Azria Health Wichita

The facility reported a census of 65 residents; the sample included five residents reviewed unnecessary medications. Based on observation, interview, and record review revealed the facility failed to monitor and respond to Resident (R) 27's lack of bowel movements. Findings included:- R27's Electronic Medical Record (EMR) revealed the following diagnoses: anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), depressive disorder (major mood disorder that causes persistent feelings of sadness), and drug induced dyskinesia (inability to execute voluntary movements)R27's 07/19/25 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) of 15, indicating intact cognition. R27 was always continent of bowel and did not have constipation.R27's Urinary Incontinence Care Area Assessment (CAA) triggered due to R27 needing assistance with toileting and toileting hygiene and was frequently incontinent of urine. Contributing factors included a cognitive communication deficit.R27's 01/19/26 Quarterly MDS documented a BIMS of 14, indicating intact cognition. R27 was always continent of bowel and did not have constipation.R27's Care Plan documented R27 took an antidepressant for depression dated 07/20/23 and directed staff to monitor for side effects which included constipation.R27's Physician Orders in the EMR documented an order to follow the bowel routine as per the facility protocol dated 07/12/23. R27's Physician Orders in the EMR documented an order for Prune juice 4-8 ounces daily as needed for constipation, dated 07/12/23. R27's Physician Orders in the EMR documented an order for Milk of Magnesia 400 milligrams (mg) per five milliliters (ml). Give 30 ml daily as needed, dated 07/12/23. R27's Physician Orders in the EMR documented an order for Fleet Enema every 24 hours as needed for constipation, dated 07/12/23. Review of R27's bowel movement frequency under the Tasks in the EMR, dated 0/27/26 through 02/25/26, revealed the resident exceeded three days/72 hours without a bowel movement and/or treatment from 02/02/26 at 12:52 AM until 02/08/26 at 05:07 PM (six consecutive days) with no medication given for constipation and no assessment documented.Review of R27's Progress Notes revealed no documentation of assessment or treatment for constipation during that time.On 02/25/26 at 10:06 AM, Licensed Nurse (LN) said the nurse monitored the residents for bowel movements. The nurse received an alert if a resident goes 3 days without a bowel movement. The nurse follows the standing orders for the bowel movement protocol.On 02/25/26 at 10:48 AM, Administrative Nurse D stated the nurse monitored the residents for bowel movements. If there was no bowel movement the nurse assessed the resident and should document the assessment. Then the nurse followed the standing orders for the bowel movement protocol.The facility's Constipation Management Policy documented if no bowel movement has occurred in three days, give Milk of Magnesia. If there are no results in 24 hours, give Lactulose 20ml every two hours up to three doses. If there are no results, give Dulcolax 10mg suppository. If there are no results, give a Fleet Enema. Notify provider if there are no results.

The facility identified a census of 91 residents. The sample included 19 residents with one resident received for an intravenous catheter (IV-catheter placed in a vein to administer medications or fluids directly into the bloodstream). Based on observation, record review, and interviews, the facility failed to provide IV care and services consistent with standards of practice when staff did not assess, identify and take actions for Resident (R) 69's soiled IV dressing and failed to use adequate infection control practices during IV medication administration.Findings included: - R69's Electronic Medical Record (EMR) included diagnoses of urinary tract infection (UTI) and hypertension (high blood pressure).R69 Annual Minimum Data Set (MDS) was still in progress.R69's Care Plan, dated 02/20/26, instructed the Licensed Nurse (LN) to change the midline dressing every Thursday. The plan instructed staff to observe and report concerns of infection to the physician and administer prescribed medication per physician order. Staff were to monitor for signs and symptoms of infection, pain, redness, infiltration (the leaking of IV fluids or medications into surrounding tissue instead of the vein), bruising, embolism (an obstruction in a blood vessel due to a blood clot or other foreign matter that gets stuck while traveling through the bloodstream), phlebitis ( a vein near an IV insertion becomes inflamed, red, or swollen), fluid overload (where the body retains excessive fluid, affecting organ function) electrolyte imbalance (the levels of minerals in your body are too high or too low disrupting essential bodily functions) and monitor for signs and symptoms of adverse reactions; report any adverse reactions to the medical doctor (MD).R69's Physician Orders, dated 02/20/26, ordered to change the midline dressing every Thursday. The orders did not indicate an as needed (PRN) dressing change was ordered.R69's Physician Orders, dated 02/20/26, ordered to monitor for signs and symptoms of infection, pain, redness, infiltration, bruising, embolism, phlebitis, fluid overload, and electrolyte imbalance two times a day.R69's Physician Orders, dated 02/19/26, ordered ertapenem sodium solution (antibiotic) one gram IV one time a day for UTI for thirteen days.R69's Physician Orders, dated 2/20/26, ordered Heparin (an injectable blood thinner used to prevent and treat blood clots), flush solution with 10 unit/milliliter (ml) use 5 ml IV one time a day for antibiotic use flush with normal saline prior to administration and after administration. Add Heparin to line after second normal saline.R69's February 2026 Medical Administration Record (MAR) and Treatment Administration Record (TAR) showed staff documented for signs and symptoms of infection, pain, redness, infiltration, bruising, embolism, phlebitis, fluid overload, and electrolyte imbalance two times a day.R69's February 2026 MAR/TAR lacked evidence staff monitored the dressing status for cleanliness and if the dressing was intact.Review of R69's Progress Notes and N ADV Skilled Evaluation, reviewed from 02/20/26 through 02/25/26, lacked documentation or evidence staff assessed R69's midline dressing.On 02/23/26 at 09:45 AM, R69 laid in bed wearing a nebulizer mask. The nebulizer treatment chamber was empty. He appeared to be sleeping. Further observation revealed a single lumen midline IV to his right upper arm. The undated dressing had a large amount of blood collected under the dressing and the blood had seeped through the soft cloth border on the dressing. The blood was dried.On 02/24/26 at 02:20 PM, Licensed Nurse (LN) Q prepared to administer R69's IV antibiotic. She washed her hands and done gloves and a gown. After applying the gloves, she placed her hand in her pocket to retrieve supplies. Wearing the same gloves, she wiped the IV hub site with an alcohol wipe then allowed the hub to rest back on R69's arm. LN Q then began untangling the IV line, touched her hair, and removed items from her pocket multiple times. Wearing the same gloves, LN Q connected the IV tubing to the hub. Upon questioning the dressing, LN Q stated that she felt it needed changed as it had dried blood soaked through the bottom portion of the dressing and it was loose. She stated that the Registered Nurse (RN) manager changed the dressing on its scheduled day. She stated that if the dressing was soiled, she could change it if there was a PRN order to do so. She stated if there was not a PRN order, and the dressing needed to be changed, she would call the physician and get an order to change it. LN Q verified there was no date on the IV dressing. LN Q then removed her gloves and gown, performed hand hygiene and exited the room.On 02/25/26 at 08:42 AM, R69's dressing was unchanged from the previous day. The dried blood remained on the cloth portion of the bottom part of the dressing. The bottom seal of dressing was loose. The top of the dressing was still reinforced.On 02/25/26 at 11:00 AM, LN J stated R69's dressing was scheduled to be changed on Thursdays. She confirmed there was dried blood on the soft cloth portion of the dressing and verified the dressing needed to be changed. After reviewing R69's orders, LN J confirmed there was not a PRN order to change the dressing if soiled and stated she would call the provider because the dressing did need to be changed.On 02/25/26 at 10:00 AM, Licensed Nurse (LN) I stated hand hygiene and glove changes should be performed when touching something dirty prior to touching something clean.On 02/25/26 at 10:48 AM, Administrative Nurse D stated she expected to always do good hand hygiene and change gloves when they touch anything dirty.On 02/25/26 at 11:50 AM, Administrative Nurse D stated IV sites should be assessed daily and the assessment should always include the dressing. She stated she expected midline dressings to be changed to Monday, Wednesday and Fridays and as needed. She stated if the dressing needed to be changed and there was no order, the nurses should contact the physician to obtain the order. She confirmed that if they assess it while administering medication, they should be documenting the site and dressing condition. She expected them to change it if it was soiled.The facility policy .Peripheral IV Catheter and Site Selection documented the purpose of the policy was to select the most appropriate intravenous access device for the resident's condition. The policy did not address the care and monitoring of the site and the dressing.

