 was awoken by staff and taken to the dining area for lunch. This occurrence was not documented in the EMR. R75's bedding was not changed after the occurrence.
On 01/18/24 at 11:50 AM R60 slept in her roommate's (R101) bed. Staff awoke her and escorted her to the dining room for lunch. This occurrence was not documented in the EMR. The bedding was not changed after this occurrence.
On 01/23/24 at 11:20 AM Certified Nurse's Aide (CNA) M stated staff should walk and direct severely impaired residents to their rooms and ensure they were oriented with their environment. She stated the facility should place confused residents closer to the nurse's station to help with supervision and assistance. She stated residents should not be allowed to use other resident's beds due to the risk of spreading illnesses and infections.
On 01/23/24 at 11:55 AM Licensed Nurse (LN) I stated R60 often roamed the halls looking for her room. She stated a large sign was placed on her door and the unit had memory boxes outside each resident's room to help familiarize them with the unit. She stated wandering occurrences should be reported to the unit nurse and documented.
On 01/23/24 at 12:50 PM Administrative Nurse D stated the facility provided frequent training related to caring for residents with dementia or cognitive impairments. He stated staff were expected to closely monitor all residents in the dementia unit and intervene when needed. He stated residents should not be allowed to sleep in other residents' beds and that staff should redirect residents to their appropriate beds.
The facility's provided Dementia police indicated staff will continue to provide supervision and supportive care to individuals with cognitive impairment. The policy indicated individualized interventions will be implemented and adjusted to address changes in each resident's condition.
The facility failed to provide adequate supervision and activities to R60 to prevent her from wandering into other resident's rooms and beds. This deficient practice placed R60 at risk for unmet care needs to maintain her highest practicable level of functioning.

The facility identified a census of 102 residents. The sample included 22 residents. Based on observation, record review, and interview, the facility failed to ensure staff secured and protected the privacy and confidentiality of Resident (R) 47's medical record. This placed this resident's personal and confidential information at risk of being accessed by unauthorized individuals.
Findings included:
- Observation on 01/18/24 at 12:14 PM R47's Medication Administration Record (MAR) was left open, visible, and unattended on the medication cart outside of his room.
On 01/18/24 at 12:16 PM Certified Medication Aide (CMA) R stated it was his mistake, he walked away from his medication cart and left the screen unlocked with R47's information visible. CMA R stated normally he locked the laptop screen every time he walked away from the cart.
On 01/18/24 at 03:09 PM Licensed Nurse (LN) H stated the laptop screen should be locked every time the medication aide or nurse walked away from the laptop area.
On 01/23/24 at 01:00 PM Administrative Nurse D stated he expected nursing staff to lock the laptop screen any time staff left the direct area of their laptop when passing medications so resident privacy and personal information was protected.
The Protected Health Information (PHI), Safeguarding Electronic policy revised February 2014 documented that electronic PHI was safeguarded by administrative, technical, and physical means to prevent unauthorized access to protected health information. Physical access to electronic information systems was limited to individuals who were authorized to access the system. All workstations are protected from unauthorized access by physical barriers that discourage attempts to tamper with or violate security rules including placing computer terminals and workstations away from high-traffic areas. Automatically locking computer screens after a specified number of incorrect password attempts.
The facility failed to ensure that staff secured and protected the privacy and confidentiality of R47's medical record. This placed this resident's personal and confidential information at risk of being accessed by unauthorized individuals.

The facility identified a census of 102 residents with one kitchen and two dining areas. Based on observation, record review, and interviews, the facility failed to follow sanitary dietary standards related to food preparation, service, and storage. The facility additionally failed to ensure sanitary cleaning of kitchen service areas and equipment. These deficient practices placed the residents at risk related to food-borne illnesses and food safety concerns.
Finding Included:
- On 01/17/24 at 08:03 AM an inspection of the facility's kitchen was completed. An inspection of the microwave oven revealed dried food residue on the top and back walls of the inside of the microwave. The kitchen's deep fryer contained dark brownish oil covered with old food debris all over the inside and outside the frying unit. A five-gallon bucket filled with used oil and old food debris under the kitchen's convection oven.
An inspection of the kitchen's clean equipment storage area revealed saucers and water pitchers stored upward and uncovered on the rack.
An inspection of the kitchen's reach-in refrigerator revealed an unlabeled/undated ham sandwich and a container of juice.
An inspection of the kitchen's walk-in freezer unit revealed unlabeled and updated opened bags of wedge fries and onion rings. The unit contained a broken-up cardboard box of corndogs with no covering barrier.
On 01/17/24 at 08:45A an inspection of the facility's Abby Hall small kitchenette area revealed an unlocked refrigerator. The refrigerator only had two days of temperature checks completed for January 2024. The refrigerator's top freezer had severe frost build-up. The lower refrigerator unit had unlabeled and undated biscuits and moldy cheese with salami. The kitchenette's heater unit had food wrappers and trash on the floor between the heater and the wall. At 08:50 AM Licensed Nurse (LN) I stated the kitchen was responsible for maintaining the fridge for de-frosting issues. She stated direct care staff should be labeling and removing old foods. She stated unit staff were to be completing the temperature checks each shift but acknowledged the daily check sheet was not filled out.
On 01/17/24 at 12:01 PM unidentified staff member wheeled Resident (R)18 to the dining room and positioned him at a table. The staff member retrieved R18's meal tray and set up his food. The staff member repositioned the resident's wheelchair and assisted in positioning another resident's chair. The staff member returned to R18's table and assisted him with eating his entire meal without completing hand hygiene.
On 01/22/24 at 11:20 AM a follow-up inspection of the kitchen was completed. The inspection revealed old dried-up food residue on the inside and outside glass barrier of the steam table. The five-gallon bucket of used oil remained under the convection oven.
On 01/22/24 at 11:25 AM Dietary Staff BB stated staff were expected to clean throughout the day and in between food services. He stated the food storage areas and unit should be checked daily for food labeling and expiration. He stated staff were expected to clean up areas before prepping food and wipe down surfaces that may be potentially soiled or contaminated. He stated the Abbey Hall refrigerator should be checked by staff each shift. He stated staff were expected to complete hand hygiene during meal services. He stated the bucket of oil should have been removed by staff and not left in the kitchen.
The facility's provided Food Preparation/Handling/Storage policy revised in October 2017 indicated the kitchen staff will ensure all food shall be stored in a manner that complies with safe food handling practices. The policy noted staff will ensure food storage areas remain clean and temperature units will be closely monitored. The policy indicated all food products will be maintained and handled in a manner that prevents contamination and exposure to potentially unsafe conditions. The policy indicated all food products will be dated and labeled to ensure freshness and safety. The policy indicated all kitchen areas will be cleaned and sanitized per safe practices.
The facility failed to follow sanitary dietary standards related to food preparation, service, and storage. The facility additionally failed to ensure sanitary cleaning of kitchen service areas and equipment. These deficient practices placed the residents at risk related to food-borne illnesses and food safety concerns.

The facility identified a census of 102 residents. The sample included 22 residents. Based on observation, record review, and interview, the facility failed to ensure staff followed appropriate infection control practices and procedures when Resident (R)88's oxygen tubing and nasal cannula (a hollow tube used to deliver supplemental oxygen) were left on the floor. The facility further failed to ensure nursing staff appropriately sanitized a community-used Hoyer (total body mechanical lift) after each use. This deficient practice placed the residents at risk related to infectious diseases.
Findings included:
- On 01/17/24 at 08:49 AM R88's portable oxygen tank was on the back of her wheelchair and the oxygen tubing and nasal cannula attached to the tank laid on the floor in R88's room, no bag was noted.
01/17/24 11:39 AM Certified Nurse Aide (CNA) P and Certified Medication Aide (CMA) R did not clean/sanitize the Hoyer lift after use in R51's room and CNA P then wheeled the lift into R63's room.
On 01/23/24 at 11:55 AM CNA M stated lifts should be cleaned after each use and/or before entering a resident's room. CNA M stated oxygen tubing should be stored in a bag when it was not being used and should not be left on the floor. CNA M stated she would replace the tubing if she noticed the cannula was on the floor.
On 01/23/24 at 12:21 PM, Licensed Nurse (LN) H stated oxygen tubing/nasal cannula should never be on the floor and should be replaced if found on the floor. LN H stated the tubing should be stored in a bag when not in use. LN H stated staff should be sanitizing the lift with disinfectant wipes after each use with a resident.
On 01/23/24 at 12:55 PM Administrative Nurse D stated oxygen tubing was supposed to be in a storage bag when not in use and should not be on the floor. Administrative Nurse D stated lifts and shared equipment should be sanitized with disinfectant wipes after use on each resident.
The Oxygen Administration policy revised in October 2010 lacked direction for appropriate nasal cannula storage.
The Standard Precautions policy revised in September 2022 documented that reusable equipment was not used for the care of more than one resident until it had been appropriately cleaned and reprocessed.
The facility failed to ensure staff followed appropriate infection control practices and procedures when R88's oxygen tubing and nasal cannula were left on the floor. The facility further failed to ensure nursing staff appropriately sanitized a community-used Hoyer lift after each use. This deficient practice placed the residents at risk related to infectious diseases.

The facility identified a census of 99 residents. The facility had one main kitchen. Based on observation, record review, and interview, the facility failed to ensure that food items were properly stored in a safe and sanitary manner after the original sealed package had been opened and the food item was not placed in a sealed container/storage bag with the proper labeling and date. The facility further failed to ensure prepared pitchers of drinks were labeled and dated. This deficient practice had the potential for food borne illnesses for residents.
Findings included:
- The initial tour of the facility kitchen on 05/09/22 at 07:35 AM revealed the following: in dry storage area there was a bag of white cake mix that was opened and wrapped in cellophane wrap that was not labeled or dated. In the refrigerator there was a small bowl of potato salad that was uncovered, not labeled and not dated. There were seven prepared pitchers of various drinks that were not labeled or dated. The walk-in refrigerator had three trays of baked pies that were not covered, not labeled, and not dated, and a covered bowl of sliced pickles without a label or a date. The walk-in freezer had an open bag of frozen chicken nuggets that had not been put in a labeled or dated sealed bag; a bag of open frozen French fries not in a labeled or dated sealed bag; and an open bag of frozen corn that was not in a sealed, labeled or dated bag (frozen items were thrown away).
An interview with Dietary Staff CC on 05/09/22 at 07:50 AM stated that open items in the refrigerator or freezers should all be labeled and have a date.
An interview with Dietary Staff DD on 05/09/22 at 07:52 AM stated items in the refrigerator should be covered and have a label and date. The frozen items should be put in sealed, labeled, and dated bag.
An interview with Dietary Staff BB 05/10/22 at 07:31 AM that any food item's original bag/container had been opened should be place in a sealed, labeled and dated bad. Dietary staff were trained upon hire of the proper way to store and label food items after being opened.
The facility policy Food Receiving and Storage revised October 2017 documented: Food shall be received and stored in a manner that complies with safe food handling practices. All foods sored in the refrigerator or freezer will be covered, labeled and dated (use by date).
The facility failed to ensure kitchen/dietary staff properly stored, labeled, and dated food items after their original storage container/package was opened, and failed to date and label prepared drinks, which had the potential for food borne illnesses for residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 99 residents. The sample included 23 residents with five reviewed for unnecessary medication. Based on observation, record review, and interviews, the facility failed to ensure Resident (R)36's hypertensive medication (class of medication used to treat hypertension [high blood pressure]) were administered as ordered by the physician, and failed to ensure bowel monitoring for R81. This deficient practice had the potential of unnecessary medication administration thus leading to possible harmful side effects.
Findings included:
- R36's electronic medical record (EMR) from the Diagnoses tab documented diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion) and hypertension.
The admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of six which indicated severely impaired cognition. The MDS documented that R36 was dependent of two staff members assistance for activities of daily living (ADL's). The MDS documented R36 received antipsychotic medication (class of medications used to treat psychosis (any major mental disorder characterized by a gross impairment in reality testing) and other mental emotional conditions) for seven days and antianxiety medication (class of medications that calm and relax people with excessive anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), nervousness, or tension) for two days.
The Quarterly MDS dated 03/23/22 documented a BIMS score of zero which indicated severely impaired cognition. The MDS documented no staff interview would be completed. The MDS documented R36 was dependent on two staff members assistance for ADL's. The MDS documented R36 received antipsychotic medication, antianxiety medication, and diuretic medication (medication to promote the formation and excretion of urine) for seven days during the look back period.
R36's Cognitive Loss Care Area Assessment (CAA) dated 06/23/21 documented she was at risk for safety concern and staff not meeting her needs met related to her cognitive impairment. Staff were to monitor R36, report and document any changes.
R36's Care Plan last revised 03/25/22 documented for staff to administer medications as ordered.
Review of the EMR under Orders tab revealed physician orders:
Amlodipine besylate (antihypertensive medication) 10 milligram (mg) give one tablet by mouth daily related to hypertension. Hold for blood pressure (BP) for systolic (SBP-relating to the phase of the heartbeat when the heart muscle contracts and pumps blood from the chambers into the arteries) less than (<), 100 millimeters of mercury (mmHg) or diastolic blood pressure (DBP-minimum level of blood pressure measured between contractions of the heart; the bottom number of a blood pressure reading) < 60mmHg or <60 mmHg date ordered 06/09/2021 and discontinued 04/28/2022.
Review of the EMR under Reports tab of the Medication Administration Report and Treatment Administration Report from 02/01/22 to 04/28/22 (86 days) revealed hypertensive medication was given
(eight times) outside physician ordered parameters on: 02/02/22, 02/12/22, 03/11/22, 03/19/22, 03/21/22, 03/22/22, 03/26/22 and 04/11/22.
On 05/10/22 at 10:13 AM R36 sat reclined in a broda chair (specialized wheelchair with the ability to tilt and recline) in the common area with several other residents. R36 yelled out several times. One nursing staff approached R36 and spoke to her for a moment and walked away. R36 began to yell out again after a few minutes.
On 05/12/22 at 05:10 PM in an interview, Licensed Nurse (LN) J stated the Certified Medication Aides (CMA) usually obtain the vital signs and administer the medications. LN J stated that if a BP was outside the physician ordered parameters the CMA would notify the charge nurse before administering the medication. LN J stated the charge would recheck the BP or heart rate and assess the resident. LN J stated the charge nurse would notify the physician if needed.
The facility Administering Medication policy last revised August 2019 documented medications are administered in accordance with prescribers' orders, including any required time frame. The following information was checked /verified for each resident prior to administering medication: a. allergies to medication; and vital signs, if necessary.
The facility failed to ensure R36's antihypertensive medication was administered as physician ordered, which had the potential of unnecessary medication administration thus leading to possible harmful side effects.
- R81's electronic medical record (EMR) from the Diagnoses tab documented diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness), and psychosis (any major mental disorder characterized by a gross impairment in reality testing).
The Significant Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of zero which indicated severely impaired cognition. The MDS documented no staff interview would be completed. The MDS documented R81 required extensive assistance of two staff for activities of daily living (ADL's). The MDS documented R81 received antipsychotic medication (class of medications used to treat psychosis and other mental emotional conditions), antidepressant medication (class of medications used to treat mood disorders and relieve symptoms of depression), anticoagulant medication (class of medications used to prevent the formation of blood clots), for seven days, opiod medication (a class of medication used to treat pain) for four days and antianxiety medication (class of medications that calm and relax people with excessive anxiety, nervousness, or tension) for three days.
The Quarterly MDS dated 04/13/22 documented a BIMS score of 12 which indicated severely impaired cognition. The MDS documented that R81 was dependent on two staff members assistance for ADL's. The MDS documented R81 received antipsychotic medication, antidepressant medication, anticoagulant medication, opioid medication for seven days antianxiety medication for one day during the look back period.
R81's Nutritional Status Care Area Assessment (CAA) dated 01/27/22 documented she received mechanically altered diet with thickened liquids at meals and staff assistance with eating.
R 81's Care Plan dated 04/21/22 documented staff to administer medication as ordered. Increase fiber and fluid intake to provide more bulk in diet. Record bowel movement pattern each day. Describe amount, color, and consistency. Staff to monitor/document/report to physician as needed (PRN) signs/symptoms of complications related to constipation (difficulty passing stools). Change in mental status, new onset of confusion, sleepiness, inability to maintain posture, agitation, bradycardia (low heart rate, less than 60 beats per minute). Abdominal distension, tenderness, guarding, rigidity, or fecal impaction, small loose stools, fecal smearing and vomiting. Monitor medications for side effects of constipation.
Review of the EMR under Orders tab reveled physician orders:
Docusate sodium tablet (laxative- medication used to stimulate or facility evacuation of the bowels) 100 milligrams (mg) give one tablet by mouth two times a day for constipation dated 04/20/2022.
MiraLAX powder (laxative) 17 grams by mouth one time a day for constipation Mix the powder with a glass (four-eight ounces/120-240 milliliters) of liquid such as water or juice dated 12/11/2021.
Review of the EMR under Documentation Survey Report for bowel elimination for R81 reviewed from 02/01/22 through 05/09/22 (98 days) lacked documentation of bowel movement charting from 02/14/22 to 02/19/22 (six days) PRN MiraLAX was administered on 02/17/22, 02/25/22 to 03/01/22 (five days), 04/05/22 to 04/09/22 (four days), 04/12/22 to 04/23/22 (12 days), and 05/01/22 to 05/07/22 (seven days). The nurses note, and the medication administration record lacked any documentation of as needed medication was given for constipation.
On 05/11/22 at 10:09 AM R81 sat in broda chair (specialized wheelchair with the ability to tilt and recline) reclined in living room area. TV was a western show, R81 yelled out and was cussing repeatedly at the other four ladies in the area.
On 05/12/22 at 03:09 PM in an interview, Certified Nurse's Aide (CNA) P stated an alert pops up on the Point of Care POC for residents that not had a bowel movement charted for three days. CNA P stated she reported to nurse if the resident did not have a bowel movement on that shift.
On 05/12/22 at 03:35 PM in an interview, Licensed Nurse (LN) G stated an alert pops up from the POC charting for every resident that has not had a bowel movement charted in the past three days or 72 hours. LN G stated the nurse would then assess the resident, administer PRN laxative if ordered or notify the physician to obtain an order for laxative.
On 05/12/22 at 04:19 PM in an interview, Administrative Nurse D stated an alert pops up on the dashboard for the nurses to see the residents who have not had a bowel movement charted for the past 72 hours and the nurse must do an intervention to address the alert. Administrative Nurse D stated the charge nurse would assess the residents on the list and follow up with a PRN laxative or notify the physician for orders.
The facility Azria Bowel (Lower Gastrointestinal [NAME]) Disorders-Clinical Protocol policy last revised September 2017 documented the staff and physician would identify risk factors related to bowel dysfunction: for example, severe anxiety disorder, recent antibiotic () use, or taking medication that are used to treat, or that may cause contribute to, gastrointestinal erosion, bleeding, diarrhea or dysmotility.
The facility failed to identify multiple episodes in which R81 had no documented bowel movements. The facility further failed administer as needed medications to assist R81 in having a bowel movement which placed her at risk for negative outcomes and unnecessary medications

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 99 residents. The sample included 23 residents with five reviewed for unnecessary medication. Based on observation, record review, and interviews, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported irregularities for Resident R36's hypertensive medication (class of medication used to treat hypertension [high blood pressure]) given outside the physician ordered parameters, and for irregularities related to bowel movement monitoring for R81. This deficient practice which had the potential of unnecessary medication administration thus leading to possible harmful side effects.
Findings included:
- R36's electronic medical record (EMR) from the Diagnoses tab documented diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion) and hypertension.
The admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of six which indicated severely impaired cognition. The MDS documented that R36 was dependent of two staff members assistance for activities of daily living (ADL's). The MDS documented R36 received antipsychotic medication (class of medications used to treat psychosis (any major mental disorder characterized by a gross impairment in reality testing) and other mental emotional conditions) for seven days and antianxiety medication (class of medications that calm and relax people with excessive anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), nervousness, or tension) for two days.
The Quarterly MDS dated 03/23/22 documented a BIMS score of zero which indicated severely impaired cognition. The MDS documented no staff interview would be completed. The MDS documented R36 was dependent on two staff members assistance for ADL's. The MDS documented R36 received antipsychotic medication, antianxiety medication, and diuretic medication (medication to promote the formation and excretion of urine) for seven days during the look back period.
R36's Cognitive Loss Care Area Assessment (CAA) dated 06/23/21 documented she was at risk for safety concern and staff not meeting her needs met related to her cognitive impairment. Staff were to monitor R36, report and document any changes.
R36's Care Plan last revised 03/25/22 documented for staff to administer medications as ordered.
Review of the EMR under Orders tab revealed physician orders:
Amlodipine besylate (antihypertensive medication) 10 milligram (mg) give one tablet by mouth daily related to hypertension. Hold for blood pressure (BP) for systolic (SBP-relating to the phase of the heartbeat when the heart muscle contracts and pumps blood from the chambers into the arteries) less than (<), 100 millimeters of mercury (mmHg) or diastolic blood pressure (DBP-minimum level of blood pressure measured between contractions of the heart; the bottom number of a blood pressure reading) < 60mmHg or <60 mmHg date ordered 06/09/2021 and discontinued 04/28/2022.
Review of the EMR under Reports tab of the Medication Administration Report and Treatment Administration Report from 02/01/22 to 04/28/22 (86 days) revealed hypertensive medication was given
(eight times) outside physician ordered parameters on: 02/02/22, 02/12/22, 03/11/22, 03/19/22, 03/21/22, 03/22/22, 03/26/22 and 04/11/22.
Review of the CP's Monthly Medication Review (MMR) from June 2021 through April 2022 revealed no documentation of hypertensive medication given outside of physician ordered parameters reported to facility.
On 05/10/22 at 10:13 AM R36 sat reclined in a broda chair (specialized wheelchair with the ability to tilt and recline) in the common area with several other residents. R36 yelled out several times. One nursing staff approached R36 and spoke to her for a moment and walked away. R36 began to yell out again after a few minutes.
On 05/12/22 at 05:10 PM in an interview, Licensed Nurse (LN) J stated the Certified Medication Aides (CMA) usually obtain the vital signs and administer the medications. LN J stated that if a BP was outside the physician ordered parameters the CMA would notify the charge nurse before administering the medication. LN J stated the charge would recheck the BP or heart rate and assess the resident. LN J stated the charge nurse would notify the physician if needed.
On 05/16/22 at 11:26 CP was unavailable for interview.
The facility Medication Regimen Review (MRR) policy last revised May 2019 documented goal of the MRR's was to promote appositive outcome while minimizing adverse consequences and potential risks associated with medication. The MRR involved a thorough review of the resident's medical record to prevent, identify, report and resolve medication related problems, medication errors and other irregularities, such as potential significant medication-related adverse consequences or actual signs any symptoms that could represent adverse consequences and other medication errors, including those related to documentation.
The facility failed to ensure the CP identified and reported irregularities when antihypertensive medication for R36 were administered outside the physician ordered parameters, which had the potential of unnecessary medication administration thus leading to possible harmful side effects.
- R81's electronic medical record (EMR) from the Diagnoses tab documented diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness), and psychosis (any major mental disorder characterized by a gross impairment in reality testing).
The Significant Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of zero which indicated severely impaired cognition. The MDS documented no staff interview would be completed. The MDS documented R81 required extensive assistance of two staff for activities of daily living (ADL's). The MDS documented R81 received antipsychotic medication (class of medications used to treat psychosis and other mental emotional conditions), antidepressant medication (class of medications used to treat mood disorders and relieve symptoms of depression), anticoagulant medication (class of medications used to prevent the formation of blood clots), for seven days, opiod medication (a class of medication used to treat pain) for four days and antianxiety medication (class of medications that calm and relax people with excessive anxiety, nervousness, or tension) for three days.
The Quarterly MDS dated 04/13/22 documented a BIMS score of 12 which indicated severely impaired cognition. The MDS documented that R81 was dependent on two staff members assistance for ADL's. The MDS documented R81 received antipsychotic medication, antidepressant medication, anticoagulant medication, opioid medication for seven days antianxiety medication for one day during the look back period.