The facility reported a census of 65 residents. Based on observation, interview, and record review, the facility failed to ensure the posted daily nurse staffing sheets included accurate and identifiable information to include the actual hours worked, as required.Findings included:- Observed on 02/23/26 at 08:00 AM, the posted staffing sheet lacked the actual hours workedObserved on 02/24/26 at 07:30 AM, the posted staffing sheet lacked the actual hours worked.Review of the daily staffing sheets from 12/21/24 and 07/21/25 revealed that the staffing sheets lacked the actual hours worked.On 02/24/26 at 09:47 AM, Administrative Staff A stated that the staffing coordinator, Certified Medication Aide (CMA) R, had been responsible for the posting and accuracy of the daily staffing sheets.On 02/24/26 at 09:57 AM, CMA R stated that she had provided the staffing numbers to the receptionist and the receptionist then printed the daily staffing sheet and posted it in the lobby. CMA R verified that the actual hours worked had not been listed on the posted daily staffing sheets.On 02/24/26 at 11:46 AM, Administrative Staff A confirmed that the posted daily staffing sheets did not include the actual hours worked for the resident care medical staff.The facility policy Posting Direct Care Daily Staffing Number, dated July 2016, documented that the shift staffing information would be recorded the Nursing Staff Directly Responsible for Resident Care for each shift. The policy also documented that the information recorded on the form would include the name of the facility, the date for which the information was posted, the resident census at the beginning of the shift, the 24-hour shift schedule operated by the facility, the shift for which the information was posted, the type and category of nursing staff who was working that shift, the actual time worked during that shift for each category and type of nursing staff, and the total number of licensed and non-licensed nursing staff working for the posted shift.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 65 residents. The sample included 16 residents with five sampled residents reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported when Resident (R) 3's antihypertensive medications were given outside of the physician ordered hold parameters.Findings included:- R3's Electronic Medical Record (EMR) documented diagnoses of hypertension (HTN- elevated blood pressure) and congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid).R3's admission Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 12, which indicated a moderately impaired cognition. R3 was dependent on staff for her activities of daily living (ADLs). R3 received an anticoagulant (a class of medications sued to prevent the blood from clotting) and a diuretic (a class of medications sued to prevent the blood from clotting).R3's Functional Abilities Care Area Assessment (CAA), dated 10/16/25, documented her care plan would be developed to improve the highest practical level the ADL functional abilities, optimize comfort, and plan to have caregivers assist with ADLs as needed.R3's Care Plan, revised on 11/03/25, directed staff to administer medications as ordered. The plan directed staff to obtain vital signs at least daily per physician's orders and as needed and notify the physician of any abnormal readings.R3's Orders tab of the EMR documented a physicians order, dated 10/16/25, for isosorbide mononitrate (medication used to treat high blood pressure) 30 milligram (mg) tablet give one tablet by mouth one time a day for HTN; hold medications if pulse less than 50 beats per minute (BPM) or greater than 120 BPM; hold if blood pressure (BP) was less than 120/40 or greater than 200/90 millimeters of mercury (mm/Hg).R3's Orders tab of the EMR documented a physicians order, dated 10/16/25, for amlodipine besylate (medication used to treat high blood pressure) 10 mg to give one tablet by mouth one time a day for HTN; hold medications if pulse was less than 50 BPM or greater than 120 BPM; hold if BP was less than 120/40 or greater than 200/90 mm/Hg.Review of R3's November 2025 Medication Administration Record (MAR) revealed the amlodipine was given outside of the physician ordered parameters on six of 30 opportunities.Review of R3's November 2025 MAR revealed her physician ordered antihypertensive isosorbide mononitrate was given outside of the ordered parameters on six of 30 opportunities.Review of R3's December 2025 MAR revealed her physician ordered amlodipine was given outside of the physician ordered parameters on 12 of 30 opportunities. Review of R3's December 2025 MAR revealed her physician ordered isosorbide mononitrate was given outside of the physician ordered parameters on 12 of 30 opportunities.Review of R3's January 2026 MAR revealed her physician order antihypertensive medication amlodipine was given outside of the physician ordered parameters on 15 of 30 opportunities.Review of R3's January 2026 MAR revealed her physician ordered antihypertensive isosorbide mononitrate was given outside of the physician ordered parameters on 15 of 30 opportunities.Review of R3's February 2026 MAR revealed R3's amlodipine was given outside of the physician ordered parameters on five of 24 opportunitiesReview of R3's February 2026 MAR revealed her physician ordered antihypertensive isosorbide mononitrate was given outside of the physician ordered parameters on five of 24 opportunities.The CP Medication Regimen Review (MRR) for R3 from January 2025 to present lacked identifying or reporting that antihypertensive medications amlodipine and isosorbide were given outside of the physician order parameters.On 02/24/26 at 08:13 AM, R3 sat in her wheelchair upon her return to the facility after an appointment. Staff propelled her to the dining table for breakfast.On 02/24/26 at 08:24 AM, Consultant GG stated that although the physician parameters for R3's BP medications were not hers, she interpreted them as the medications that should be held if any reading or the pulse were below or above the ordered numbers. Consultant GG stated she would expect the CP to identify and report when the medication was not held when the BP or pulse was outside of the ordered parameters.On 02/25/26 at 08:01 AM, Certified Medication Aide (CMA) R stated she would get the BP and pulse, and if the reading was low, she would wait for a bit and retake it. CMA R stated if the BP and or pulse continued to still be low, she would notify the nurse and would hold the medication.On 02/25/26 at 08:10 AM, Licensed Nurse (LN) I stated that the physicians provided the parameters for the BP medications. LN I stated if she was the one passing medications, she would hold the medication if the BP reading or pulse was below the parameters. LN I stated she would expect CMAs to notify her when a residents BP or pulse was low and have them retake the reading before the medication was held.On 02/25/26 at 12:20 PM, Administrative Nurse D stated she expected anyone that was administering medication to hold the medication when the BP or pulse reading was outside of the ordered parameters. Administrative Nurse D stated she expected the CP to report when medications were given outside of the ordered parameters.The facility's Pharmacy Services Overview, dated April 2019. documented the consultant pharmacist, in collaboration with the dispensing pharmacy and the facility, oversees the development of procedures related to pharmacy services, including (but not limited to): acquisition and availability of medications: receipt, labeling and storage of medications; reconciliation of medications from the pharmacy; control of medications from point of receipt to secured storage areas; and facility staff roles and responsibilities during the receipt and storage of medication; medication packaging and dispensing systems; administration of medications; disposition of medications; authorization, training and competency of personnel; and documentation of processes, as applicable.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 65 residents. The sample included 16 residents with five sampled residents reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure staff held Resident (R) 3's antihypertensive medications per physician's orders when R3's blood pressure (BP) and pulse measurements were outside of the physician ordered parameters.Findings included:- R3's Electronic Medical Record (EMR) documented diagnoses of hypertension (HTN- elevated blood pressure) and congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid).R3's admission Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 12, which indicated a moderately impaired cognition. R3 was dependent on staff for her activities of daily living (ADLs). R3 received an anticoagulant (a class of medications sued to prevent the blood from clotting) and a diuretic (a class of medications sued to prevent the blood from clotting).R3's Functional Abilities Care Area Assessment (CAA), dated 10/16/25, documented her care plan would be developed to improve the highest practical level the ADL functional abilities, optimize comfort and plan to have caregivers assist with ADLs as needed.R3's Care Plan, revised on 11/03/25, directed staff to administer medications as ordered. The plan directed staff to obtain vital signs at least daily per physician's orders and as needed and notify the physician of any abnormal readings.R3's Orders tab of the EMR documented a physicians order, dated 10/16/25, for isosorbide mononitrate (a medication used to treat high blood pressure) 30 milligram (mg) tablet give one tablet by mouth one time a day for HTN; hold medications if pulse less than 50 beats per minute (BPM) or greater than 120 BPM; hold if blood pressure (BP) was less than 120/40 or greater than 200/90 millimeters of mercury (mm/Hg).R3's Orders tab of the EMR documented a physicians order, dated 10/16/25, for amlodipine besylate (a medication used to treat high blood pressure) 10 mg to give one tablet by mouth one time a day for HTN; hold medications if pulse was less than 50 BPM or greater than 120 BPM; hold if BP was less than 120/40 or greater than 200/90 mm/Hg.Review of R3's November 2025 Medication Administration Record (MAR) revealed the amlodipine was given outside of the physician ordered parameters on six of 30 opportunities.Review of R3's November 2025 Medication Administration Record (MAR) revealed her physician ordered antihypertensive isosorbide mononitrate was given outside of the ordered parameters on six of 30 opportunities.Review of R3's December 2025 MAR revealed her physician ordered amlodipine was given outside of the physician ordered parameters on 12 of 30 opportunities. Review of R3's December 2025 MAR revealed her physician ordered isosorbide mononitrate was given outside of the physician ordered parameters on 12 of 30 opportunities.Review of R3's January 2026 MAR revealed her physician order antihypertensive medication amlodipine was given outside of the physician ordered parameters on 15 of 30 opportunities.Review of R3's January 2026 MAR revealed her physician ordered antihypertensive isosorbide mononitrate was given outside of the physician ordered parameters on 15 of 30 opportunities.Review of R3's February 2026 MAR revealed R3's amlodipine was given outside of the physician ordered parameters on five of 24 opportunitiesReview of R3's February 2026 MAR revealed her physician ordered antihypertensive isosorbide mononitrate was given outside of the physician ordered parameters on five of 24 opportunities.On 02/24/26 at 08:13 AM, R3 sat in her wheelchair upon her return to the facility after an appointment. Staff propelled her to the dining table for breakfast.On 02/24/26 at 08:24 AM, Consultant GG stated that although the physician parameters for R3's BP medications were not hers, she interpreted them as the medications which should be held if any reading or the pulse were below or above the ordered numbers.On 02/25/26 at 08:01 AM, Certified Medication Aide (CMA) R stated she would get the BP and pulse and if the reading was low, she would wait for a bit and retake it. CMA R stated if the BP and or pulse continued to still be low, she would notify the nurse and would hold the medication.On 02/25/26 at 08:10 AM, Licensed Nurse (LN) I stated that the physicians provided the parameters for the BP medications. LN I stated if she was the one passing medications, she would hold the medication if the BP reading or pulse was below the parameters. LN I stated she would expect CMAs to notify her when a residents BP or pulse was low and have them retake the reading before the medication was held.On 02/25/26 at 12:20 PM, Administrative Nurse D stated she expected anyone that was administering medication to hold the medication when the BP or pulse reading was outside of the ordered parameters.The facility's Azria Medication and Treatment Orders policy revised July 2016 documented physician orders shall be followed, if unable to follow physician orders, notify the Director of Nursing Services/Designee and physician as appropriate.