R81's Nutritional Status Care Area Assessment (CAA) dated 01/27/22 documented she received mechanically altered diet with thickened liquids at meals and staff assistance with eating.
R 81's Care Plan dated 04/21/22 documented staff to administer medication as ordered. Increase fiber and fluid intake to provide more bulk in diet. Record bowel movement pattern each day. Describe amount, color, and consistency. Staff to monitor/document/report to physician as needed (PRN) signs/symptoms of complications related to constipation (difficulty passing stools). Change in mental status, new onset of confusion, sleepiness, inability to maintain posture, agitation, bradycardia (low heart rate, less than 60 beats per minute). Abdominal distension, tenderness, guarding, rigidity, or fecal impaction, small loose stools, fecal smearing and vomiting. Monitor medications for side effects of constipation.
Review of the EMR under Orders tab reveled physician orders:
Docusate sodium tablet (laxative- medication used to stimulate or facility evacuation of the bowels) 100 milligrams (mg) give one tablet by mouth two times a day for constipation dated 04/20/2022.
MiraLAX powder (laxative) 17 grams by mouth one time a day for constipation Mix the powder with a glass (four-eight ounces/120-240 milliliters) of liquid such as water or juice dated 12/11/2021.
Review of the EMR under Documentation Survey Report for bowel elimination for R81 reviewed from 02/01/22 through 05/09/22 (98 days) lacked documentation of bowel movement charting from 02/14/22 to 02/19/22 (six days) PRN MiraLAX was administered on 02/17/22, 02/25/22 to 03/01/22 (five days), 04/05/22 to 04/09/22 (four days), 04/12/22 to 04/23/22 (12 days), and 05/01/22 to 05/07/22 (seven days). The nurses note, and the medication administration record lacked any documentation of as needed medication was given for constipation.
Review of the CP's Monthly Medication Review (MMR) from September 2021 through April 2022 revealed no documentation of irregularities related to bowel monitoring reported to facility.
On 05/11/22 at 10:09 AM R81 sat in broda chair (specialized wheelchair with the ability to tilt and recline) reclined in living room area. TV was a western show, R81 yelled out and was cussing repeatedly at the other four ladies in the area.
On 05/12/22 at 03:09 PM in an interview, Certified Nurse's Aide (CNA) P stated an alert pops up on the Point of Care POC for residents that not had a bowel movement charted for three days. CNA P stated she reported to nurse if the resident did not have a bowel movement on that shift.
On 05/12/22 at 03:35 PM in an interview, Licensed Nurse (LN) G stated an alert pops up from the POC charting for every resident that has not had a bowel movement charted in the past three days or 72 hours. LN G stated the nurse would then assess the resident, administer PRN laxative if ordered or notify the physician to obtain an order for laxative.
On 05/12/22 at 04:19 PM in an interview, Administrative Nurse D stated an alert pops up on the dashboard for the nurses to see the residents who have not had a bowel movement charted for the past 72 hours and the nurse must do an intervention to address the alert. Administrative Nurse D stated the charge nurse would assess the residents on the list and follow up with a PRN laxative or notify the physician for orders.
On 05/16/22 at 11:26 CP was unavailable for interview.
The facility Medication Regimen Review (MRR) policy last revised May 2019 documented goal of the MRR's was to promote appositive outcome while minimizing adverse consequences and potential risks associated with medication. The MRR involved a thorough review of the resident's medical record to prevent, identify, report and resolve medication related problems, medication errors and other irregularities, such as potential significant medication-related adverse consequences or actual signs any symptoms that could represent adverse consequences and other medication errors, including those related to documentation.
The facility Azria Bowel (Lower Gastrointestinal [NAME]) Disorders-Clinical Protocol policy last revised September 2017 documented the staff and physician would identify risk factors related to bowel dysfunction: for example, severe anxiety disorder, recent antibiotic () use, or taking medication that are used to treat, or that may cause contribute to, gastrointestinal erosion, bleeding, diarrhea or dysmotility.
The facility failed to ensure that the CP noted and reported the irregularities related to bowel movement monitoring for R81 which has the potential for negative outcomes and unnecessary medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 99 residents. The sample included 23 residents; five residents were reviewed for dementia (progressive mental disorder characterized by failing memory, confusion) care. Eighteen residents resided on the memory care unit. Based on observations, record review, and interviews, the facility failed to provide dementia care and services for Resident (R) 248 when the facility failed to identify and implement resident-centered interventions to address violent/aggressive behaviors, wandering, and negative resident-to-resident altercations which included physical aggression. The facility further failed to assess, identify, record, and respond to R248's specific behaviors, triggers, and past/present interests and activities in order to promote an environment which supported R248's individualized care needs. As a result of these failures, R248, who was allowed to roam freely on the memory care unit, was involved in multiple resident-to-resident altercations which created an unsafe living environment and resulted in intimidation, acute care evaluations, hospital transfers for R248 and the other memory care residents and serious resident injury on [DATE]. This deficient practice placed all 18 residents who resided on the memory care unit in Immediate Jeopardy.
Findings included:
- R248 admitted to facility on [DATE], transferred to memory care unit on [DATE], transferred to hospital [DATE], readmitted to facility [DATE], transferred to hospital [DATE], readmitted to facility [DATE], transferred to hospital [DATE], readmitted to hospital [DATE], and transferred to hospital [DATE].
The Diagnoses tab of R248's Electronic Medical Record (EMR) documented diagnoses of dementia with behavioral disturbance, anxiety disorder, psychosis (any major mental disorder characterized by a gross impairment in reality testing) not due to a substance or known physiological condition, impulse disorder (mental health disorder characterized by the inability to control impulsive urges that can lead to the harm of oneself or others), and cerebral infarction (cerebrovascular accident [CVA]- 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).
The Annual Minimum Data Set (MDS) dated [DATE], documented R248 had a Brief Interview for Mental Status (BIMS) score of three which indicated severe cognitive impairment. R248 had physical and verbal symptoms directed towards others that occurred one to three days during the lookback period, rejection of care that occurred one to three days during the lookback period, and wandering that occurred daily. R248 was independent with one staff with bed mobility, walking, and locomotion; supervision with one staff with transfers; extensive physical assistance with two staff for dressing; limited physical assistance with one staff for toileting and personal hygiene; and independent with setup help only with eating. The interview for daily and activity preferences was not conducted. R248 received antipsychotic (class of medications used to treat psychosis and other mental emotional conditions) and antidepressant (class of medications used to treat mood disorders and relieve symptoms of depression) medications six days, and antianxiety (class of medications that calm and relax people with excessive anxiety, nervousness, or tension) medications seven days in the seven-day lookback period.
The Delirium [sudden severe confusion, disorientation and restlessness] Care Area Assessment (CAA) dated [DATE], documented inattention and disorganized thinking were baseline for R248.
The Cognitive Loss/Dementia CAA dated [DATE], documented R248 had a diagnosis of dementia.
The Behavioral Symptoms CAA dated [DATE], documented R248 had regular behaviors; staff referred to the care plan.
The Care Plan dated [DATE], documented R248 resided on a secured unit due to his impulsivity and high risk for elopement (an incident in which a cognitively impaired resident with poor or impaired decision making ability/safety awareness leaves the facility without the knowledge of staff) and recorded R248 was encouraged to participate in all activities, frequently monitored for safety, and supervised/accompanied by staff when not on secured unit.
The Cognitive Impairment/Dementia Care Plan dated [DATE], directed R248 had impaired cognitive function/dementia related to CVA and directed staff administered medications as ordered, asked yes/no questions to determine R248's needs, and assisted R248 with decision making. It further directed staff monitored/documented/reported to medical doctor any changes in cognitive function, specifically changes in: decision making ability, memory recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, and mental status.
The General Behavior Symptoms Care Plan dated [DATE]and revised [DATE], directed R248 displayed behavioral symptoms such as refusing/resisting care, voiding in inappropriate areas, impulsivity, wandering, and physical aggression towards staff and residents. The Care Plan documented interventions, initiated [DATE], that directed staff gave psychoactive medication (drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior) as ordered and recorded behavioral symptoms/side effects, intervened when inappropriate behavior was observed, and used interventions that addressed the abilities and needs reflected in the specific symptom or symptoms. The Care Plan documented an intervention, initiated [DATE], that staff offered redirection such as restroom, snack, coffee, going outside, and activities when R248 was seen wandering in other residents' rooms
The Physically Aggressive Behavior Care Plan initiated [DATE], documented R248 demonstrated physical aggression towards others and on [DATE] R248 had a physical altercation and was placed on one-to-one supervision until transported to the hospital for psychiatric evaluation. The Care Plan directed if R248 became physically abusive, staff attempted to calm R248 by explaining that ladies and gentlemen do not behave like this. We do not touch other people. If talking to R248 was unsuccessful in stopping the behavior, staff tried walking with R248 to a quiet area, away from other individuals. Staff intervened by speaking calmly and professionally in a soft tone of voice and avoided raising own voice which tended to make R248 more upset. R248 often believed that others were in his home and he needed to remove them from his house, staff reassured him that they were where they need to be, and he was safe.
R248's clinical record lacked an individualized Care Plan for activities.
The Documentation Survey Report for February 2022 to [DATE] revealed the following behaviors for R248: [DATE] day rejection of care; [DATE] day wandering; [DATE] wandering; [DATE] day rejection of care, wandering, pushing, yelling/screaming, kicking/hitting, abusive language, and threatening behavior; [DATE] day sexually inappropriate and rejection of care; [DATE] day wandering; [DATE] day threatening behavior; [DATE] day wandering; [DATE] day wandering; [DATE] day wandering; [DATE] day rejection of care, kicking/hitting, and threatening behavior; [DATE] night wandering; [DATE] day rejection of care and threatening behavior; [DATE] day wandering; [DATE] day yelling/screaming, wandering, and threatening behavior; [DATE] day rejection of care, wandering, abusive language, and threatening behavior; and [DATE] day wandering.
The Notes tab of R248's EMR revealed the following:
A Behavior Note on [DATE] at 08:01 AM documented R248 displayed behaviors through out the night, he refused to be redirected. A Certified Nurse Aide (CNA) attempted to get him to bed, he kicked the CNA, was difficult through the night, did not allow staff to provide cares, and yelled, swung his fists, and attempted to kick CNAs during cares.
A Behavior Note on [DATE] at 08:18 AM documented R248 continued to have behaviors was noncompliant with instructions and cares. He became quite aggressive, swinging, and yelling at staff, redirection was helpful at times.
A Behavior Note on [DATE] at 07:44 AM documented R248 displayed many behaviors on last two night shifts on [DATE] and [DATE]. He attempted to hit the nurse when asked for permission to take vital signs, he urinated on the couch in the day room, shredded his incontinence (lack of voluntary control over urination or defecation) products in the day room and hallway, and wandered into other residents' rooms and disturbed them. He was difficult to redirect due to the language barrier and his dementia.
A Behavior Note on [DATE] at 07:31 AM documented R248 was observed using the artificial tree in the day room as a bathroom. CNA attempted to redirect and R248 hit the CNA quite hard. R248 urinated in cups that were sitting in the day room and was quite difficult with staff. Other residents were in the day room and made comments related to R248's behaviors.
A Behavior Note on [DATE] at 07:50 AM documented R248 continued to have negative reactions when staff attempted to redirect him. R248 refused to get up from the couch, swung at staff. He wandered into other residents' rooms, redirection was difficult, and he would push or swing at staff. R248 urinated in any trash can he came across and two staff were needed to get him to bed due to his aggression.
A Behavior Note on [DATE] at 07:25 AM documented R248 wandered into other residents' rooms during the night and upset and woke some of the women. Three staff attempted to provide cares, R248 was unhappy and tried to swing at staff.
A General Progress Note on [DATE] at 05:20 PM documented CNA observed R248 standing in female occupied room. The two residents in the room explained to CNA that they were extremely frightened by R248 being in their room. R248 was redirected to bathroom then to living room due to not being able to stay in room without constant supervision.