The facility had a census of 65 residents. The sample included 16 residents with three residents reviewed for hospitalization. Based on observation, interview, and record review, the facility failed to issue written notification as soon as practicable for transfers, for Resident (R) 5, R9, and R50.Findings included:1. R9's Electronic Medical Record (EMR) Nurses Note on 02/20/26 recorded R9 was observed vomiting a reddish-brown-colored substance. R9 reported pain in his right shoulder. The nurse received orders from the provider to send this resident to the emergency room (ER) for evaluation. R9 transferred to the hospital via Emergency Medical Services (EMS) on 02/20/26.R9's EMR lacked evidence the facility provided written notification of the transfer to R9 and/or his representative.2. R5's Progress Notes, dated 12/25/25 at 15:58 PM, documented that a verbal order was received to send to R5 to the ER for evaluation and treatment, and R5 was sent to the hospital via emergency medical services (EMS).R5's Electronic Medical Record (EMR) lacked evidence the facility provided written notification of the transfer to R5 and/or her representative.3. R50's Nurses Note, dated 01/24/26 at 11:35 PM, documented the resident was hallucinating and talking to people that were not there. R50's daughter was notified and wanted the resident to be taken to the hospital.R50's Electronic Medical Record (EMR) lacked evidence the facility provided written notification of the transfer to R50 and/or her representative.During an interview on 02/24/26 at 03:12 PM, Social Services X stated that the bed hold was sent with the residents upon their transfer to the hospital and the family was notified by phone call of the transfer. Social Service X stated she was not aware that a written notification of transfer was needed for a transfer to the hospital.During an interview on 02/24/26 at 03:22 PM, Administrative Staff A stated upon a residents transfer to the hospital the transfer packet included the bed hold. Administrative Staff A then stated she had not heard of the written notification for transfers to the hospital and asked what regulation that fell under. Administrative Staff A stated that the facility would create a form that included all of the required information, and the form would be sent to the representative when a resident transferred to the hospital.The facility's policy Azria Transfer or Discharge, Facility-Initiated, dated 2001 (October 2002), documented facility-initiated discharges require resident/representative notification, orientation, and documentation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had one main kitchen and two kitchenette/serving areas. Based on observation, record review, and interview, the facility failed to ensure foods in the kitchen were properly labeled and stored. The facility failed to ensure food service areas, refrigerators, counters and cabinets in the kitchenettes were clean. Findings included:- Observation during the initial tour of the main kitchen on 02/23/26 at 08:04 AM revealed the following:The dry storage area had a box of cream of wheat that was opened, not dated and not in a sealed container/bag.An opened 10-pound bag of macaroni noodles that was not dated and not in a sealed bag.A half-gallon sized opened carton of rainbow sprinkles that was not dated or in a sealed container.An open bag with five hamburger buns not dated or sealed.The walk-in refrigerator had a five-pound bag of shredded cheese that was opened, not dated and not in a sealed bag, and a container with fish in it was not sealed.The kitchen serving area refrigerator had about 12 slices of cheese in plastic wrap not sealed or dated, an onion wrapped in plastic wrap contained no date, lettuce in a Ziploc bag was not dated, and a pint-sized plastic container with chicken base was opened without an open date on it.The kitchen freezer had an opened and undated bag of chicken strips which were not in a sealed bag, two opened bags of potato wedges were not dated or in sealed bag, an open box with beef patties with an open bag had no open date, an opened bag with chicken nuggets were not sealed, dated, or labeled, an opened box of corn dogs was unsealed and a few of the corn dogs had frost buildup on them. The ice machine was not working and had visible rust at the hinges of the machine.On 02/23/26 at 08:31 AM, there was trash in the dining kitchenette area on the [NAME] side. The bottom cabinet had clean folded towels stored directly on floor. The juice machine area had open single water bottle, unlabeled and undated. A juice concentrate box had a black sticky substance on bottom of it, with the expiration date illegible. A small refrigerator had a Rubbermaid food container that was undated and the inside of the refrigerator was dirty. There was an open, one third full unlabeled bottle of Coke. Further observation revealed calcium buildup on ice dispenser; black particles floating amongst ice in cooler at nurses' station, and the scoop laid on a towel where the cooler sat.On 02/23/26 at 09:40 AM, an observation of the East dining room revealed calcium buildup on the juice machine, and juice splatter behind the dispenser and on the wall next to juice machine. In the small refrigerator, there was an undated and unlabeled container with a spoon inside, partially full of some type of green dessert, and a [NAME] single serve applesauce, opened with no name or open date. The inside of the refrigerator was dirty. There was a container of rice casserole in a Rubbermaid container with no name or date. The lower cabinet near the drink serving area had food crumbs and particles, the second drawer had loose coffee grounds and the trash cabinet, and under the sink had discoloration from leakage, grounds, spills, and peeling laminate present with exposed wood.On 02/24/26 at 07:53 AM, the dietary aide in the [NAME] kitchenette plated food. Wearing the same pair of gloves, the aide touched the scoop of the eggs, picked up two meal tickets and set them back down on the counter, then picked up bread, touching the bread, and placed it on the plate. The aide then removed her gloves but did not perform hand hygiene. She put on new gloves and took a container of food from another staff, rearranged more meal tickets, touched the egg scoop and the hashbrown scoop, and while wearing the same gloves, picked up toast with her hands and buttered it. She set the toast down, grabbed two clean plates, then picked up the toast with the same soiled gloves and placed the toast on the plate.On 02/24/26 at10:04 AM, the [NAME] kitchen dining area ice cooler had the scoop laying directly in the ice, and dirty cups and pitcher on the cart. The cart had a sign that stated no dirty dishes on this rack.On 02/24/26 at 10:15 AM, in the East kitchenette, the condiments cabinet area had dried liquid spills and crumbs. There were baskets and food debris on floor as well as a thermometer. Under the sink was dried brown stains from liquids or leaks, and dried black chunks of an unknow substance. The trash compartment had food debris, crumbs, and laminate missing exposing raw wood. The refrigerator had a food container with a green dessert. The container had a plastic spoon in it laying on the food, and was unlabeled and undated. There was also a plastic container with rice casserole in it without a date or name who it belonged to.On 02/24/26 at 10:35 AM, the East kitchenette serving area was visibly soiled under the sink with brown and spots with black debris of unknown substance around the buckets of liquid cleaner in the cabinet below the sink. The counter had an opened bag hot dog buns with no date or label on them. The East dining area ice and water machine appeared to have rust on the drain/drip rack, and there was water deposits or calcium build up on the metal dispenser area on the outside of the machine.On 02/24/26 at 10:00 AM, observation revealed a tray of food for Resident (R) 50 sat on top of the serving table. It had a bowl of oatmeal with a plastic cover, and a plate with a plastic cover that contained eggs, bacon, and toast.On 02/24/26 at 10:50 AM, R50's tray remained on top of the service table. Dietary CC measured the temperature of the food items upon request. The temperatures were as follows: oatmeal was 95 degrees Fahrenheit (F.), the eggs were 76 degrees F., and the bacon was 77 degrees F. Dietary CC confirmed the temperatures were not appropriate holding temperatures for the food items and stated the tray would be discarded at 11:00 AM if the resident did not eat it before then.On 02/24/26 at 11:55 AM, upon request, Dietary DD discarded R50's food tray.On 02/24/26 at 11:59 AM, Dietary CC brought the food to the kitchenette area on a cart. Dietary CC put gloves on but did not perform hand washing prior to putting on the gloves. With gloved hands, Dietary CC removed the covered food containers and set them up on the steam table. Dietary CC left the steam table area and removed her gloves but did not perform hand hygiene after removal. She made a phone call, and without washing her hands or donning gloves, she resumed removing covers on food containers and placed them in servicing area. Dietary CC then placed tongs and spoons in the food containers. Without performing hand hygiene, Dietary CC then put on clean gloves and began to serve the food.On 02/25/26 at 07:48 AM, observation of the East end dining area revealed the area was still dirty; The condiments cabinet, trash cabinet, and under the sink area was unchanged from the previous day. The trash cabinet had additional trash noted.On 02/25/26 at 09:03 AM, the [NAME] side dining area was unchanged from the previous day's observations.On 02/23/26 at 08:31 AM, Dietary CC stated the dietary aides were responsible for cleaning the kitchenettes and the dining area service station. She said there was no one in the facility to clean on the weekends though so it would get messy. Dietary CC said she would clean the area.On 02/25/26 at 10:34 AM, Dietary BB stated in the kitchenettes dietary aides are to wipe down the beverage area, around the steam table, and the dining tables, before and after each meal, and as needed throughout the day. Dietary BB stated the floor-cleaning duties are shared with housekeeping, due to them getting off their shift by 6pm each night. Dietary BB stated that it was standard practice to remove the trash can while scraping plates and emptying items into trash can so that food was not spilled. The facility's Food Receiving and Storage policy, dated October 2017, documented food services, or other designated staff, will maintain clean food storage areas at all times. Dry foods that are stored in bins will be removed from original packaging, labeled and dated (use by date). Such foods will be rotated using a first in - first out system. All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date).

The facility identified a census of 65 residents. The sample included 16 residents with three sample residents reviewed for Hospice services. Based on record review and interview. The facility failed to ensure the collaboration of care between Resident (R) 7 and R50's hospice provider and the facility which included the hospice provider contact information, the services the hospice provider would provide to the residents, the supplies, equipment and medications the hospice provider would provide, as well as how often hospice staff members would visit the facility.Findings included:1. R7's Orders tab of the Electronic Medical Record (EMR) documented a physician's order, dated 01/06/26, for a referral for hospice services. The EMR lacked an order to admit to Hospice services.R7's Care Plan, dated 01/07/26, directed staff to adjust provision of activities of daily living (ADLs) to compensate for resident's changing abilities. The plan directed staff to encourage resident participation to the extent the resident wishes to participate. The plan directed staff to consult with physicians and Social Services to have Hospice care for residents in the facility. The plan directed staff to encourage support systems of family and friends. The plan directed staff to work cooperatively with hospice team to ensure the resident's spiritual, emotional, intellectual, physical and social needs are met. The plan directed staff to work with nursing staff/hospice staff to provide maximum comfort for the residents. R7's plan lacked staff direction on the services the hospice provider would provide to the residents, the supplies, equipment and medications the hospice provider would provide, as well as how often hospice staff members would visit the facility.On 02/23/26 at 11:20 AM, R7 sat in a high-back wheelchair in his room. He had a soft touch call light near him, on the dresser. There was a fall mat folded up and leaning against the wall.2. R50's Orders tab of the EMR documented a physician's order, dated 10/15/25.R50's Care Plan, which was revised on 02/02/26, directed staff she was on end-of-life support. The plan directed staff to have residents participate in activities as tolerated, the plan directed staff to assist with supporting ADL function of ambulation and mobility to the extent needed. The plan directed staff to keep her comfortable to the extent possible. R50's plan lacked staff direction on the services the hospice provider would provide to the residents, the supplies, equipment, and medications the hospice provider would provide, as well as how often hospice staff members would visit the facility.On 02/25/26 at 11:03 AM, Certified Nurse Aide (CNA) N stated typically the nurse would notify the aide who was on hospice. CNA N stated the nurse would tell them which days the hospice aide would be here to give the hospice resident their shower. CNA N stated she could not say what hospice provided as far as supplies and equipment, but the nurse did know.On 02/25/26 at 11:10 AM, Licensed Nurse (LN) I stated that each resident on hospice had a book that had the hospice provider's plan of care that included the medications, supplies, equipment, and when and how often hospice staff would make visits. LN I stated the hospice book had all the hospice information in it and did not feel it needed to be included in the resident's person-centered plan.On 02/25/26 at 12:10 PM, Administrative Nurse D stated she expected the nurse to inform staff when a resident was on hospice as well as telling staff what equipment, supplies and how often hospice staff would visit. Administrative Nurse D stated that the residents plan of care should include all the information such as the medications, supplies, equipment, and what hospice staff would visit and how often they would visit. Administrative Nurse D verified there was not an order for hospice in R7's EMR and stated the order was likely in the hospice binder. She stated the information in hospice's binder was not entered into the residents' EMR until after the resident passed or when the hospice event ended.The facility policy Palliative/End-of Life Care - Clinical Protocol, dated March 2018, documented the physician and staff will identify individuals who desire or are likely candidates for palliative care; for example, those with a known terminal illness or end-stage condition (that is, a condition that has resulted in substantial functional dependency, impairment and/or medical instability and continued decline anticipated, regardless of whether medical treatments are rendered). The physician will review the resident's decision-making capacity and support the resident's participation in the plan to the extent possible. The interdisciplinary assessment of the resident and the family is the basis of the individualized plan. The assessment will include at least: documentation of disease status, including diagnosis and prognosis; documentation of co-morbid medical and/or psychiatric conditions; functional status; strengths; concerns, goals, and values of the resident and family; preferences and documentation for end-of-life decisions and care; and appropriateness of hospice referral. Comprehensive assessment will recur on a regular basis and in response to significant changes of condition, or a change in resident and family goals and wishes.

The facility reported a census of 65 residents. The sample included 16 residents. Based on observation, interview and record review, the facility failed to use appropriate infection control practices related to hand hygiene, respiratory equipment, Enhanced Barrier Precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms which employ targeted gown and glove use during high contact care), and indwelling catheter (tube placed in the bladder to drain urine into a collection bag) care.Findings included:1. On 02/23/26 at 10:37 AM, Resident (R)30 was in her room in bed, with the catheter bag attached to her bed. A sign for EBP was on the door. There was a bin for personal protective equipment (PPE- gowns, face shields and/or eyeglasses/goggles, and gloves), but there were no gowns in the bin.On 02/24/26 at 09:10 AM, R30 sat at the dining room table drinking her chocolate milk, the catheter bag was hanging outside of the dignity bag and catheter bag was touching the floor.On 02/24/26 at 09:20 AM, Certified Medication Aide (CMA) S assisted R30 back to her room. R30's catheter bag remained dragging on the ground as CMA S wheeled her wheelchair.On 02/25/26 at 07:42 AM, Certified Nurse Aide (CNA) N unhooked the catheter bag and placed the bag on the floor and drained the urine from the catheter tubing into the bag. CNA N then hooked the bag on the foot board above the level of the bladder. CNA P entered the room, applied gloves, and attached the bag to the bed at a lower position to be below the level of the bladder. CNA N and CNA P continued taking off R30's brief. CNA N wiped R30 several times and placed the wipes in the trash that CNA P was holding up for her. CNA N removed the soiled brief placed a fresh brief under R30 while CNA P held her to her side. They adjusted the brief and fastened it. CNA N and CNA P each took a pant leg and put her legs in the pant leg. CNA P put the catheter bag through the pant leg. Both CNAs rolled R30 as they pulled her pants up and placed the sling under her. The CNA's attached the sling and lifted her with the mechanical lift. CNA N removed R30's gown, then applied the deodorant and applied the shirt. Throughout all this there was no hand hygiene or glove changes. No gown was worn throughout the procedure.On 02/25/26 at 10:00 AM, CNA P stated she was aware that the catheter had to be below the level of the bladder. CNA P also stated that the catheter bag should never touch the floor. She said she was not aware that her gloves had to be changed and hand hygiene performed while doing cares. CNA P stated she would normally wait until she was finished with resident's care then do hand hygiene when she left. CNA P did not know if she should wear a gown when providing cares for a resident with a catheter.On 02/25/26 at 10:00 AM, Licensed Nurse (LN) I stated she expected staff to perform excellent infection control when dealing with a catheter. She stated the bag should never be above the level of the bladder and should never touch the floor; hand hygiene and glove changes should be performed when touching something dirty prior to touching something clean.2. On 02/23/26 at 11:26 AM, R27's oxygen tubing was wrapped around the handle of her wheelchair. R27 laid in bed at that time with her oxygen on.On 02/24/26 at 08:08 AM, R27's oxygen tubing remained wrapped around the handle of her wheelchair.On 02/25/26 at 10:00 AM, CNA P stated when she assisted a resident with oxygen out of bed or transferred them to a chair or back to bed, she wound the tubing up and laid it on something. She was not aware of a bag or sanitary container to place the tubing.On 02/25/26 at 10:00 AM, LN I stated she expected staff to place oxygen tubing in a bag when not in use.On 02/25/26 at 10:48 AM, Administrative Nurse D stated she expected staff to provide good peri care and catheter care and wear the proper PPE for EBP. She said the catheter should never be above the bladder or touch the ground and staff should always do good hand hygiene and change gloves when they touch anything dirty. Administrative Nurse D said oxygen tubing should be kept in a bag when not in use to avoid contamination. The policy Azria Catheter Care, Urinary documented the catheter drainage bag is to be kept off of the floor. Position the catheter drainage bag lower that the bladder at all times to prevent urine from flowing back into the urinary bladder.The policy Azria Handwashing/Hand Hygiene documented to preform hand hygiene after removing gloves, and after touching a contaminated area of the body or coming into contact with body fluids.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 65 residents; the sample included 16 residents which included one resident reviewed for communication-sensory. Based on observation, interview, and record review the facility failed to provide necessary hearing treatments and failed to maintain the hearing devices for Resident (R) 21.Findings included:-R21's Electronic Health Record (EHR) revealed a diagnosis of cognitive communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness), and a need for assistance with personal care.R21's Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The assessment documented R21 was independent for putting on his footwear. He needed supervision or touching assistance for bathing and required set-up or clean-up assistance for all other activities of daily living (ADL). The assessment also documented that R21 had highly impaired hearing.R21's Care Plan (CP), had a revised intervention, dated 04/06/22, which instructed staff to anticipate and meet R21's needs, as needed.R21's CP, dated 12/03/25, lacked documentation related to his impaired hearing.R21 had an audiology (hearing) report, dated 12/22/25, which documented R21 had impacted cerumen (earwax).The facility's Team Health: Standing Orders for Skilled Nursing & Long-Term Care Units, dated 04/24/24, documented a standing order for Cerumen Impaction-Debrox (a medication used to remove excessive ear wax) 5-6 drops twice daily for three days and then flush the ears with warm water and a bulb syringe.R21's EHR revealed a standing order, dated 12/23/25, for Debrox Solution 6.5 %, instill five drops in both ears one time a day for wax build up for three days. May use up to 10 drops per instillation. Flush the affected ear with water at end of third day.R21's December 2025 Medication Administration Record (MAR) revealed that Debrox solution had been administered on 12/03/25, 12/04/25, 12/05/25, 12/23/25, 12/24/25, 12/25/25 and 12/26/25. Review of R21's progress notes lacked documentation that the facility assessed effectiveness of the Debrox treatments performed in December 2025.R21's MAR for January 2026 and February 2025 lacked evidence that he received Debrox treatments.Observed on 02/23/26 10:58 AM, R21 would move closer, and he kept tilting and turning his head from side to side when he was asked questions. R21 reported he had trouble hearing and it was due to wax build up in his ears.On 02/24/26 at 08:43 AM, R21 reported he had hearing aids, but they did not work. He also reported that staff would clean his hearing aids occasionally, but not recently. On 02/24/26 at 11:54 AM, Certified Nurse Aide (CNA) M stated she would make sure hearing aids were functional when she assisted the resident with cares, and if they did not work, she would then notify the nurse. CNA M also said that if the hearing aids worked and the resident still could not hear, she would then notify the nurse, and the nurse would then clean the resident's ears.On 02/24/26 at 12:03 PM, Licensed Nurse (LN) H, stated that she would verify that hearing aids worked and if there was an issue with them, she would notify the director of nursing (DON). LN H also said that R21's ears were cleaned regularly.On 02/24/26 at 12:13 PM, administrative Nurse D stated that she expected staff to have provided daily verification that the hearing aids were fully operational. Administrative Nurse D also said that if there was a problem with the hearing aids, staff were expected to notify the assistant director of nursing (ADON) or DON for coordination to repair or replace the hearing aids. She also said that it was expected that nursing would monitor and report any hearing concerns to the provider.The facility policy Hearing Impaired Resident, Care of, dated February 2018, documented staff would assist the resident (or representative) with locating available resources, scheduling appointments and arranging transportation to obtain needed services. The policy also documented that staff would assist residents with care and maintenance of hearing devices.

The facility identified a census of 65 residents. The sample included 16 residents with five residents sampled for unnecessary medications. Based on observation, interview, and record review, the facility failed to inform Resident (R) 27 or her representative about the risk and benefits of taking an antianxiety (a class of medications that calm and relax people), antidepressant (a class of medications used to treat mood disorders), and antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality).Findings included:- R27's Electronic Medical Record (EMR) revealed the following diagnoses: anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), depressive disorder (major mood disorder that causes persistent feelings of sadness), and drug induced dyskinesia (inability to execute voluntary movements)R27's 07/19/25 Annual Minimum Data Set (MDS), documented a Brief Interview for Mental Status (BIMS) of 15, indicating intact cognition. The MDS recorded R27 took an antipsychotic, antidepressant, and antianxiety medications.R27's Psychotropic Drug Use CAA documented R27 received high risk medications; two antidepressants and anti-anxiety medications on one or more days of the lookback period. Risk factors included falls and injuries related to falls.R27's Care Plan documented R27 took an antidepressant for depression, dated 10/13/23. The plan noted R27 took an antianxiety medication for anxiety, dated 12/05/23, and directed staff to educate her family and her on the risks and benefits and the side effects of the medication. R27's Care Plan documented she took an antipsychotic medication, dated 07/18/24.R27's Physician's Orders documented an order for Lexapro (antidepressant) 10 milligrams (mg) one time a day for depression, start date 03/19/24.R27's Physician's Orders documented an order for haloperidol (antipsychotic) tablet 1 mg one time a day for dyskinesia. Take at 11:00 AM, start date 12/18/25.R27's Physician's Orders documented an order for trazodone 75 mg by mouth at bedtime for dyskinesias, start date 04/10/25.R27's Physician's Orders documented an order for Klonopin (antianxiety) 0.5 mg by mouth two times a day for anxiety, start date 05/30/24.R27's clinical record lacked evidence of informed consent regarding Lexapro, haloperidol Trazodone, or Klonopine.On 02/23/26 at 11:30 AM, R27 laid in bed with her oxygen on. She had just woken up, and she reported she usually slept until about 11:00 AM.On 10/07/25 at 11:37 AM, Licensed Nurse (LN) L stated she was unaware of what the policy was when a resident received psychotropic medication.On 10/07/25 at 11:38 AM, Administrative Nurse D stated that she or another nurse completed the Psychotropic Evaluation and notified the family when a new psychotropic medication was prescribed. She said the facility had a physician's assistant (PA) that completed psychiatric medication management and put in a note about the medications, but the PA did not see R27 because R27 saw an outside provider, so no notes were completed for her. Administrative Nurse D said the facility also did not do a psychotropic consent because the off-site provider would get the consent.The facility policy for Azria Antipsychotic Medication Use, undated, documented antipsychotic medication will be prescribed at the lowest possible dose for the shortest period of time and are subject to gradual dose reduction and review.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 68. The sample included 4 residents in the sample for reviews of misappropriation of medications. Based on observations, interview and record review the facility failed to ensure Resident (R) 1 remained free from misappropriation of medications, when on 02/04/24 Licensed Nurse D removed R1's second card of three with 45 tablets of hydrocodone (medications used for pain) 10-325 milligrams (mg) from the facility. The deficient practice placed R1 at risk for missed medication, unrelieved pain, and further misappropriate of medications.
Findings included:
- The Physicians Orders date 03/4/25 for R1 revealed the following diagnosis paraplegia incomplete paralysis characterized by motor or sensory loss in the lower limbs and trunk) muscle spasms (involuntary contractions of a muscle) lupus (autoimmune disease is only condition hat causes the immune system believe the body's tissue are foreign pathogens and attacks the tissues)
The Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score 15 indicating intact cognition. R1 dependent on staff for all Activities of Daily Living ADL, use of medications opioid for pain.
The Annual Minimum Data Set (MDS) dated [DATE] revealed there were no changes from Quarterly MDS.
The Care Plan with a revision date of 02/06/25 revealed R1 experienced acute and chonic pain related to lupus and chronic back pain related to vertebral fracture. R1 had a physcians order for hydrocodone with acetaminophen to given as needed for pain. Staff were to monitor and record pain characteristic every shift and as needed.
The Pain Assessment dated 02/12/25 revealed R1 had pain rated at a eight a few weeks ago when R1 had a urinary tract infection which was constant for three hours then stopped for about an hour and then started again. The pain does not affect R1's mood.
The Physicians Medication Orders dated 10/13/24 indicated hydrocodone- acetaminophen oral tablet 10-325 milligrams (mg) give one tablet by mouth every six hours as needed for pain that range from six to nine. Fentanyl patch (transdermal patch that provides pain medication through the skin).
Observation on 03/06/25 at 11:35 AM R1 laying in her bed propped on her right sided no facial grimaces of pain. R1 denied she was in pain at this time. R1 stated that she was aware that on her cards of pain medicatins was taken from the facility. She stated that she did recieve her pain medications.
Review of the facility investigation on missing narcotics revealed that LN G had worked on the east unit on 03/01/25 through 03/02/25 on night shift. On 03/05/25 LN G returned to work and noticed a card of hydrocodone was missing. LN H notified the unit manager which then notified Administration Nurse D of the missing pain medication. LN G was placed on suspension pending investigation and notified to come in for a urine drug screening. LNG called the facility and self-confessed to taking the card of hydrocodone 10 mgs and tried to replace it with the 30 tabs of hydrocodone.
02/07/25 Pharmacist GG completed an audit on all scheduled medication in the facility with no other diversion discovered.
An interview on 03/06/25 at 01:10 PM with LN H revealed she had given the last dose on card one on 01/28/25. The resident had three cards of hydrocodone the first card was finished on 01/28/25 and she removed the card and the count sheet gave it to the unit manager. LN H stated she pulled the second card with the count of 60 tabs with the count sheet placed in the medication cart. LN H stated she was for a couple of days and upon her return on 03/05/25 R1's card was number three not the second card that was started She notified the unit manage regarding the missing second card and a search started for the missing card. LN H revealed she worked the same hall opposite of LN G and noticed a new card of 30 tabs of hydrocodone had been ordered.
An interview on 03/11/25 at 09:40 AM, Administration Nurse D revealed her expectations when a nursing staff suspect missing medication was to report it immediately so an investigation can be completed.
The undated Administering Medication policy revealed medications are to be administered in a safe and timely manner and as prescribed. If a resident uses prn (as needed) medication frequently, the attending physician and interdisciplinary care team with support from the consultant pharmacist as needed, shall reevaluate the situation exam the individual as needed, determine if there is a clinical reason for the frequent prn use.
The facility failed to ensure Resident (R) 1 remained free from misappropriation of medications, when Licensed Nurse D removed R1's a card with 45 hydrocodone (medications used for pain) on 02/04/24. The deficient practice place R1 at risk for missed medication, uncontrolled pain and further misappropriate of medications.

The facility reported a census of 64 residents. Based on observation, interview, and record review, the facility failed to maintain and/or dispose of garbage and refuse properly in a sanitary condition to prevent the harborage and feeding of pests.