A Communication with Family Note on [DATE] at 12:04 PM documented staff discussed with R248's family member the possibility of R248 moving back to the memory care unit and explained that the behaviors R248 exhibited made secured unit appropriate for him. His family member agreed that it was for his and others' safety to move him.
An Interdisciplinary Team (IDT) Note on [DATE] at 09:35 AM documented R248 had been adjusting well to memory care and his behaviors and combativeness had diminished. R248 was pleasantly confused, wandering at times, and was easily redirected. He was found in other residents' rooms and chairs at times but when notified he was not in his room, he easily moved to his own bed. He participated in activities periodically as he chose.
A General Progress Note on [DATE] at 06:05 AM documented R248 went into other resident's room and when asked to be assisted to his room, he got upset and became combative with staff. He spoke Spanish and when caregivers spoke to him in English, he got upset.
A Behavior Note on [DATE] at 03:53 PM documented R248 walked up to another resident and attempted to use other resident's cane. The other resident told R248 it was not his cane. The nurse observed R248 lift his hand in a fist at the other resident, the nurse removed R248 and gave him his own cane. No physical contact was made, no further behaviors noted.
A General Progress Note on [DATE] at 06:38 PM documented CNA reported to the nurse about an incident involving R248 and R48. R248 smacked R48 on his head. R48 was seated quietly on the recliner in the common room when it happened. Residents were separated to ensure safety and skin assessment performed on both residents, no physical bruising or injury noted.
A General Progress Note on [DATE] at 01:20 PM documented R61 stated R248 hit her with the cane on her lip, no witness to the incident. Staff assessment revealed a small skin tear on the left side of R61's lip. R248 was sent to hospital for psychiatric evaluation.
A General Progress Note on [DATE] at 04:55 PM documented R61 was seated in the dining room making rude hand gestures towards R248. R61 got up and walked towards R248, staff walked towards her and asked what she needed, she indicated she needed the bathroom. Staff indicated for R61 to follow them and positioned themself between R61 and R248 but R61 was able to pass the nurse and made contact with the back of R248's head with an open palm. Staff separated the two residents and with help from the nurse, R61 was removed from the situation and escorted to her room while nurse stayed with R248.
An Alert Note dated [DATE] T 03:30 PM recorded R248 wanted wants to use the cane that another resident used. The unidentified staff gave the cane back to the other resident. R248 became very aggressive and believed the cane belonged to him. The note recorded the cane was with R248 for the sake of peace. The note documented the other resident surrendered his cane to R248 because he did not want to fight for it.
A General Progress Note on [DATE] at 04:40 PM documented the nurse was doing rounds on the unit when they heard a resident hollering. Nurse looked up hallway and R248 was standing outside R61's room. The nurse and the aide, who communicated in Spanish, were able to get R248 to come away from the room and to the dining room. The aide told him that dinner was ready.
A Behavior Note on [DATE] at 11:55 PM documented another resident alleged R248 hit him. R248 was observed resting on his bed.
A General Progress Note on [DATE] at 10:02 AM documented while passing medications, a resident reported that R248 had hit him in the chest while in his own room. Staff checked on R248 and he was resting in his bed, R258 was frequently checked on throughout the shift.
An IDT Progress Note on [DATE] at 03:48 PM documented R248 required redirection twice as he entered other residents' rooms believing them to belong to him. Staff intervened and attempted to show him his own room. R248 was telling female residents to get out of his house, though he was in their room. Staff escorted him to the patio to spend some time in the fresh air and sunshine which was helpful to his mood.
A General Progress Note on [DATE] at 03:09 PM documented R248 was observed swinging at another resident without provocation, no contact was made. R248 threated to punch the CNA who tried to give him a shower, CNA claimed that R248 raised his fist while refusing to take a shower. One-on-one care initiated for the safety of R248 and others around him.
An IDT Progress Note on [DATE] at 06:09 PM documented R248 was denied financially by two psychiatric hospitals. For that reason, R248 was sent to hospital for psychiatric evaluation and treatment through the emergency room (ER). Continued one-to-one care at that time.
An IDT Progress Note on [DATE] at 03:56 PM documented R248 had increased behaviors over last 48 hours. He attempted to interrupt the maintenance personnel during their painting project with the fixed belief that he was meant to oversee that job. Staff attempted to show R248 his room in efforts to redirect him. R248 was determined that a female resident's room was his own. Nurse had reported that R248 refused his medication and was confrontational and agitated when interacting with the nurse.
A General Progress Note on [DATE] at 08:00 PM documented at approximately 06:45 PM, the nurse heard screaming in the unit from the management office. Upon entering the unit, she observed R249 standing in the hallway surrounded by multiple staff members, screaming that she had been assaulted. Per staff report, once they heard the screaming multiple staff members went into the hallway and approached R249 to ask what had occurred. R249 pointed toward R248 and accused him of hitting her in the back of her neck, no staff had witnessed R248 hitting R249 and he was not within arms reach of her when the staff came into the hallway. R249 was admitted to unit one and a half hours prior to the alleged incident and was upset, attempted to leave, and was very difficult to redirect upon admission. R249 stated that R248 came up behind her and hit her in the back of the neck and pointed to the bottom of her neck, directly between her shoulder blades. R248 unable to describe what had happened. New order to send R249 out to the ER for psychiatric evaluation due to unmanageable behaviors and potential danger to other residents. R249 was placed on one-on-one until transportation arrived and R248 was placed on one-on-one until R249 was transported.
An IDT Progress Note on [DATE] at 03:44 PM documented R248 required redirection from staff throughout most of the shift. He believed other neighbors were intruders in his home and wanted them to be removed. R248 was provided reassurance and redirection, monitored and closely supported during that time.
An Incident Note on [DATE] at 08:00 AM documented R248 sat at the dining room table while breakfast was served. Licensed Nurse (LN) H received reported from off-going nurse then began passing morning medications in the dining room. She noted R248 got up from his chair in the dining room at approximately 08:00 AM and proceeded down the hallway. Nurse continued passing medications in the dining room, a short time later she heard someone yelling stop and her name. She went down the hall to investigate. CNA M yelled she was in R32's room. As LN H approached R32's room, R248 came out of R32's doorway. CNA M stated that R32 and R248 were fighting. R248 was immediately placed on one-on-one with CNA M and LN H assessed R32. R32 laid in his bed with numerous injuries.
A Medical Professional Progress Note in R32's EMR dated [DATE] at 12:45 PM documented a follow up on R32's condition following an assault on [DATE]. The note documented R32 returned to the facility from the hospital R32 was found to have a concussion (brain injury caused by a blow to the head or a violent shaking of the head and body) and a left orbital fracture (a break in one of the bones surrounding the eyeball). The note recorded R32 laid in his bed with his blanket over head and answered yes and no questions. The note further recorded R32 stated he remembered the incident that occurred the previous day.
On [DATE] at 09:57 AM, Social Services X stated she was responsible for the activity care plan and every resident had an activity care plan. She stated the activity care plan was individualized to each resident with what they like or what the family tells her the resident likes.
On [DATE] at 01:59 PM, CNA M stated on [DATE], she was tending to another resident across the hall from R32's room. She walked out of the bathroom to get a pair of pants and looked across the hall to R32's room. She observed R32 holding a chair up, pining R248 against the wall. R32's face was already bleeding. CNA M had heard R248 had other altercations with other residents, but she had not witnessed any herself. She stated if R248 had behaviors, she tried to redirect him and get him to do anything else, he was not combative or violent with her but would draw back a fist sometimes since he used to be a boxer. CNA M stated staff tried to get R248 to participate I activities and played cards and interacted with the group. She stated any interventions after altercations were found in his care plan.
On [DATE] at 02:19 PM, LN H stated R248 had been suspected before of hitting other residents but there were no witnesses so unable to be proven. She stated typically, R248 did not have a lot of behaviors. R248 understood English but Spanish was his primary language so one of the Spanish speaking aides talked to him to see what was going on with him. LN H stated she did not feel like the staff had been able to keep residents safe from R248's behaviors, especially when he used his cane as he thought it was a weapon of sorts. She stated she did not see any changes from his previous psychiatric visits. R248 had incidents of violence and threatening people, he did not participate in activities but mostly sat and watched television (TV). LN H did not know if the care plan was updated after each altercation/incident.
On [DATE] at 03:20 PM, Administrative Nurse F stated on [DATE], staff came to get her and told her something had happened on the unit. Upon entering the unit, CNA M was standing in R248's doorway and R248 was sitting in his recliner. LN H told Administrative Nurse F the details of what happened. R32 had a scratch on the left side of his face and his eye was starting to swell so she got him an ice pack. R32 and R248 were kept separated until R248 was transported to the hospital for psychiatric evaluation. R248 liked to watch TV, staff provided him with snacks, did one-on-one talks with him about his boxing, and took him outside to the patio sometimes. Administrative Nurse F stated R248 was easily redirected and felt like staff were able to redirect him well enough to keep residents safe.
On [DATE] at 03:48 PM, Administrative Nurse D stated on [DATE], the CNA was assisting a resident across R32's room. R32 was yelling and holding a chair up trying to block R248 with the chair. CNA went up to the residents and removed the chair then called for help. R32 was already bloodied, the nurse tended to R32's injuries. CNA escorted R248 back to his room. R32 could not say what happened and R248 denied doing anything. The police, management, and the doctor were called, order for R248 to go out for psychiatric evaluation. Administrative Nurse D stated R32 was sent to ER for evaluation of his injuries. He stated the facility did not plan to accept R248 back at this time as it was not safe for the other residents on the memory care unit. Administrative Nurse D stated new interventions were put into place after each incident and updated on the care plan.
On [DATE] at 04:19 PM, Administrative Nurse D stated R248 was generally a mild person when he was around other residents. The intervention on his care plan for staff to talk to him was more for redirection, not education and R248 was receptive to the staff on the memory care unit. The plan for behaviors was to increase monitoring when residents needed redirection. R248 was a touchy person, he would go up to other residents and touch them gently on the shoulder. Administrative Nurse D stated he felt like the staff kept the residents safe on the unit. He stated if there was information to back up allegations then the facility would put something in place to prevent the likelihood of another incident, the biggest intervention was redirection and he felt there was enough staff to redirect and assist residents.
On [DATE] at 03:03 PM, CNA N stated she received dementia training and received in-services each month. She did not normally work on the memory care unit and had not received special dementia training. CNA N stated all dementia interventions were the same for all residents and she had received training on behaviors.
On [DATE] at 03:08 PM, Social Services X stated dementia care plan basics were populated and staff could go in and add specific things for some residents. If a resident had behaviors, those interventions were on the behavior focus care plan. Social Services X stated during clinical meeting, the team discussed behaviors, determined root cause, and put new interventions in place for behaviors. R248 used to join activities, he liked going outside, liked to be alone, sat in his recliner in his room, and watched Spanish channels on TV. She stated CNAs accessed behavior interventions through EMR which included interventions if a resident was escalating.
On [DATE] at 03:47 PM, LN G stated she received dementia training during in-services and was taught how to communicate with dementia residents. She stated she would look on the resident's care plan for specific interventions for dementia or behaviors and the social worker developed the individualized care plan for activities, dementia, and behaviors. She stated different interventions work on different residents so interventions on the care plan were usually specific to each resident. LN G stated R248 was difficult to redirect, snacks were not very helpful. She stated she had to use the interpreter and even then, most of what R248 said was jumbled and make sense some of the time.
On [DATE] at 04:19 PM, Administrative Nurse D stated dementia training was received initially in orientation then in monthly in-services. If someone had not worked the memory care unit before, they received additional training. He stated interventions were set up in the EMR for CNAs regarding dementia and were individualized for each resident. Administrative Nurse D stated the care plans had general interventions for all residents, if a behavior was recurring then staff added specific interventions for that behavior. He stated the care plan was revised after any incident.
The facility's Programming for Residents with Cognitive Impairments and Other Special Needs policy, revised [DATE], directed activity programs were provided for the maintenance and enhancement of each resident's quality of life while promoting physical, cognitive, and emotional health. The facility offered meaningful programs for residents with cognitive impairments that us reality and sensory awareness techniques.