Findings included:
- Initial tour of the kitchen facilities on 04/09/24 at 09:50 AM with Dietary Staff H, revealed that the outside dumpster area was littered with medical waste that included soiled bandages and disposed gloves and that the dumpster lid was in the open position.
On 04/09/24 at 09:53 AM, Dietary Staff H stated that she was unaware of the requirement that kitchen staff were responsible for the cleanliness of the area around the dumpster or that the dumpster lid was to always remain closed.
On 04/09/24 at 09:58 AM, Administrative Nurse B stated that her expectation was for all staff that takes trash to the dumpster to ensure that the area around the dumpster is kept free of any debris and that the lid of the dumpster should be closed at all times. The presence of medical waste on the ground outside the dumpster was an unacceptable practice as it had the potential to attract pest animals and could be a potential infection control concern.
On 04/09/24 at 10:25 AM, Housekeeping Supervisor J stated that she was unaware of the requirement that the dumpster area be free of debris and that the lid of the dumpster remain closed when not in use.
The facility failed to provide a policy related to garbage and refuse handling and disposal as requested on 04/09/24.
The facility failed to provide sanitary garbage and refuse containers that were maintained in a sanitary condition free of debris with lids or otherwise contained and covered. This deficient practice had the potential to lead to harborage and feeding of pest animals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 64 residents which included 16 residents sampled. Based on observation, interview and record review, the facility failed to provide a sanitary and safe environment to prevent cross contamination and infection related to provision appropriate use of personal protective equipment (PPE) for 13 residents (R)1, R 4, R 11, R 19, R 25, R 26, R 37, R 38, R 40, R 48, R 50, R 55, and R 57, which required enhanced barrier precautions to be in place and available for nine residents with catheters (R 1, R 26, R 11, R 55, R19, R 37, R 50, R 04, R 25), five residents with wounds (R 38, R 40, R 19, R 50, and R 25), two residents with percutaneous enteral gastrostomy tube (PEG- artificial opening through the abdominal wall where a catheter is placed to supply nutrition), (R 37 and R 48), four residents (R 55, R 38, R 48, and R 57 of the 13 identified residents that required enhanced barrier precautions during care received therapy.
Additionally, the facility failed to provide safe and sanitary handling of glucometer (a device used to measure glucose/sugar content of the blood) between residents hand hygiene with don (application) and doffing (removal) of gloves, to prevent cross contamination and infections for residents (R)34, R 56, and R 113 related to glucometer use.
Furthermore, the facility failed to provide appropriate catheter care and hand hygiene for R1 and R 25 to prevent infection and prevent cross contamination.
Findings included:
- On 04/11/24 at 09:46 AM, Licensed Nurse (LN) P reported he had three blood sugars order for two hours after meals. He stated that each resident had their own glucometer to test their blood sugar, which was maintained in a closed container and stored in their rooms. LN P stated the facility kept a community glucometer contained in a closed plastic container stored in the treatment cart to use in the event of a new admission and/or inability to locate the resident's personal glucometer. He removed the community glucometer from the treatment cart and examined the content of the box which contained the glucometer, lancets (device to stick finger to obtain a blood sample), container of test strips, cotton balls, and alcohol swab. LN P stated when the staff used the community glucometer, they were required to sanitize the glucometer after each use and between each resident to prevent cross contamination and prevention of blood borne pathogens. He explained further the wipes for sanitizing the glucometer were in the drawer of the medication cart. LN P verified the order for Resident (R) 34 on the electronic health record (EHR). The order directed staff to check the resident's blood sugar fasting, two hours after meals, call the physician if the resident's blood glucose/sugar reading was below 60 and/or above 350. LN P proceeded to the resident's room and determined the resident did not have his individual glucometer present in the room. He returned to the cart and removed the Community glucometer container, stating he could not locate the resident's glucometer in his room. LN P reentered the room, retrieved gloves from the box by the door and applied the gloves without performing hand hygiene. Upon inquiry, he stated he should have washed his hands prior to applying the gloves. He placed the glucometer container on the resident's dresser, then removed the gloves and disposed of them in the resident's trash can. He provided hand hygiene and applied gloves. He then picked up the glucometer container from the dresser with his gloved hand. He reached into his scrub uniform pocket with his gloved hand and pulled out his cell phone and explained he needed to shut his phone off. He swiped his gloved hand across the cell phone screen and replaced the cell phone in his pocket. LN P then picked up the glucometer with his gloved hand, approached the resident and explained that he was going to check the resident's blood sugar. The resident agreed and LN P cleansed the third finger of the resident's left hand with an alcohol swab, while continuing to wear the same gloves. He then used the lancet to obtain a blood sample which he then applied to the test strip, applied a cotton ball to the resident's sampled finger while continuing to wear the same gloves. The nurse removed his gloves, performed hand hygiene, disposed of the paper towels in the resident's trash can, placed the glucometer in the container which sat directly on the resident's dresser, and took it to the treatment cart, opened the drawer and placed it in the cart without sanitizing the glucometer or the container. He proceeded to set the container with the glucometer directly on top of the medication cart, opened the drawer of the cart and insert the glucometer container in the drawer with other stored medications. LN P did not sanitize the surface of the medication cart nor the glucometer or its container. He then proceeded to roll the medication cart down the hall and checked on R 56 . LN P reported he would come back to check her blood sugar because her floor was wet. He rolled the medication cart across the hall to R 113. He reported he could not locate the resident's glucometer in her room. He then removed the community glucometer from the medication cart and proceeded to R 11's doorway. Upon inquiry he agreed the glucometer and container , and med cart had not been sanitized after its use with R56 as it should. He returned to the cart, opened the bottom drawer and reported the cart lacked Sani-wipes to sanitize the glucometer, the container and contents, and the medication cart to prevent cross contamination. At that point Certified Medication Aide(CMA) I walked by, and LPN P asked her to get the Sani-wipes. CMA I provided sanitizing wipes with a two-minute dwell time. LPN P removed a wipe and swiped the glucometer a coupe of times and replaced the glucometer back in the unsanitized container. He stated he should have sanitized the glucometer, medication cart top, the resident's dresser, washed his hands prior to applying gloves and upon removal of gloves to prevent cross contamination and prevent the spread of infections.
On 04/11/24 at 02:45 PM, Administrative Nurse B verified that each resident should have a plastic container to store their individual glucometer and supplies to obtain their blood sugar. The facility maintained a container with a glucometer and supplies for use with new admits. The staff should sanitize their hands before applying gloves and after removing gloves. There should be a barrier between a surface where the glucometer rests and while the glucometer is wrapped in the sanitizing wipes to remain wet for the dwell time to prevent infection and cross contamination.
The facility policy titled Obtaining a Fingerstick Glucose, dated 10/2011, documentation included always ensure that glucose meters intended for reuse are cleaned and disinfected between resident uses. Clean and disinfect reusable equipment between uses according to current infection control standard. Remove gloves and discard into designated container and perform hand hygiene.
The facility failed to provide a sanitary and safe environment to prevent cross contamination and infection related to the provision appropriate use of personal protective equipment (PPE) and the safe and sanitary handling of glucometer (a device used to measure glucose/sugar content of the blood) between residents hand hygiene with don (application) and doffing (removal) of gloves, to prevent cross contamination and infections for residents (of the facility.
- On 04/09/24 at 09:30 AM, during resident screening the following residents were noted to lack Enhanced Barrier precautions (EBP) or the readily available Personal Protective Equipment (PPE) nor signage during the resident screening process of the following as required:
1. Nine residents with catheters (R 1, R 26, R 11, R 55, R19, R 37, R 50, R 04, R 25),
2. Five residents with wounds (R 38, R 40, R 19, R 50, and R 25)
3. Two residents with percutaneous enteral gastrostomy tube (PEG- artificial opening through the abdominal wall where a catheter is placed to supply nutrition), (R 37 and R 48)
4. Four residents (R 55, R 38, R 48, and R 57 of the 13 identified residents that required enhanced barrier precautions during care received therapy.
On 04/10/24 at 02:35 PM, Administrative Nurse B reported the facility had not implemented Enhanced Barrier precautions for the resident on 04/01/24 to date for the residents with catheters, wounds, percutaneous enteral feeding tubes, and residents that received therapy that should have PPE enhanced precautions as required by Centers for Medicare and Medicaid Services (CMS). She reported she did not think the facility had to fully implement Enhanced Barrier Precautions for 30 days after the 04/01/24 directive.
On 04/11/24 at 09:46 AM, Licensed Nurse P reported that he was not aware of the need for the use of EBP for residents with feeding tubes, catheters, and wounds until yesterday (04/10/24). He stated the gowns were not accessible in the rooms and the signage was not up until then as well.
On 04/11/24 10:21 AM, therapy staff V reported she had direct contact with residents during therapy. She reported she had one resident she provided direct care for that had a feeding tube. Therapy staff V stated she did not know the resident had to utilize EBP including PPE until the day before. She stated she always wore gloves and a mask, but did not wear a gown until yesterday when the signs were put on the door, and full PPE was not available.
On 04/15/24 at 3:30 PM, Administrative Nurse B reported 13 residents (R)1, R 4, R 11, R 19, R 25, R 26, R 37, R 38, R 40, R 48, R 50, R 55, and R 57, which required enhanced barrier precautions to include available PPE supplies to include gowns, and signage as specified in the 04/01/24 CMS memo was not in place until 04/10/24.
The facility policy titled Enhanced Barrier Precautions, dated 08/2022 documentation included EBPs are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of multiple drug resistant organisms (MDRO)'s to staff hands and clothing. Examples of high contact resident care activities requiring the use of gowns and gloves for EBPs include device care such as urinary catheters, feeding tubes, wound care, during providing hygiene, transfers during assistance with bathing and when working with residents in the therapy gym. Specifically, while assisting with transfers and mobility. Signs are posted on the door or wall outside the resident's room indicating the type of precautions and PPE required.
The facility failed to provide a sanitary and safe environment to prevent cross contamination and infection related to provision EBP related to the availability and appropriate use of personal protective equipment (PPE) for the residents of the facility.
- The Physician Order dated 03/22/24 indicated Resident (R)50 had the following diagnoses of retention of urine unspecified (Lack of ability to urinate and empty the bladder) urinary catheter (insertion of a catheter into the bladder to drain the urine into a collection bag).
The admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of three, indicating severely impaired cognition. The Activities of Daily Living (ADL's) indicated R 50 required extensive assistance with two or more person for bed mobility, transfers, and toilet use.
The Quarterly (MDS) dated [DATE], indicated a BIMS score of 12, indicating moderate impaired cognition. R50 required an indwelling urinary catheter.
The Care Plan dated 08/11/23, revealed F50 required the need of a indwelling foley catheter for terminal illness and urinary retention. Staff were to ensure the catheter bag was below the level of the bladder to minimize the risk of infection. Staff were to provide catheter care per facility policy.
The Enhanced Barrier Precautions dated 04/10/24, revealed R50 required the Enhanced Barrier Precautions due to wound and catheter. Staff were to wear gloves and gowns for all dressing, changing brief, transfer, toileting, peri-care, catheter care/ bathing/showering, hygiene changing lines and wound care.
On 04/10/24 at 10:58 AM, observed Certified Nurse Aide (CNA) C provided catheter care. CNA C did not wash her hands prior to applying gloves and did not apply a gown before starting the cleaning of R50's catheter. CNA C used disposable wipes to cleanse the penis and catheter. CNA C placed the soiled wipes on top of the package of the clean wipes. CNA C finished the catheter care, then failed to wash her hands after removing her soiled gloves and before leaving R50's room.
On 04/10/24 at 11:04 AM, interview with CNA C revealed she was not aware of the guidelines for catheter care and proper hand hygiene.
On 04/11/24 at 01:30 PM, Interview with Licensed Nurse (LN) F revealed the staff now must follow the Enhanced Barrier Precautions, that indicated staff must wear a gown and gloves while providing care of catheters.
On 04/11/24 at 02:35 PM, Interview with Administrative Nurse C revealed the nursing staff should perform hand hygiene with either alcohol-based hand sanitizer or soap/water before the procedure and with every glove change, then at the end of the procedure.
The facility's policy for Catheter Care Urinary dated 2001, revealed the purpose of this procedure is to prevent urinary catheter-associated complication, including urinary tract infections. The Routine Perineal Hygiene (guidance is to) place the clean equipment on the bedside stand or overbed table. Perform hand hygiene with non-dominant hand and retract the foreskin of uncircumcised male residents. Maintain the position of this hand throughout the procedure. Cleanse the glans using circular strokes from the meatus outward with a clean washcloth or wipe, rinse using the about technique, return foreskin to normal position. Perform hand hygiene after finishing catheter care.
The facility failed to provide this resident, who required a urinary catheter, infection control techniques to prevent possible urinary system infections.
- R1's Electronic Medical Record (EMR) revealed diagnoses that included acute kidney failure (a sudden decline in kidney function that occurs within a few hours or days), neuromuscular dysfunction of bladder (the muscles that control the flow of urine out of the body do not relax and prevent the bladder from fully emptying), and urinary tract infection ([UTI] infection of any part of the urinary system, including kidneys, ureters, bladder, and urethra).
R1's Annual Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The resident required extensive to total assistance for all cares. R1 had an indwelling urinary catheter (insertion of a catheter into the bladder to drain the urine into a collection bag).
The Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA) dated 06/22/23, documented risk factors included recurrent UTIs and injury from use of the catheter.
The Bladder/Bowel care plan, dated 01/27/23, revealed R1 required a urinary catheter, and guided staff to provide catheter care policy.
Observation on 04/09/24 at 11:19 AM revealed R1's catheter bag stored top of a dignity bag that was stored directly on the floor.
Observation on 04/10/24 at 10:13 AM, revealed R1's catheter bag hung from the edge of her bed, with dark amber colored urine in the drainage bag, and clear yellow urine with sediment in the tubing.
Observation of 04/10/24 at 01:23 PM, revealed Licensed Nurse (LN) AA donned a gown and pushed the gown sleeves above her wrists. She then washed her hands with soap and water, removed a gait belt from the back of door handle, then donned her gloves and pulled the gown sleeves back down to her wrists. LN AA wiped the catheter tubing with a no-rinse foam soap-soaked gauze, and removed and reapplied a new pair of gloves without performing hand hygiene, removed the spigot from the catheter collection system, emptied the urine from the collection bag into a urinal, then washed the spigot with a no-rinse foam soap-soaked gauze, then saline soaked gauze, then alcohol wipes. She removed her gloves, emptied the urinal into the commode and rinsed the urinal with tap water from the resident's sink. She pulled her sleeves up on her arms, washed her hands with soap and water and removed her gown.
On 04/09/24 at 02:09 PM, R1 reported that she required a urinary catheter because she was unable to urinate.
On 04/10/24 at 01:32 PM, LN AA confirmed no hand hygiene was done when changing her gloves and carrying the urinal to the bathroom and improper infection control techniques.
Interview on 04/10/24 at 02:35 PM, Administrative Nurse B reported wipes should be used for one wipe per swipe for either peri or catheter care. Hand hygiene should be performed with either alcohol-based hand rub (ABHR) or soap/water before the procedure and with every glove change, and with soap/water only at the end of a procedure.
The facility's policy for Catheter care, dated 08/22, revealed the purpose of this procedure is to prevent urinary catheter -associated complications including urinary tract infections. Use aseptic technique when handling or manipulating the drainage system.
The facility's policy for Enhanced Barrier Precautions, dated 08/22 revealed EBPs are used in conjunction with standard precautions and expand the use of Personal Protective Equipment to donning of gown and gloves during high contact resident care activities that provide opportunities for transfer of Multi Drug Resistant Organisms (MDRO) to staff hands or clothing.
The facility failed to provide necessary services to decrease the risk of a urinary tract infection when the staff failed to use proper hand hygiene and Enhanced Barrier Precautions when providing catheter care for resident (R)1.
- Resident (R) 25's diagnoses included neuromuscular dysfunction of bladder (dysfunction of the urinary bladder caused by a lesion of the nervous system), and urinary tract infection (Infection of any part of the urinary system, including kidneys, ureters, bladder, and urethra).
The Significant Change Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The resident was dependent for all cares and had an indwelling urinary catheter (insertion of a catheter into the bladder to drain the urine into a collection bag).
The 11/03/23 Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA), dated 11/03/23, revealed the resident required a urinary catheter.
The care plan, dated 10/13/23, revealed the resident required a urinary catheter.
Revision of the care plan revealed on 04/10/2024, the resident required Enhanced Based Precautions (EBP) related to wound and catheter. Staff were to wear gloves and gowns for all dressing, changing brief, catheter care, emptying catheter, transfers, toileting, peri care, bathing/showering, hygiene, changing linens, and wound care.
The Physician Orders included to check and verify catheter securement was in place and the tubing was free of kinks, two times a day, ordered 04/12/2024.
Observation on 04/10/24 at 10:55 AM revealed Licensed Nurse (LN) M provided urinary catheter care with the assistance of Certified Nursing Aide (CNA) D. CNA D performed hand hygiene upon entry to the room and donned gloves, LN M failed to perform hand hygiene and donned gloves when entering the room. CNA D left the resident's room to retrieve the full body mechanical lift outside the room with neither staff member engaged in enhanced barrier precautions. Staff transferred the resident with the mechanical lift to her bed. CNA D went to the bathroom to retrieve warm/soapy wash cloth while LN M removed the resident's brief at the front and assisted the resident to hold her legs apart. The resident was incontinent of bowels. CNA D wiped the front of the resident, then discarded the soiled washcloth and changed gloves without performing hand hygiene. CNA D retrieved incontinence wipes from the bedside table drawer and initiated peri-care. Staff assisted the resident and the resident positioned to her left side. LN M started cleaning up feces with multiple swipes with the same wipe, LN M changed her gloves without hand hygiene. CNA D removed her gloves and left the resident room for additional supplies and failed to perform hand hygiene. When CNA D returned to the resident's room, CNA D donned new gloves and took the washcloth to the bathroom to make a warm/soapy wash cloth, then walked to bedside and cleaned resident's genitals, then cleaned around the resident's catheter, then wiped the resident's genitals a second time, then cleaned the resident's catheter a second time, folding and /refolding the same washcloth with each pass. CNA D then disposed of the washcloth and changed gloves but failed to perform hand hygiene. LN M removed gloves and left the resident's room to obtain additional supplies and failed to perform hand hygiene. CNA D replaced resident's brief and LN M returned to the room and failed to perform hand hygiene. LN M attempted to place a commercially available adhesive catheter securement device to the resident, but the resident declined this as she had a documented history of adverse reaction to the adhesive. LN M removed her gloves and performed hand hygiene with an alcohol-based hand solution, then left the room. CNA D collected the soiled supplies and removed gloves, then exited the room without performing hand hygiene.
On 04/10/24 at 09:38 AM, R25 stated staff have not put on any full personal protective equipment (PPE) when emptying her catheter bag. She reported she did not have a tubing anchoring/securement device because she was allergic to the anchor, and the facility was to get her a harness type securement device but had not done that yet.
Interview on 04/10/24 at 11:20 AM, CNA D stated she would not have changed anything with the procedure as observed except that staff may have needed extra supplies to prevent having to leave to go get additional supplies. CNA D confirmed that no EBP were in place at the time of catheter/peri care.
On 04/10/24 at 11:18 AM, LN M stated she would not have changed anything with the procedure as observed.
Interview on 04/10/24 at 02:06 PM with LN M confirmed that no EBP was in place at the time of catheter/peri care, and reported it was acceptable to wipe/fold/reuse with wash cloth but not with wipes, confirmed that she had reused wipe to remove BM from resident's skin. Stated that CNA D should not have re-wiped a second time of genitals or catheter with wash cloth because it presented as an infection control concern.
Interview on 04/10/24 at 02:35 PM, Administrative Nurse B reported an expectation for staff that wash cloths should not be used for peri care or catheter care, only for bathing. Wipes should be used for one wipe per swipe for either peri or catheter care. Hand hygiene should be performed with either alcohol-based hand rub (ABHR) or soap/water before procedure, and with every glove change and with soap/water only at the end of a procedure. Residents with catheters should have some sort of securement device for the tubing to be secured to the resident's leg. It is never acceptable for resident to have a catheter without it being secured to the leg.
Interview on at 04/10/24 at 04:05 PM, CNA CC reported there were no special orders in progress for a foley securement device. Walk through with CNA CC of the facility's supply room revealed leg securement straps in house stock.
Interview on at 04/10/24 at 04:25 PM with Administrative Nurse B, informed of above and was unable to provide an explanation as to why a securement device had not been in place prior to location of the device in the facility's supply room.
The facility's policy for Catheter care, dated 08/22, revealed the purpose of this procedure was to prevent urinary catheter -associated complications including urinary tract infections. Use aseptic technique when handling or manipulating the drainage system.
The facility's policy for Enhanced Barrier Precautions, dated 08/22, revealed EBPs are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high contact resident care activities that provide opportunities for transfer of Multi Drug Resistant Organisms (MDRO) to staff hands or clothing.
The facility failed to provide necessary services to decrease the risk of a urinary tract infection when the staff failed to use proper hand hygiene, catheter cleansing, and Enhanced Barrier Precautions when providing catheter care for resident (R)25.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 64 residents which included 16 residents sampled, which included one resident reviewed for bed rail safety. Based on interview, observation, and record review, the facility failed to assess Resident (R)25 for safety and risk of entrapment from bed rail use and failed to ensure R25 obtained informed documented consent from the resident or resident representative prior to installation of the siderails. This deficient practice placed R25 at a risk for uninformed decisions related to the risks and benefits associated with the use of side rails and placed the resident at risk due to possible injury due to bed rail use.
Findings include:
- The Electronic Health Records (EHR) for Resident (R)25 included diagnoses of generalized muscle weakness, reduced mobility, incomplete paraplegia (paralysis characterized by motor or sensory loss in the lower limbs and trunk) and muscle wasting with atrophy (wasting or decrease in size of a part of the body).
R25's Significant Change Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. R25 was dependent on staff for all cares except eating and oral care which required supervision. The MDS lacked documentation related to grab bar use.
The 11/30/23 Activities of daily living (ADL's such as walking, grooming, toileting, dressing and eating) Functional / Rehabilitation Potential Care Area Assessment (CAA), documented R25 required ADL assistance due to functional impairment in activity from generalized weakness and incomplete paraplegia. The CAA lacked documentation related to grab bar use.
The 11/30/23 Pressure Ulcer/Injury CAA documented that R25 had an increased risk of pressure ulcers/injury due to functional impairment and mobility impairment but lacked documentation related to grab bar use for bed mobility.
The Quarterly MDS dated 03/01/24 documented a BIMS of 15 and R25 was dependent on staff for all cares except eating and oral care which required supervision. The MDS lacked documentation related to grab bar use.
The 04/09/24 Care Plan lacked documentation related to the use of grab bars while R25 was in bed.