The facility's Activity Programs policy, revised [DATE], directed activity programs were designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident. Activities offered were based on the comprehensive resident-centered assessment and the preferences of each resident. Activity programs were designed to encourage maximum individual participation and are geared to the individual resident's needs. Residents are encouraged, but not required, to participate in scheduled activities.
The facility did not provide a policy on dementia care upon request.
The facility failed to provide dementia care and services for R248 to address violent/aggressive behaviors, wandering, and negative resident-to-resident altercations which included physical aggression. The facility further failed to assess, identify, record, and respond to R248's specific behaviors, triggers, and past/present interests and activities in order to promote an environment which supported R248's individualized care needs. As a result of these failures, R248, who was allowed to roam freely on the memory care unit, was involved in multiple resident-to-resident altercations which created an unsafe living environment and resulted in resident injury, intimidation, acute care evaluations, and recurrent hospital transfers for R248 and other memory care residents. This deficient practice placed all 18 residents who resided on the memory care unit in Immediate Jeopardy.
The facility completed the following corrections by [DATE]:
R248 discharged to an acute care facility.
All resident to resident altercations on the memory care unit were reviewed to ensure appropriate interventions added to residents' plan of care.
All applicable interventions related to resident behaviors and dementia behavioral symptoms were linked to the [NAME].
A root cause analysis was completed for all resident to resident behaviors on the memory care unit.
The facility staff reviewed memory care residents for activity assessments and evaluations.
The facility policy admission Criteria for Memory Care Program was updated.
Inservice and education was provided to staff on resident management process, root cause analysis for behavioral symptoms and dementia training.
The deficiency was cited as past noncompliance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 99 residents. The sample included 23 residents, with one resident reviewed for hemodialysis (procedure using a machine to remove excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally). Based on observation, record review, and interviews, the facility failed to document arteriovenous (AV-a surgically created connection between artery and a vein used for hemodialysis) fistula for thrill (palpable vibration) and bruit (an audible vascular sound associated with turbulent blood flow usually heard with stethoscope that may occasionally also be palpated as a thrill) every day for Resident (R) 71. This deficient practice placed R71 at risk of potential adverse outcomes and physical complications related to dialysis.
Findings included:
- R71's electronic medical record (EMR) from the Diagnoses tab documented diagnoses of end stage renal (kidney) disease (a terminal disease because of irreversible damage to vital tissues or organs).
The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS documented that R71 was dependent of two staff members assistance for activities of daily living (ADL's). The MDS documented R71 received dialysis services during the look back period.
The Quarterly MDS dated 04/11/22 documented a BIMS score of 14 which indicated intact cognition. The MDS documented that R71 was dependent of two staff members assistance for ADL's. The MDS documented R71 received dialysis services during the look back period.
R71's Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA) dated 01/21/22 documented she was incontinent of bladder and bowel. R71 had end stage renal disease and received dialysis as scheduled.
R71's Care Plan dated 02/03/22 documented her fistula in the right upper extremity was to be monitored for bruit and thrill.
Review of the EMR under Orders tab revealed physician orders:
Check bruit/thrill of AV Fistula every shift and document dated 5/9/2022.
Review of the EMR under Reports tab of the Medication Administration Report (MAR) and Treatment Administration Report (TAR) from 02/01/22 to 05/10/22 (98 days) lacked evidence of assessment of bruit/thrill.
On 05/10/22 at 02:39 PM R71 laid in bed with head of bed elevated, TV on in room. Her eyes were closed, and she wore her boot on the lower right foot. Her dressing was intact on her right upper arm.
On 05/12/22 at 03:09 PM in an interview, Certified Nurse's Aide (CNA) P stated R71 usually left for dialysis when CNA P arrived at work. CNA P stated when R71 returned from dialysis, two staff members would transfer R71 with the Hoyer lift (total body mechanical lift used to transfer residents) back into bed.
On 05/12/22 at 03:35 PM in an interview, Licensed Nurse (LN) G stated staff assisted R71 with dressing and transferred into a dialysis chair with the Hoyer lift. LN G stated R71 was weighed during the transfer into the chair, vital signs and blood sugar was obtained and communication sheet was filled out and sent with R71 to dialysis. LN G stated upon R71's return to the unit, a weight was obtained, blood sugar and vitals was obtained and documented in resident's EMR. LN G stated that assessment of the bruit and thrill should be documented on the MAR/TAR on daily basis.
On 05/12/22 at 04:19 PM in an interview, Administrative Nurse D stated dialysis assessment would include the fistula site, vital signs, dressing of the fistula and then documented of the MAR/TAR and on the dialysis communication sheet.
The facility Hemodialysis Access Care policy last revised September 2010 documented care of the fistula was to check patency of the site at regular intervals. Palpate the site to feel the thrill or use a stethoscope to hear the whoosh or bruit of the blood flow through the access. Documentation in resident's medical record every shift of location of catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid). Condition of the dressing. If dialysis was done during the shift. Any part of report from dialysis nurse post-dialysis that was given. Observations post-dialysis.
The facility failed to monitor and document assessment of fistula for hemodialysis for R71, which had potential for adverse outcomes and physical complications.

The facility identified a census of 99 residents. The sample included 23 residents with one reviewed for pain. Based on observation, record review, and interviews, the facility failed to provide non-pharmacological pain interventions for Residents (R) 298. This deficient practice placed the residents at risk for ineffective pain management and decreased psychosocial well-being.
Findings included:
-The electronic medical record (EMR) indicated the following diagnosis for R298: chronic pain, chronic kidney disease, type two diabetes(when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), heart failure, hypertension (high blood pressure), major depressive disorder (major mood disorder), overactive bladder, insomnia (inability to sleep), retention of urine, muscle weakness, anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), obstructive sleep apnea (disorder of sleep characterized by periods without respirations), and need for assistance with personal cares.
A review of R298's admission Change Minimum Data Set (MDS) dated 04/12/22 noted a Brief Interview for Mental Status (BIMS) score of 14 indicating intact cognition. The MDS indicated he had frequent pain and received an opioid medication.
A review of R298's Pain Care Area Assessment (CAA) dated 04/12/22 indicated that he reported chronic pain concerns upon admission related to past surgeries. The CAA noted that a care plan would be developed to improve management of his pain.
R298's Care Plan dated 04/21/22 indicated he had chronic pain related to past surgeries. The care plan indicated that he reported that his pain level was tolerable or had relief with interventions at the time of his admission assessment. The plan stated that staff should have offer medication prior to therapy, provide pain medication as ordered, and utilize non-pharmacological interventions. The care plan lacked specific interventions to be offered.
A review of R298's Medication Administration Report (MAR) revealed an order dated 04/14/22 for hydrocodone-acetaminophen (medication used to treat moderate to severe pain). The order indicated to give one tablet of 5 milligram (mg)/325mg by mouth every six hours as needed for pain. The MAR also revealed R3298had an order started 05/11/22 for diclofenac gel one percent formula (topical gel used to sooth pain associated with joints). The order indicated to apply topically to his back as needed every 12 hours.
A review of R298's Treatment Administration Report (TAR) revealed an order for staff to Document Non-Pharmacological Pain Management Intervention dated 04/14/22. The order revealed the interventions as deep relaxation, heat to the site, cold to the site, massage, music, meditation, sleep, repositioning, quiet place, aromatherapy, and guided imagery. A review of this order administration history revealed no documentation showing that any of the interventions listed were given. The TAR noted that his pain should be assessed every shift using the numeric pain scale.
R298's nursing Progress Note on 04/24/22 at 03:50 AM revealed he had complaints of back pain, sleeplessness, and anxiety. The note stated that he was needy and calling every five to ten minutes for medications. The progress note lacked documentation showing that non-pharmacological interventions or offered or utilized.
R298's nursing Progress Note on 04/30/22 at 05:33 AM stated that staff felt the resident was so needy and using his call light every five minutes for staff to come to his room. The progress note lacked documentation showing that non-pharmacological interventions were offered or utilized.
R298's nursing Progress Note on 05/04/22 at 08:11 AM stated that R298 had a rough early morning with complaints of back pain, restlessness, and abdominal pain. Staff noted that different s medications and different interventions were offered but the resident continued to call for the nurse. The writer assisted R298 with laying and elevating his feet to comfort the resident until he fell asleep. The writer noted that the resident was very anxious and uncertain if pain was being controlled well. A review of R298 EMR notes revealed this to be the only time a non-pharmacological intervention was documented.
R298's nursing Progress Note on 05/06/22 at 06:32 AM noted that R298 was calling out to the nurse frequently asking for something for pain, sleep, and anxiety. The noted stated that when R298 was given the medication, he would continue to call out to staff. The note lacked documentation showing that non-pharmacological interventions or offered or utilized.
R298's nursing Progress Note on 05/08/22 at 05:58 AM noted that R298 kept calling out for the nurse and reported that he did not sleep well the night before. The note revealed the resident asked to be taken somewhere else to sleep. The note lacked documentation showing that non-pharmacological interventions or offered or utilized.
On 05/11/2022 at 08:36 AM R298 reported that he was still waiting on his morning medications. He reported that he was supposed to have pain cream for his back, but no-one has given it to him yet. He reported that he struggles at night with sleep because he does not feel good and his back hurts all night. He reported that the low air loss on his mattress does alleviate some of the pain, but the nursing staff do little to help the pain other than bring his medications. He reported that the therapy department offered him non-pharmacological interventions, but the nursing staff do not.
On 05/09/22 at 03:31 PM an interview with Licensed Nurse (LN) I stated that R298 did complain a lot about pain and often will continue to call the nurse after he has received his medication. She reported that the nursing staff often do not have time to review the resident's care plans due to the ongoing needs of the patient. She was unable to identify non-pharmacological intervention listed for R298.
On 05/09/22 at 04:19 PM an interview with Administrative Nurse D stated that the facility's pain interventions were individualized to the specific needs of each resident. He reported that the residents start out with general interventions upon admission and then become more comprehensive over time. He reported staff are required to document the interventions offered or given to each resident and reviewed for effectiveness. He reported that R298 may have had a lot of anxiety that was leading into his pain and made him difficult to treat his pain.
A review of the facility's Pain Assessment and Management policy revised 03/2020 stated the facility's goal is to identify pain in the resident and develop interventions that are consistent with the resident's goals and needs. The policy stated that staff are to implement the medication regimen as ordered and documenting the results.
The facility failed to provide non-pharmacological pain interventions for R298. This deficient practice placed the resident at risk for ineffective pain management and decreased psychosocial well-being.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 99 residents. The sample included 23 residents. Based on observation, record review, and interviews, the facility failed to provide care and assistance, consistent with professional standards of practice, for Resident (R)13's prosthesis, related to his preference to wear his prosthetic device and his goal to return home. This deficient practice placed R13 at risk for impaired dignity and loss of independence.
Findings included:
- R13's electronic medical record (EMR) from the Diagnoses tab documented diagnoses of absence of left leg below the knee, diabetes mellitus (when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin), and peripheral vascular disease (PVD-abnormal condition affecting the blood vessels).
The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS documented that R13 required extensive assistance of one staff member for toileting and personal hygiene. R13 required limited assistance of one staff member for bed mobility, and dressing. R13 required supervision of one staff member for transfers and supervision with set up assistance for locomotion on and off the unit. The MDS documented no physical therapy, occupational therapy or restorative provided during the look back period for R13.
The Quarterly MDS dated 02/16/22 documented a BIMS score of 15 which indicated intact cognition. The MDS documented that R13 required extensive assistance of two staff members for transfers, extensive assistance of one staff member dressing, toileting and personal hygiene. R13 required assistance of one staff member for bed mobility and locomotion on and off the unit. The MDS documented no physical therapy, occupational therapy or restorative provided during the look back period for R13.
R13's Activities of Daily Living Functional/Rehabilitation Potential Care Area Assessment (CAA) dated 10/01/21 documented he required assistance related to weakness, unsteady gait and utilization of his prosthetic left leg.
R13's Care Plan last revised 12/18/19 documented the social service designee was to schedule a meeting in two weeks, with R13 and his representative as well as any outside agencies to discuss strengths and weakness along with his ability to return home
The Care Plan last revised 09/30/21 documented R13 required assistance with applying and removing his left leg prosthesis.