The physician's orders lacked directions specific for grab bar use.
The EHR Assessments lacked documentation of grab bar safety assessment.
On 04/09/24 at 02:22 PM, R25 revealed that she used grab bars on the bed to help with bed mobility and repositioning with and without staff assistance.
On 04/10/24 at 02:06 PM, Licensed Nurse (LN) M stated that safety assessments should be accessible in the EHR.
On 04/15/24 at 03:33 PM, Administrative Nurse B confirmed R25's EHR lacked a safety assessment for bed rail use.
On 04/15/24 at 03:40 PM, Administrative Nurse B provided a safety assessment performed by Administrative Nurse BB on 04/15/24 and confirmed that no safety assessment existed previously.
On 04/17/24 at 09:40 AM, Administrative Staff A provided a copy of the informed consent from the resident that was dated 04/15/24 and confirmed that no consent had existed previously.
The facility's undated Bed Safety and Bed Rails policy identified bed rails to include side rails, safety rails and grab assistance bars and defined as adjustable metal or rigid plastic bars that attach to the bed. The policy documented that the use of bed rails was prohibited unless the criteria had been met which included resident assessment for potential risks to the resident(s) associated with the use of bed rails and informed consent about the benefits and potential hazards associated with the use of bed rails.
The facility failed to assess R25 for safety and risk of entrapment from bed rail use and failed to obtain informed documented consent from the resident or resident representative prior to installation of the siderails. This deficient practice placed R1 at risk for uninformed decisions related to the risks and benefits associated with the use of a side rail and placed the resident at risk for possible injury due to bed rail use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 64 residents that included 16 residents sampled. Based on observation, record review and interview, the facility failed to maintain Resident (R)20's dignity when staff talked to the resident in a demeaning manner, for R25, when staff failed to close a window when providing incontinence cares, and for R50, that failed to cover the resident's urinary catheter collection bag when in public view.
Findings included:
- The undated Physician Orders, for Resident (R)20 documented diagnoses which included cognitive communication deficit, cerebral vascular accident (stroke is a 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), traumatic brain injury, repeated falls, fractures (broken bones) and other multiple traumas.
The Annual Minimum Data Set (MDS) dated [DATE], documented the resident with a Brief Mental Status Interview, (BIMS) score of 13, indicating cognitively intact. The resident did not exhibit behaviors. Choices about her routine and preferences were very important. The resident was always continent of bowel and bladder. She received medications which included diuretics and antidepressants during the look back period.
The Care Plan, (CP) dated 11/21/23, instructed staff the resident participated in daily activities of interest in the facility. She was outgoing and liked to be involved in community events and activities. The resident did not like conflict.
On 04/09/24 at 12:12 PM, R20 sat in her room in a chair beside her bed. R20 reported that there was a nurse that would speak to her in a demeaning manner, telling her That's not my job Resident (R)20 stated she asked the nurse what was wrong, to which the nurse responded, The resident was lying in their waste. She stated she asked the nurse who was going to take care of the resident to which the nurse stated nursing will. Additionally, she stated she was concerned there are residents in the facility that are confined to their room and cannot help it they cannot control their bowels. If the nurses do not feel like it is their job to clean someone lying in their own waste, then what will happen to them? R20 reported what happened in a meeting and some of the staff came to my room and told me they would take care of the situation. No one has gotten back to me about my report. The girls that took my report said they had other concerns from another resident's regarding the same nurse.
On 04/09/24 at 02:07 PM, Administrative Staff A and Administrative Nurse B confirmed R 20 reported a grievance in the Resident Council Meeting on 03/27/24. The resident reported the grievance to the Activity Director (AD) S, who was also a certified nurse aide (CNA). Administrative Staff A stated she instructed CNA/AD S to interview the resident and obtain additional information to clarify what the resident meant by the nurse stating, that's not my job. Administrative Staff A and Administrative Nurse B confirmed the Grievance Log, lacked inclusion of R 20's grievance/complaint filed on 03/27/24 in Resident Council. Additionally, the facility lacked follow-up with the resident regarding an action plan to address the concern with the resident.
On 04/10/24 at 11:04 AM, Certified Medication Aide (CMA) I reported there was a nurse that was grumpy to other staff members.
The facility's undated Dignity policy documented that all residents were to be treated with dignity and respect at all times and included to promote, maintain and protect resident privacy during assistance with personal care.
The facility failed to protect the dignity of R20 when staff talked to the resident in a demeaning manner.
- The Physician Orders dated 03/22/24 revealed Resident (R)50 had a diagnosis of retention of urine unspecified (Lack of ability to urinate and empty the bladder) and urinary catheter (insertion of a catheter into the bladder to drain the urine into a collection bag).
The admission Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of , indicating severely impaired cognition. The Activities of Daily Living (ADL's) indicated R50 required extensive assistance with two or more persons for bed mobility, transfers, and toilet use.
The Quarterly MDS dated [DATE], indicated a (BIMS) score of 12, indicating moderately impaired cognition. R50 required an indwelling catheter.
The Care Plan dated 08/11/23, revealed F50 required the need of an indwelling urinary catheter for terminal illness and urinary retention. Staff were to ensure the catheter bag was below the level of the bladder and provide catheter care per the facility policy.
The Enhanced Barrier Precautions dated 04/10/24 sign placed on R50's room door, revealed due to R50's wound and catheter, staff were to utilize gloves and gowns for all dressing, changing briefs, transfer, toileting, peri-care, catheter care/ bathing/showering, hygiene changing lines and wound care.
On 04/10/24 at 10:32 AM, observed R50 in bed and the urinary catheter bag hung off his wheelchair. The urinary collection bag did not have a privacy bag attached to the wheelchair or R50's bed.
On 04/10/24 at 02:51 PM, observed R50 in the wheelchair and propelled towards the nurses' station, without a privacy bag attached to the wheelchair Observed Certified Nurse Aide (CNA) D attach a privacy bag to the wheelchair.
On 04/10/24 at 02:51 PM, Interview with CNA D revealed she observed R50 without a privacy bag for the catheter bag and knew R50 required a collection bag, so she obtained one and placed it on the wheelchair.
On 04/11/24 at 01:40 PM, Interview with Licensed Nurse (LN) F revealed that all residents with catheter bags should have a privacy bag.
On 04/11/24 at 02:40 PM, Interview with Administrative Nurse B revealed the expectation for any resident with an indwelling urinayr catheter should have a privacy bag to protect the resident's dignity.
The facility's policy Dignity dated 2001 revealed demeaning practices and standards of care that compromise dignity is prohibited. Staff are expected to promote dignity and assist residents, for example: A. helping the resident to keep urinary catheter bags covered.
The facility failed to provide a privacy bag for R50's indwelling foley catheter to promote dignity.
- The Electronic Health Records (EHR) for Resident (R)25 included diagnoses of generalized muscle weakness, reduced mobility, incomplete paraplegia (paralysis characterized by motor or sensory loss in the lower limbs and trunk) and muscle wasting with atrophy (wasting or decrease in size of a part of the body).
R25's Significant Change Minimum Data Set (MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. R25 was dependent on staff for all cares except eating and oral care which required supervision. R25 had a urinary catheter (insertion of a catheter into the bladder to drain the urine into a collection bag) and was always incontinent of bowel.
The 11/30/23 Activities of daily living (ADL's such as walking, grooming, toileting, dressing and eating) Functional / Rehabilitation Potential Care Area Assessment (CAA), documented R25 required ADL assistance due to functional impairment in activity from generalized weakness and incomplete paraplegia.
The 03/01/24 Quarterly MDS documented a BIMS of 15 and R25 was dependent on staff for all cares except eating and oral care which required supervision. R25 had a urinary catheter and was always incontinent of bowel.
The 04/09/24 Care Plan lacked documentation of instructions for staff to protect R25's dignity during cares.
On 04/10/24 at 10:55 AM, Licensed Nurse (LN) M and Certified Nurse Aide (CNA) D performed incontinence care and catheter care and failed to lower the window blind that was open to a courtyard that was approximately 50 feet by 50 feet and was adjacent to and visible from the main entrance of the building approximately 100 feet away. During the procedure, the resident's lower abdomen and genitals were fully exposed.
On 04/10/24 at 01:42 PM, R25 recalled the incontinence and catheter care that the window blind was open and stated that this bothered her and had a negative psychosocial effect on her feeling of dignity.
On 04/10/24 at 01:50 PM, CNA D confirmed that the window was open during the procedure and stated that window blinds should be closed during procedures in which resident's bodies are exposed.
On 04/10/24 at 02:16 PM, LN M confirmed that the window was open during the procedure and stated that window blinds should be down whenever the resident's body is exposed.
On 04/10/24 at 02:35 PM, Administrative Nurse B stated that the expectation of staff is to close window blinds whenever resident's body is exposed for any reason to protect the resident's privacy and dignity.
The facility's undated Dignity policy documented that all residents were to be treated with dignity and respect at all times and included to promote, maintain and protect resident privacy during assistance with personal care.
The facility failed to protect the privacy and dignity of R25. This deficient practice led to R25's body being potentially exposed to the public.

The facility had a census of 64 residents, which included 16 residents sampled, including one resident reviewed for accommodation of needs related to assistive devices. Based on observation, record review, and interview, the facility failed to ensure Resident (R)11's call light remained within his reach.
Findings included:
- The Electronic Health Records (EHR) for Resident (R)11 included diagnoses of diabetes mellitus type 2 (DM2 - when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), generalized weakness, aphasia (condition with disordered or absent language function) following cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain) and rheumatoid arthritis (RA - a chronic inflammatory disease that affected joints and other organ systems).
The 12/23/23 admission Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 15, which indicates intact cognition. R11 required substantial assistance from staff for all cares except eating, which required setup and supervision.
The 12/23/23 Activities of daily living (ADL's such as walking, grooming, toileting, dressing and eating) Functional / Rehabilitation Potential Care Area Assessment (CAA), documented R11 had an ADL self-care deficit related to impaired balance during transfers, functional impairment during activity, generalized weakness, and decreased safety awareness.
The 12/23/23 Falls CAA documented R11 was at increased risk for falls due to impaired gait (manner or style of walking), impaired mobility, weakness, and physical performance limitations.
The 03/05/24 Quarterly MDS documented a BIMS score of 15, which indicated intact cognition and R11 required substantial/maximum assistance for all cares except eating which required supervision and setup.
The 04/10/24 Care Plan, documented an intervention dated 12/28/23 for staff to place R11's call light within his reach.
On 04/11/24 at 07:52 AM, R11 observed in his bed watching TV waiting for staff to assist him up for the morning. R11 observed to be unable to easily reach call light that was tied to the left upper grab bar on the bed with approximately 8 inches of the call light button's cord hanging. R11 had to reposition himself in the bed with his head pressed against the right grab bar with his neck bent at an unnatural angle and right shoulder hung off the bed so that his left hand could grasp the call light. R11 attempted to grasp at the call light chord three times before being able to successfully hold onto the device and press the button for staff assistance.
On 04/11/24 at 07:55 AM, R11 stated that due to the deformity of his fingers due to RA, he had trouble grasping the call light and/or pressing the button. R11 further stated that due to mobility problems with his left shoulder and arm, he was unable to easily grasp things that were placed above his shoulders. R11 stated that he had advised staff that he wanted an easier way to alert staff for assistance, but none had been provided.
On 04/11/24 at 09:08 AM, Certified Nurse Aide (CNA) D revealed that call lights should be placed near the hands of residents, especially if they have mobility problems. If a resident was unable to press the call light button easily, CNAs could initiate a change to a pressure-pad call light without having to get an order from the nurse on duty, and that the nurse would be notified of the change after it had been completed.