Review of the EMR lacked documentation of the care and application of the prosthesis.
On 05/09/22 at 10:31 AM R13 stated his prosthetic left leg was broken and sent out to be fixed and now he had become weak. R13 stated he had not worked with therapy in the use of his left leg prosthesis for many months.
On 05/10/22 at 08:09 AM R13 laid in bed. R13 stated he had not been out of bed much in the past three months or more related to his prosthesis had been broken and not fitting correctly.
On 05/12/22 at 11:45 AM R13 laid in bed and worked on putting a model car together. R13 stated his goal to return home had not changed. R13 stated he wanted to become stronger and walk out the front door to return home.
On 05/11/22 at 01:12 PM in an interview, Certified Nurse's Aide (CNA) O stated R13 prosthetic leg was returned a week ago. CNA O stated R13 probably had been in bed longer than three months and she was waiting a little while before she encouraged R13 to use his prosthetic leg to get out of bed. CNA O stated she did not know how to refer anyone for skilled therapy.
On 05/12/22 at 11:15 AM Consultant Physical Therapy GG stated he was not aware of any problems with R13's prosthesis and R13 was not on therapy at the current time.
On 05/12/22 in an interview, Licensed Nurse (LN) G stated R13 wore his prosthesis off and on. LN G stated R13 was going to remain in the facility long term. LN G stated that therapy had repaired R13 prosthetic leg with in the last month and returned it to him.
On 05/12/22 at 04:19 PM in an interview, Administrative Nurse D stated he was not aware of any problems with R13 prosthetic left leg. Administrative Nurse D stated there was not a restorative program in the facility currently, that the facility was attempting to get one started.
The facility Care of Prosthesis (Artificial Limb) policy last revised February 2018 documented the prosthesis would be inspected weekly for loose or worn parts. Report such findings to the staff/charge nurse.
The facility failed to provide care and assistance, consistent with professional standards of practice for R13's prosthesis, related to his preference to wear his prosthetic device and his goal to return home. This deficient practice has placed R13 at increased risk for impaired dignity and loss of independence.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 99 residents. The sample included 23 residents with five reviewed for incontinence care. Based on observation, record review, and interviews, the facility failed to implement incontinence care interventions for Residents (R) 28, R86 and R298. This deficient practice placed the residents at risk for complications related to incontinence.
Findings Included:
-The electronic medical record (EMR) indicated the following diagnosis for R28: chronic pain, peripheral vascular disease (abnormal condition affecting the blood vessels), hypertension (high blood pressure), osteoarthrosis (degenerative changes to one or many joints characterized by swelling and pain), bipolar disorder, vascular dementia (progressive mental disorder characterized by failing memory, confusion), major depressive disorder (major mood disorder), anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), type two diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), and history of urinary tract infections (UTI's).
A review of R28's Quarterly Minimum Data Set (MDS) dated 03/08/22 noted a Brief Interview for Mental Status (BIMS) score of nine indicating moderate cognitive impairment. The MDS indicated that she was occasionally incontinent of bowel and bladder with no toileting program. The MDS stated she required one-person assistance for toileting, transfers, dressing, mobility, and personal hygiene.
R28's Urinary Incontinence Care Area Assessment (CAA) completed 01/01/22 stated that she had occasional bladder incontinence related to impaired mobility. The CAA noted that she received both physical and occupational therapy to improve her mobility, dressing, and incontinence management.
A review of R28's Care Plan revised 02/13/22 revealed she required assistance for bathing but toileted herself. It stated that she would ask for assistance as needed. The care plan addressed incontinence cares related to skin care and environmental safety but lacked interventions related to preventing and managing her incontinence episodes. R28's care plan lacked bowel incontinence information.
A review of R28's Bowel & Bladder Look-Back report from 02/01/22 through 05/10/22 (99 days reviewed) revealed she had incontinent occurrences on 60 occasions.
A review of R28's EMR indicated that a Bowel and Bladder assessment completed on 03/05/22 indicated that she did not meet the clinical conditions necessary for an indwelling catheter to be place but lacked information related to her cognitive awareness of her bowel and bladder urgency. A previous bowel and bladder assessment completed on 10/25/21 indicated that she was aware and could identify the need to void and have bowel movements, use her call light, and ask for help.
On 05/09/22 at 10:12 AM R28 stated that she sometimes had incontinence accidents because staff do not come in the room quick enough. She reported that she was not on a bowel or bladder training program that she was aware of but did struggle with incontinence. R28 appeared to be clean at that time.
On 05/12/22 at 03:04 PM with Certified Nurse Aid (CNA) O, she stated that all the resident's care information can be viewed by the nursing staff daily. She noted that if a resident was on a special toileting program it would also be reported to the assigned licensed nurse if the resident had an episode of bowel incontinence and what interventions should have been followed. She reported that the staff can reported new or missing information to the nurse that may be pertinent to the resident's care.
On 05/12/22 at 03:31 PM with Licensed Nurse (LN) I, she stated that the nursing staff often did not have time to review each resident's full care plan but could review the [NAME] (condensed form of care information from the care plan). She stated that many of the nurses were extremely busy with taking care of the resident and may not know all the interventions listed.
A review of the facility's Urinary Incontinence Policy revised 04/2018 stated staff will provide scheduled toileting, prompted voiding, or other interventions to attempt to improve the individual's continence status. The policy stated that staff will review the progress of individuals with impaired continence until continence is restored or improved. The facility noted that assessments will be completed to identify findings related to the cause, type, treatment for each resident's continence concerns.
The facility failed to implement individualized incontinence care interventions for R28. This deficient practice placed the residents at risk for complications related to incontinence.
-The electronic medical record (EMR) indicated the following diagnosis for R86: peripheral vascular disease (PVD - abnormal condition affecting the blood vessels), hypertension (high blood pressure), overactive bladder, benign prostatic hyperplasia (BPH- non-cancerous enlargement of the prostate which can lead to interference with urine flow, urinary frequency and urinary tract infections), cognitive communication deficit (deaf and nonspeaking), atherosclerosis (hardening of the walls of the blood vessels), above the knee amputation of left leg, type two diabetes (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), and needed assistance with personal cares.
A review of R86's Quarterly Minimum Data Set (MDS) dated 03/08/22 noted a Brief Interview for Mental Status (BIMS) score of 13 indicating intact cognition. The MDS indicated that he was hearing and speech impaired, frequently incontinent of bowel and bladder, and not on a toileting program.
R86's Urinary Incontinence Care Area Assessment (CAA) dated 08/27/21 noted that he required assistance with transfers, toileting, bathing, personal hygiene, bed mobility, and dressing. It stated that he has occasional urinary incontinence related to his medical diagnoses.
A review of R86's Care Plan revised 04/26/22 stated he has a self-care deficit related to impaired mobility for his activities of daily living (ADL's) and required assistant from one staff member. The care plan addressed incontinence cares related to skin care and environmental safety but lacked interventions related to preventing and managing incontinence episodes. R86's care plan lacked bowel incontinence interventions.
A review of R86's EMR indicated that he had a Bowel and Bladder assessment completed 04/13/22 stated that he could identify the need to void or have a bowel movement, use his call light for help, and could ask to use the toilet. The assessment indicated that he was not on a bowel program.
A review of R86's Bowel & Bladder Look-Back report from 02/01/22 through 05/10/22 (99 days reviewed) revealed he had incontinent occurrences on 119 occasions.
On 05/09/22 at 09:00 AM R86 utilized a marker and dry erase board to communicate due to his hearing impairment. He reported that staff were usually good at accommodating his needs and did the best they can when it got busy. He reported that he sometimes used the portable urinal to avoid having to good to the bathroom to void. He reported that he has had incontinence episodes for a while but did not remember being put on a toileting program since being admitted . The portable urinal appeared to be within reach and contained urine.
On 05/12/22 at 03:04 PM with Certified Nurse Aid (CNA) O, she stated that all the resident's care information can be viewed by the nursing staff daily. She noted that if a resident is on a special toileting program it would also be reported to the assigned licensed nurse if the resident had an episode of bowel incontinence and what interventions should have been followed. She reported that the staff can reported new or missing information to the nurse that may be pertinent to the resident's care.
On 05/12/22 at 03:31 PM with Licensed Nurse (LN) I, she stated that the nursing staff often do not have time to review each resident's full care plan but can review the [NAME] (condensed form of care information from the care plan). She noted that many of the nurses were extremely busy with taking care of the resident and may not know all the interventions listed.
A review of the facility's Urinary Incontinence Policy revised 04/2018 stated staff will provide scheduled toileting, prompted voiding, or other interventions to attempt to improve the individual's continence status. The policy stated that staff will review the progress of individuals with impaired continence until continence is restored or improved. The facility noted that assessments will be completed to identify findings related to the cause, type, treatment for each resident's continence concerns.
The facility failed to implement indicidualized incontinence care interventions for R86. This deficient practice placed the residents at risk for complications related to incontinence.
-The electronic medical record (EMR) indicated the following diagnosis for R298: chronic kidney disease, type two diabetes (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), hypertension (high blood pressure), major depressive disorder (major mood disorder), overactive bladder, insomnia (inability to sleep), obstructive sleep apnea (disorder of sleep characterized by periods without respirations), urinary retention (lack of ability to urinate and empty the bladder), muscle weakness, anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear),and need for assistance with personal cares.
A review of R298's admission Minimum Data Set (MDS) dated 04/12/22 noted a Brief Interview for Mental Status (BIMS) score of 14 indicating intact cognition. The MDS indicated that he was continent of both bowel and bladder and not on a toileting program.
A review of R298's Urinary Incontinence Care Area Assessment (CAA) dated 04/12/22 indicated a care plan would be implemented to improve current toileting skills and the ability to transfer to the toilet.
R298's Care Plan dated 04/04/22 indicated he had self-care performance deficits related to his medical diagnoses and impaired mobility. The plan noted that he required extensive assist from one staff for toileting, transfers, hygiene, and clothing management. The care plan stated that he is continent of bladder, but staff should not leave him unattended. The plan lacked interventions related to his bowel and bladder occurrences.
A review of R298's Bowel & Bladder Look-Back report from 04/04/22 through 05/10/22 (38 days reviewed) revealed he had incontinent occurrences on 13 occasions.
A review of R298's EMR indicated that he had a Bowel and Bladder assessment completed 04/21/22 stated that he could identify the need to void or have a bowel movement, use his call light for help, and ask to use the toilet. The assessment indicated that he was not on a bowel program.
On 05/09/22 at 08:12 AM R298 reported that he did have incontinence accidents and does utilize a portable urinal during the daytime. He stated that he was not on a toileting program and does not receive prompts or reminders from staff to go to the restroom.
On 05/12/22 at 03:04 PM with Certified Nurse Aid (CNA) O, she stated that all the resident's care information can be viewed by the nursing staff daily. She noted that if a resident is on a special toileting program it would also be reported to the assigned licensed nurse if the resident had an episode of bowel incontinence and what interventions should have been followed. She reported that the staff can reported new or missing information to the nurse that may be pertinent to the resident's care.
On 05/12/22 at 03:31 PM with Licensed Nurse (LN) I, she stated that the nursing staff often due not have time to review each resident's full care plan but can review the [NAME] (condensed form of care information from the care plan. She noted that many of the nurses were extremely busy with taking care of the resident and may not know all the interventions listed.
A review of the facility's Urinary Incontinence Policy revised 04/2018 stated staff will provide scheduled toileting, prompted voiding, or other interventions to attempt to improve the individual's continence status. The policy stated that staff will review the progress of individuals with impaired continence until continence is restored or improved. The facility noted that assessments will be completed to identify findings related to the cause, type, treatment for each resident's continence concerns.
The facility failed to implement individualized incontinence care interventions for R298. This deficient practice placed the residents at risk for complications related to incontinence.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 99 residents. The sample included 23 residents, with five residents reviewed for activities. Based on observation, record review, and interviews, the facility failed to consistently provide activities for Resident (R)52. This deficient practice had the risk for a decline in physical, mental, and psychosocial well-being and independence.
Findings included:
- The electronic medical record (EMR) for R52 recorded diagnoses of dementia without behavioral disturbance (progressive mental disorder characterized by failing memory, confusion), Parkinson's Disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), psychosis (any major mental disorder characterized by a gross impairment in reality testing).
The Annual Minimum Data Set (MDS) dated [DATE] documented R52 had a Brief Interview for Mental Status (BIMS) score of three which indicated a severely impaired cognition. R52 required extensive to total dependence on staff of one to two for all his activities of daily living (ADLs).
The Quarterly MDS dated 03/20/22 documented R52 had a BIMS score of four which indicated severely impaired cognition. R52 displayed no signs or symptoms of delirium (sudden severe confusion, disorientation and restlessness). R52 required total dependence on staff of one to two for his ADLS.
The Communication Care Area Assessment (CAA) dated 09/29/21 documented R52 was alert and oriented to self and displayed inattention and disorganized thinking both of which appeared to fluctuate in intensity. R52 was able to hear and sometimes understood when spoken to and could sometimes be understood when he spoke.
The Cognition/Dementia Care Plan revised 06/22/21, documented R52 needed approaches that maximized his involvement in daily decision making and activity: limit choices, use cueing, task segmentation, written lists, and instructions.
The Limited Activity Involvement Care Plan revised 01/06/22 documented R52 would have the opportunity to be outdoors, weather permitting, as part of his activity. It directed staff to develop an activity plan centering around his interests and history that takes lifetime values, attitudes, leisure patterns and psychosocial well-being into consideration. The care plan direction for individualized person-centered activities for cognitively impaired R52.The Individual Resident Daily Participation Record sheet for the month of February 2022 lacked any documentation for activities.
The Individual Resident Daily Participation Record sheet for the month of March 2022 documented R52 participated in the following activities on the following dates: educational programs (03/02/22, 03/4/22, 03/06/22, 03/08/22); family/friends (03/06/22); movies (03/02/22, 03/04/22, 03/06/22, 03/08/22, 03/10/22); music (03/01/22, 03/03/22, 03/05/22, 03/07/22, 03/09/22); radio (03/02/22, 03/04/22, 03/06/22, 03/08/22, 03/10/22, 03/11/22); religious services/studies (03/07/22); television (03/01/22 to 03/11/22); sports (3/03/22, 03/06/22, 03/07/22); and coloring (03/03/22, 03/05/22, 03/08/22, 03/10/22). The Individual Resident Daily Participation Record for March 2022 lacked documentation of activity participation from 03/12/22 to 03/31/22.
The Individual Resident Daily Participation Record sheet for the month of April 2022 for R52 lacked any documentation for participation in activities.
The Individual Resident Daily Participation Record for the month of May 2022 through 05/09/22 documented R52 participated in beauty/barber on 05/01/22 and 05/08/22); educational programs (05/01/22, 05/03/22, 05/05/22, 05/07/22); family/friends (05/06/22); movies (05/01/22, 05/03/22, 05/07/22, 05/09/22); music (05/02/22, 05/05/22, , 05/06/22, 05/08/22); radio (05/01/22, 05/02/22, 05/04/22, 05/07/22, 05/09/22); religious services/studies (05/07/22); television (05/01/22 to 05/09/22); sports (5/02/22, 05/05/22, 05/07/22); and coloring (05/01/22, 05/03/22, 05/05/22, 05/09/22, 05/10/22). ). The Individual Resident Daily Participation Record for May 2022 lacked documentation of activity participation from 05/11/22 to 05/31/22.
On 05/09/22 at 10:17 AM R52 laid in his bed, his tv was off.
On 05/10/22 10:48 AM R52 laid in his bed, his tv was off.
On 05/11/22 11:22 AM R52 laid in bed. His tv and radio inthe room were both off.
On 05/12/22 at 08:17 AM R52 laid on his back in his bed, call light within reach. His tv was turned off.
On 05/12/22 at 03:07 PM Certified Nurse Aide (CNA) P stated that she really did not help much with activities. Staff all are required to do the dementia training when hired and have it every year too.
On 05/12/22 at 03:23 PM Licensed (LN) G stated that R52 liked to listen to [NAME] Cash music and to look out the window watching the birds and loves westerns. Group activities were harder for R52 to do because of the progression on his Parkinson's. LN G stated there is a Task tab where the aides can chart when a resident participated in an activity. The activity director does go around and do things one on one with some of the residents. The facility had dementia care training staff in-service not long ago, the in-service is done when hired and annually.
On 05/12/22 at 04:19 PM Administrative Nurse D stated dementia training was done upon being hired and then they have routine monthly in-services. Interventions should be individualized for residents with dementia. Administrative Nurse D further stated that R52 loved to watch westerns on tv or listen to music or to go outside when it was nice because he used to go hiking a lot.
On 05/12/22 at 02:37 PM Activity Staff Z stated that an activity assessment was done at admission and quarterly. The information from the activity assessment information was then entered into the resident's care plan as far as their preferences, their likes and dislikes. She stated that R52 like to color and listen to rock music on the radio, he likes old cars and had restored a few. Activities were documented under the Tasks tab by the aides and each resident had an activity sheet that was supposed to be completed after each activity a resident did. Activity staff Z stated she did have an assistant that was no longer with the facility that was responsible for completing the activity log but had not apparently been doing that so not all activities were being logged.
The facility's Programming for Residents with Cognitive Impairments and Other Special Needs policy, revised June 2018, directed activity programs were provided for the maintenance and enhancement of each resident's quality of life while promoting physical, cognitive, and emotional health. The facility offered meaningful programs for residents with cognitive impairments that use reality and sensory awareness techniques.
The facility's Activity Programs policy, revised June 2018, directed activity programs were designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident. Activities offered were based on the comprehensive resident-centered assessment and the preferences of each resident. Activity programs were designed to encourage maximum individual participation and are geared to the individual resident's needs. Residents are encouraged, but not required, to participate in scheduled activities.
The facility failed to develop and revise a person-centered activity program with interventions to address specific activities for cognitively impaired R52, which put R52 at risk for further decline.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 99 residents. The sample included 23 residents with five reviewed for activities of daily living (ADL's). Based on observation, record review, and interviews, the facility failed to provide consistent bathing opportunities for Residents (R) 298. This deficient practice placed the residents at risk for ineffective skin care and decreased psychosocial well-being.
Findings included:
-The electronic medical record (EMR) indicated the following diagnosis for R298: chronic kidney disease, type two diabetes(when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), heart failure, hypertension (high blood pressure), major depressive disorder (major mood disorder), overactive bladder, insomnia (inability to sleep), retention of urine, muscle weakness, anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), obstructive sleep apnea (disorder of sleep characterized by periods without respirations), and need for assistance with personal cares.
A review of R298's admission Change Minimum Data Set (MDS) dated 04/12/22 noted a Brief Interview for Mental Status (BIMS) score of 14 indicating intact cognition. The MDS stated that he required physical help in part of bathing.
A review of R298's ADL's Care Area Assessment (CAA) dated 04/12/22 stated that he had a self-care deficit related to his diabetes, and impaired mobility.
R298's Care Plan dated 04/04/22 indicated he had a self-care performance deficit related to his medical diagnoses and impaired mobility. The care plan indicated the he required extensive assistance from one staff member. The care plan indicated that if he refused to be bathed, staff notified the charge nurse and honored his right to refuse. The care plan noted that staff offered a different time or date upon refusal of his shower.
A review of R298's Bathing Look Back report between 04/04/22 through 05/11/22 (38 days reviewed) revealed R298 received five showers (4/8, 4/22, 4/26, 4/29, 5/6) and refused on three occasions (4/5, 4/12, 4/15). The report noted that he was scheduled to receive bathing opportunities every Tuesday and Friday morning.
On 05/09/22 at 08:35 R298 reported that he received his bath last three days ago. He reported that he does refuse when he is not feeling good, but he is supposed to be given a bath on Tuesday and Friday. He reported that some weeks he has only received one bath a week. He reported that he knows that staff are busy but he felt staff needed to try harder to adjust or reschedule the shower for another time.
On 05/12/22 at 03:04 PM with Certified Nurse Aid (CNA) O, she stated that all the resident's care information can be viewed by the nursing staff daily. She reported that the staff can reported new or missing information to the nurse that may be pertinent to the resident's care. She reported that each resident should have been provided two bathing occurrences per week based on the shower schedule. She stated that when a resident refused to shower, the nurse will be notified and attempt to talk the resident into bathing. She reported that bathing forms are completed and then turned into the nursing staff. She reported that the care information for each resident can be found of the [NAME] (condensed form of care information from the care plan).
On 05/12/22 at 03:31 PM with Licensed Nurse (LN) I, she stated that the nursing staff often do not have time to review each resident's full care plan but can review the [NAME]. She noted that many of the nurses are extremely busy with taking care of the resident and may not know all the interventions listed. She reported that R298 does refuse basic cares offered by the staff making it difficult to complete certain tasks. She stated that if a resident refused to bathe, it will be documented on the shower forms and reviewed by the interdisciplinary team.
A review of the facility's Bathing policy revised 10/2010 stated that resident shower refusals should be documented with the date and reason why the activity was refused. It stated that upon refusal the nursing supervisor should be notified.
The facility failed to provide consistent bathing opportunities for Residents (R) 298. This deficient practice placed the residents at risk for ineffective skin care and decreased psychosocial well-being.

The facility identified a census of 99 residents. The sample included 23 residents with five reviewed for care plan revisions. Based on observation, record review, and interviews, the facility failed to remove an discontinued or unnecessary intervention on R39's care plan. This deficient practice placed the resident at risk for ineffective or unnecessary treatments.
Findings Included-
-The electronic medical record (EMR) indicated the following diagnosis for R39: 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), left hand contracture (abnormal permanent fixation of a joint), muscle spasms, hemiplegia (paralysis of one side of the body), hemiparesis (muscular weakness of one half of the body), major depressive disorder (major mood disorder), dysphagia (swallowing difficulty), and chronic pain.
A review of R39's Quarterly Minimum Data Set (MDS) dated 03/25/2022 noted a Brief Interview for Mental Status (BIMS) score of eight indicating moderate cognitive impairment. The MDS indicated she required extensive assist with bed mobility, transfers, locomotion, toileting, and bathing.
R39's Activities of Daily Living (ADL's) Care Area Assessment (CAA) dated 07/07/21 indicated that she admitted to hospice service on 07/07/21. The CAA revealed that a decline in her physical abilities were expected as she declined during the end of life process.
A review of R39's Care Plan revised 03/02/22 indicated the she required extensive assistance for all ADL's. A review of the care plan revealed an active intervention dated 05/25/21 for R39 to wear a left-hand splint related to her hand contractures She was admitted to hospice care, but this intervention was never removed from the care plan.
A review of R39's EMR revealed no orders for her to wear a splint for her contractures.
A review of R39's Treatment Administration Record (TAR) revealed no information regarding if the splint had ever been applied.
On 05/10/22 at 10:45 AM R39 reported that she has never worn or offered a hand splint for her contractures since arriving at the facility. She appeared to be comfortable on her low air loss mattress bed.
On 05/12/22 at 03:31 PM Licensed Nurse (LN) I reported that she was not aware of R39 had interventions for contracture and reported that she had not reviewed her care plan. She reported that R39 was on hospice and did not have an active order for the hand splints.
On 05/12/22 at 04:05 PM Consultant GG reported that R39 has not been treated or seen by therapy since starting hospice the previous year and he was not aware that she had an active intervention to wear the splint.
A review of the facility's Care Plans, Comprehensive Person Centered policy revised 12/2016 stated that the interdisciplinary team must review and update the care plan when a significant change in the resident's condition has occurred.
The facility failed remove an unnecessary intervention on R39's care plan. This deficient practice placed the resident at risk for unnecessary treatments.

The facility identified a census of 99 residents. The sample included 23 residents. Based on observations, record reviews, and interviews, the facility failed to ensure accurate assessment and documentation on the Minimum Data Set (MDS) for documentation of anticoagulant (medication used to prevent blood from thickening or clotting) use for Resident (R) 2, R76, and R94. This deficient practice had the risk for miscommunication related to anticoagulation status.
Findings included:
- The Quarterly Minimum Data Set (MDS) dated 01/28/22, documented R2 received anticoagulant medications seven days in the seven-day lookback period.
The Orders tab of R2's Electronic Medical Record (EMR) documented an order with a start date of 11/08/21 for clopidogrel bisulfate (antiplatelet medications- works by preventing platelets [a type of blood cell] from collecting and forming clots that may cause a heart attack or stroke) 75 milligrams (mg) one time a day related to cerebral infarction (cerebrovascular accident [CVA]- sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain) and an order with a start date of 11/08/21 for aspirin (nonsteroidal anti-inflammatory drug [NSAID] used to reduce pain, fever, or inflammation) 81 mg one time a day related to cerebral infarction.
The Quarterly MDS dated 03/21/22, documented R76 received anticoagulant medications seven days in the seven-day lookback period.
The Orders tab of R76's EMR documented an order with a start date of 11/03/20 for clopidogrel bisulfate 75 mg related to cerebral infarction.
The Quarterly MDS dated 04/22/22 documented R94 received anticoagulant medications seven days in seven-day lookback period.
The Orders tab of R94's documented an order with a start date of 03/19/20 for aspirin 81 mg one time a day related to cerebral infarction.
On 05/09/22 at 09:30 AM, R2 laid in bed with her eyes open. She had finished eating breakfast and appeared comfortable. R2 conversed with surveyor.
On 05/12/22 at 03:15 PM, Administrative Nurse E stated she looked up what medications were anticoagulants on Epocrates.com (medical reference website) or checked the medication order which stated what class the medication was. She stated aspirin and clopidogrel (Plavix) were not anticoagulant medications. Administrative Nurse E stated if another nurse completed MDS assessments and triggered anticoagulant medications when the resident was not on an anticoagulant, she would not have been notified of that.
On 05/12/22 at 04:19 PM, Administrative Nurse D stated Point Click Care (PCC- EMR system) told staff what medications were anticoagulants. Aspirin and Plavix were not considered anticoagulants.
The facility's Certifying Accuracy of the Resident Assessment policy, revised November 2019, directed any person completing a portion of the MDS signed and certified the accuracy of that portion of the assessment. The policy directed that any health care professional who participated in the assessment process was qualified to assess the medical, functional, and/or psychosocial status of the resident that was relevant to the professional's qualifications and knowledge. The Resident Assessment Coordinator was responsible for ensuring that an MDS assessment had been completed for each resident.
The facility failed to ensure accurate assessment and documentation on the MDS for documentation of anticoagulant use for R2, R76, and R94. This deficient practice had the risk for miscommunication related to anticoagulation status.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 99 residents. The sample included 23 residents; two residents reviewed for hospitalization. Based on observations, record reviews, and interviews, the facility failed to provide a written notification of transfers to Resident (R) 63 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) in a practicable amount of time. This deficient practice had the risk of miscommunication between facility and resident/family and possible missed opportunity for healthcare services.
Findings included:
- R63 admitted to the facility on [DATE], discharged to hospital on [DATE], readmitted to facility on 01/19/22, discharged to hospital 02/09/22, readmitted to facility on 02/14/22, discharged to hospital 03/28/22, and readmitted to facility 04/01/22.
The Diagnoses tab of R63's Electronic Medical Record (EMR) documented diagnoses of personal history of pulmonary embolism (a condition in which one of the pulmonary arteries in the lungs gets blocked by a blood clot), seizures, unsteadiness on feet, lack of coordination, and need for assistance with personal care.
The admission Minimum Data Set (MDS) dated 12/24/21, documented R63 had a Brief Interview for Mental Status (BIMS) score of 14 which indicated intact cognition. R63 required extensive physical assistance with one staff for bed mobility, dressing, and personal hygiene; total dependence with one staff with toileting.
The Quarterly MDS dated 04/05/22, documented R63 had a BIMS score of 15 which indicated intact cognition. R63 required extensive assistance with two staff with bed mobility and dressing; extensive assistance with one with toileting and personal hygiene; and total dependence with two staff for transfers.
The Activities of Daily Living (ADL) Functional/Rehabilitation Potential Care Area Assessment (CAA) dated 12/30/21, documented R63 had an ADL self care performance deficit and impaired mobility.
The Self-Care/Mobility Care Plan dated 12/28/21, revised 02/21/22, directed R63 had an ADL self care performance deficit and impaired mobility and staff encouraged R63 to participate to the fullest extent possible with each interaction.
Upon request, the facility failed to provide written notification of transfers to hospital for 01/18/22, 02/14/22, and 03/28/22.
On 05/11/22 at 09:51 AM, R63 laid in bed with her eyes open. She appeared comfortable and without signs of distress.
On 05/11/22 at 09:51 AM, R63 stated she had never received a written notification of transfer for her hospital transfers.
On 05/11/22 at 10:50 AM, Administrative Staff A stated the facility notified family/DPOA via phone call with transfers. The facility did not send a written notification of transfer to family/DPOA.
On 05/12/22 at 01:40 PM, Social Services Y stated the facility did not send a written notification of transfer to resident and/or family. She stated the facility called the family to let them know about transfers. Social Services Y stated she did not talk to residents about their right to appeal transfers.
The facility's Transfer or Discharge Notice policy, revised December 2016, directed a notice was given as soon as practicable but before the transfer or discharge under the following circumstances: the transfer was necessary for the resident's welfare and the resident's needs cannot be met in the facility and an immediate transfer or discharge was required by the resident's urgent medical needs. The resident and/or representative was notified in writing of the following information: the reason for the transfer or discharge; the effective date of the transfer or discharge; the location to which the resident was being transferred or discharge; a statement of the resident's rights to appeal the transfer or discharge; the bed-hold policy; the name, address, and telephone number of the Office of the State Long-term Care Ombudsman; the name, address, email, and telephone number of the agency responsible for the protection and advocacy of residents with intellectual and developmental disabilities; the name, address, email, and telephone number of the agency responsible for the protection and advocacy of residents with a mental disorder or related disabilities; and the name, address, and telephone number of the state health department agency that had been designated to handle appeals of transfers and discharge notices.
The facility failed to provide a written notification of transfer to R63 or her DPOA in a practicable amount of time. This deficient practice had the risk of miscommunication between facility and resident/family and possible missed opportunity for healthcare services.

The facility identified a census of 99 residents. The sample included 23 residents with three reviewed for Center for Medicare and Medicaid Services (CMS) Beneficiary Liability notices. Based on record review, and interviews, the facility failed to provide form CMS 10123, Notice of Medicare Non-Coverage (NOMNC- a notice that indicated when the resident's care was set to end from skilled nursing facility [SNF]). It includes information for how to appeal the provider 's decision to a Quality Improvement Organization for Resident's (R) 66, R56, and R71. This deficient practice placed three residents at risk for uninformed decisions.
Findings included:
- The Medicare NOMNC form informed the beneficiaries that are receiving skilled therapy that are eligible for expedited determination process, even if they agree with the termination of the services. The NOMNC has a section for information related to their right to appeal the decision.
The facility lacked documentation staff provided R66 or their representative the NOMNC form 10123 when the resident's skilled services ended 02/27/22. The facility provided form CMS-10095 which lacked the correct information to appeal the decision to terminate skilled therapy.
The facility lacked documentation staff provided R56 or their representative the NOMNC form 10123 when the resident's skilled services ended 04/22/22. The facility provided form CMS-10095 which lacked the correct information to appeal the decision to terminate skilled therapy.
The facility lacked documentation staff provided R71 or their representative the NOMNC form 10123 when the resident's skilled services ended 04/20/22, The facility provided form CMS-10095 which lacked the correct information to appeal the decision to terminate skilled therapy.
On 05/12/22 at 01:40 PM in an interview, Social Services Y stated she had been trained by a pervious facility employee regarding which form was to be filled out and given to the beneficiaries.
The facility did not provide a policy regarding beneficiary notification.
The facility failed to provide R56, R66 and R71 with the appropriate non-coverage notice placing the residents at risk for uninformed decisions regarding skilled services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 99 residents. The sample included 23 residents. Based on observations, record reviews, and interviews, the facility failed to notify Resident (R) 31's Durable Power of Attorney (DPOA- legal document that names a person to make healthcare decisions when the resident was no longer able to) when R31 was transferred to the hospital for change in mental status. This deficient practice had the risk for miscommunication between R31, their DPOA, and the facility.
Findings included:
- R31 admitted to facility on 09/16/21 and transferred to hospital on [DATE].
The Diagnoses tab of R31's Electronic Medical Record (EMR) documented heart failure (a progressive heart disease that affects pumping action of the heart muscles. This causes fatigue, shortness of breath), chronic kidney disease (gradual loss of kidney function), cerebral infarction (cerebrovascular accident [CVA]- 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) without residual deficits, and generalized muscle weakness, and dependence on renal dialysis (procedure where impurities or wastes were removed from the blood).
The admission Minimum Data Set (MDS) dated 09/20/21, documented R31 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. R31 required extensive physical assistance with two staff for bed mobility, transfers, dressing, toileting, and personal hygiene.
The Quarterly MDS dated 03/10/22, documented R31 had a BIMS score of 15 which indicated intact cognition. R31 required limited assistance with one staff with bed mobility, locomotion, and dressing; extensive physical assistance with one staff with transfers and toileting; and independent with personal hygiene.
The Activities of Daily Living (ADL) Functional/Rehabilitation Potential Care Area Assessment (CAA) dated 09/27/21, documented R31 had an ADL self-care performance deficit and impaired mobility related to heart failure, lack of coordination, and need for assistance with personal care.
The Self-Care/Mobility Care Plan dated 09/27/21, revised on 04/06/22, directed R31 had an ADL self-care performance deficit and impaired mobility related to heart failure, lack of coordination, and need for assistance with personal care. She got upset when staff tried to assist her with cares. The care plan directed staff encouraged R31 to participate to the fullest extent possible with each interaction.
The Notes tab of R31's EMR revealed the following:
A Nursing Note on 05/06/22 at 12:45 PM documented the nurse was notified that R31 had a change in her mental status at approximately 12:00 PM. The Certified Nurse Aides (CNAs) reported they went to get R31 up and ready for dialysis. The CNAs reported R31 could not answer questions; this was not her normal neurological baseline. The nurse entered her room and found R31 laying in her bed and giggling. The nurse asked a few simple questions and she was unable to answer any of them. The nurse notified the Assistant Director of Nursing (ADON) for a second opinion. The ADON reported that was not normal behavior for R31. Orders to send to hospital were obtained, paramedics arrived and transported R31 to the emergency department (ED) for evaluation.
A Communication with Family/POA Note on 05/08/22 at 04:28 PM documented the nurse spoke with R31's son about R31's whereabouts. He was upset he was not notified of her transfer to the hospital. He stated he had been trying to call for some time with no answer.
On 05/12/22 03:47 PM, Licensed Nurse (LN) G stated when a resident had a change in condition, the nurse practitioner gave the order to send to the hospital and the unit manager, ADON, administrator, and family as well. If the unit manager was in the building, then they helped notify the family; if it is a weekend then the nurse who sent the resident to the hospital notified the family. R31 was sent to the hospital on the weekend. LN G spoke to R31's son on Monday and he stated he was not notified. She stated she assured him that that was not the facility's process.
On 05/12/22 at 04:19 PM, Administrative Nurse D stated if a resident had a change in condition and was sent out to the hospital, the Director of Nursing (DON), ED, family, and provider were notified. The POA was notified of change in condition or transfers regardless of resident's cognition.
The facility's Change in Residents Condition or Status policy, revised May 2017, directed facility promptly notified the resident, his or her attending physician, and representative of changes in the resident's medical/mental condition and/or status. Unless otherwise instructed by the resident, a nurse notified the resident's representative when there was a significant change in the resident's physical, mental, or psychosocial status or it was necessary to transfer the resident to a hospital/treatment center.
The facility failed to notify R31's DPOA when R31 was transferred to the hospital for a change in condition. This deficient practice had the risk for miscommunication between R31, their DPOA, and the facility.