On 04/11/24 at 09:30 AM, CNA N revealed that call lights should be placed near the resident's hands especially if they have mobility problems. If a CNA discovered that a resident had problems with being able to press the call light, the nurse should be notified so that they could assess the resident to see what could be done to help the resident's ability to utilize a call system for staff assistance
On 04/11/24 at 09:32 AM, Licensed Nurse (LN) P confirmed CNA staff should place call lights where residents could easily reach them, especially if the resident had mobility problems. CNA staff should notify the LN on duty if they discover that a resident had difficulty pressing the call light so that it could be addressed and immediately corrected.
On 04/11/24 at 09:39 AM, Administrative Nurse B confirmed that CNA staff should place the call lights where residents could reach them, especially if the resident had mobility problems. The expectation was if a staff member identified a problem with call light placement or functionality, staff should report it to the LN on duty and/or administrative staff, so that the problem could be corrected, and a care plan intervention created.
The facility failed to provide a policy related to reasonable accommodations of individual needs as requested on 04/15/24.
The facility failed to provide R11 with appropriate call light equipment, which failed to accommodate this resident's individual needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 64 residents which included 16 residents sampled for review. Based on observation, interview and record review, the facility failed to track grievances through to their conclusions and provide prompt efforts to resolve a grievance filed by a resident (R)20 regarding the behavior of staff, offer or provide written grievance decisions to the resident regarding his or her grievance, and to offer or provide a summary of the pertinent findings or conclusions regarding the resident's concerns(s), a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance.
Findings included:
- The undated Physician Orders, for Resident (R)20 documented diagnoses which included cognitive communication deficit, cerebral vascular accident (stroke is a 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), traumatic brain injury, repeated falls, fractures (broken bones) and other multiple traumas.
The Annual Minimum Data Set (MDS) dated [DATE], documented the resident with a Brief Mental Status Interview, (BIMS) score of 13, indicating cognitively intact. The resident did not exhibit behaviors. Choices about her routine and preferences were very important. The resident was always continent of bowel and bladder. She received medications which included diuretics and antidepressants during the look back period.
The Care Plan, (CP) dated 11/21/23, instructed staff the resident participated in daily activities of interest in the facility. She was outgoing and liked to be involved in community events and activities. The resident did not like conflict.
On 04/09/24 at 12:12 PM, the resident sat in her room in the chair beside her bed. She was alert orient and her responses to questions regarding her concern were appropriate. Upon inquiry, she responded, A nurse told a lie. She reported she frequently walked up and down the hallway to and from the nurse's station. Last month when she went down the hall, a nurse came out of the room and said That is not my job. Resident (R)20 stated she asked the nurse what was wrong, to which the nurse responded, The resident was lying in their waste. She stated she asked the nurse who was going to take care of the resident to which the nurse stated nursing will. Additionally, she stated she was concerned there are residents in the facility that are confined to their room and cannot help it they cannot control their bowels. If the nurses do not feel like it is their job to clean someone lying in their own waste, then what will happen to them? R20 reported what happened in a meeting and some of the staff came to my room and told me they would take care of the situation. No one has gotten back to me about my report. The girls that took my report said they had other concerns from another resident's regarding the same nurse.
On 04/09/24 at 01:30 PM, Social Service Worker U stated she was responsible for tracking grievances and complaints filed by the residents. She maintained a log which included grievance/complaints from resident council meetings. She stated the Resident Council meetings were conducted by the Activities Director who forwarded concerns from the meeting to her to follow-up with the appropriate department. The interdisciplinary team discusses resident complaints and grievances at the morning meeting. Review of the Grievance Logs, dated 03/01/24 through 04/09/24 lacked documentation of the concern/Grievance that had been described by R 20. Social Service Worker U stated she was not aware of a grievance or concern that the resident reported last month.
On 04/09/24 at 02:07 PM, Administrative Staff A and Administrative Nurse B confirmed R 20 reported a grievance in the Resident Council Meeting on 03/27/24. The resident reported the grievance to the Activity Director (AD) S, who was also a certified nurse aide (CNA). Administrative Staff A stated she instructed CNA/AD S to interview the resident and obtain additional information to clarify what the resident meant by the nurse stating, that's not my job. Administrative Staff A and Administrative Nurse B confirmed the Grievance Log, lacked inclusion of R 20's grievance/complaint filed on 03/27/24 in Resident Council. Additionally, the facility lacked follow-up with the resident regarding an action plan to address the concern with the resident.
The facility policy titled Grievances, dated 04/01/2020, documentation included, Grievances is a written complaint or verbal complaint that cannot be resolved promptly by staff. Any complaint that is reduced to writing is considered a grievance. The goal is to provide prompt investigation and resolution to all complaints. The Director of Social Services is the designated Grievance officer which provides oversight of the grievance process including receiving, tracking grievances through their conclusion, and coordinating the issuance of written response, at the direction of the administrator to the person who initiated the grievance. A final response is provided to the complaining party along with a summary of the resolution. A grievance is considered resolved when the resident or grievant is satisfied with the action taken on his/her behalf.
The facility failed to track grievances through to their conclusions and provide prompt efforts to resolve a grievance filed by a resident regarding the behavior of staff, offer or provide written grievance decisions to the resident regarding his or her grievance, and to offer or provide a summary of the pertinent findings or conclusions regarding the resident's concerns(s), a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** - Review of Resident (R)27's undated Physician Orders, (POS) revealed diagnoses which included heart failure and chronic respiratory failure.
The admission Minimum Data Set, (MDS), dated [DATE], included the Brief Interview for Mental Status (BIMS) score of BIMS 10, indicating moderate cognitive impairment. She received Oxygen (O2) as a special care and treatment.
The Quarterly MDS, dated 03/25/24, documented the resident with BIMS score of 11, indicating continued moderate cognitive impairment. She received oxygen, as special care and treatment .
The Care Plan, (CP) dated 02/07/24, lacked address of special care and treatment related to oxygen which was initially ordered on 07/12/23. Additionally, the CP lacked guidance to the nursing staff related to the expectations to maintain the oxygen equipment to prevent infection.
The POS documentation included an order to apply oxygen to keep oxygen saturation rate (percentage of oxygen content in the blood) greater than or equal to 90 percent (% ) as needed, ordered on 07/12/2023.
On 04/09/24 at 11:06 AM, the resident sat on the side of the bed with oxygen administered at two liters per minute by way of nasal cannula. The tubing, cannula, and humidifier bottle did not have a date indicating placement. An undated 2/3rd full gallon container of distilled water sat directly on the resident's bed side commode. The resident stated the staff used the distilled water to fill the humidifier bottle to keep her nasal passages from drying out.
On 04/09/24 11:45 AM, Certified Medication Aide (CMA) I verified the above findings. She stated the CP and/or policy should provide guidance to the nursing staff regarding the care and treatment of the resident's oxygen and equipment. To prevent infection and cross contamination, the oxygen tubing, cannula, humidifier bottle and distilled water should be labeled to indicate the date it was placed into service to ensure routine changes to prevent the spread of infection. Additionally, CMA I reported the distilled water should be stored in the resident's room in a location other than the bedside commode to prevent cross contamination.
On 04/11/24 at 09:46 AM, Licensed Nurse (LN) P stated the resident's CP should provide guidance to the staff regarding the care and treatment of the resident related to the maintenance of oxygen equipment including tubing cannula and humidifier bottles should be marked when changed. The protocol for changing the set up includes night shift on Sundays, and as needed to prevent cross contamination. Changes in treatment and care should be addressed in the care plan when they occur.
On 04/15/24 02:48 PM , Administrative Nurse B stated the nursing staff were responsible for maintain the oxygen equipment in a manner to prevent cross contamination and the spread of infection. The CP provided guidance to the staff for the care and treatment of the resident's oxygen tubing, cannula, humidifier bottle, and distilled water should be labeled when initiated or changed. The oxygen supplies should be stored in a manner to prevent cross contamination and the spread of infection.
The facility policy Care Plans, Comprehensive Person-Centered, dated 03/2022, documentation included the comprehensive person-centered care plan describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being including any specialized services to be provided
The facility failed to develop and implement a plan of care for respiratory care related to oxygen use for the resident.
The facility reported a census of 64 residents which included 16 residents sampled, which included two residents reviewed for comprehensive care plan development. Based on interview, observation, and record review, the facility failed to develop a comprehensive, individualized person-centered care plan for Resident (R) 25 related to the use of grab bar use for bed mobility and for R27 to include the use of oxygen and oxygen related equipment. This deficient practice placed the residents at risk for uncommunicated care needs.
Findings include:
- The Electronic Health Records (EHR) for Resident (R)25 included diagnoses of generalized muscle weakness, reduced mobility, incomplete paraplegia (paralysis characterized by motor or sensory loss in the lower limbs and trunk) and muscle wasting with atrophy (wasting or decrease in size of a part of the body).
R25's Significant Change Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. R25 was dependent on staff for all cares except eating and oral care which required supervision. R25 had a urinary catheter (insertion of a catheter into the bladder to drain the urine into a collection bag) and was always incontinent of bowel. The MDS lacked documentation related to grab bar use.
The 11/30/23 Activities of daily living (ADL's such as walking, grooming, toileting, dressing and eating) Functional / Rehabilitation Potential Care Area Assessment (CAA), documented R25 required ADL assistance due to functional impairment in activity from generalized weakness and incomplete paraplegia. The CAA lacked documentation related to grab bar use.
The 11/30/23 Pressure Ulcer/Injury CAA documented that R25 had an increased risk of pressure ulcers/injury due to functional impairment and mobility impairment but lacked documentation related to grab bar use for bed mobility.
The Quarterly MDS dated 03/01/24 documented a BIMS of 15 and R25 was dependent on staff for all cares except eating and oral care which required supervision. R25 had a urinary catheter and was always incontinent of bowel. The MDS lacked documentation related to grab bar use.
The 04/09/24 Care Plan lacked documentation related to the use of grab bars while R25 was in bed.
The physician's orders lacked directions specific for grab bar use.
The EHR Assessments lacked documentation of grab bar safety assessment.
On 04/09/24 at 02:22 PM, R25 revealed that she uses grab bars on bed to help with bed mobility and repositioning with and without staff assistance.
On 04/10/24 at 01:50 PM, Certified Nurse Aide (CNA) D stated that interventions performed by staff should be on the care plan.
On 04/10/24 at 02:06 PM, Licensed Nurse (LN) M stated that interventions performed by staff should be on the care plan and the care plans are accessible in the EHR.
On 04/15/24 at 03:33 PM, Administrative Nurse B confirmed R25's care plan lacked guidance related to a grab bar.
The facility's undated Care Plans, Comprehensive Person-Centered policy documented that the care plan was based on a thorough assessment and described services to be furnished and included any specialized service to be provided.
The facility failed to develop a comprehensive individualized person-centered care plan for R25 related to the use of grab bar use for bed mobility and for R27 to include use of oxygen and oxygen related equipment. This deficient practice placed the residents at risk for uncommunicated care needs.

The facility reported a census of 64 residents and identified 11 residents as confused and self-mobile. Based on observation, record review, and interview, the facility failed to ensure the environment was free of accident hazards for these 11 residents, including failure to keep hazardous chemicals out of reach. Furthermore, the facility failed to maintain a safe environment when staff utilized a gait belt to secure Resident (R)1's door to remain in the open position.
Findings included:
- On 04/09/24 at 11:44 AM, observation revealed R1's room contained an unidentified, unlabeled spray bottle that hung from the foot of the bed. R1 identified the contents as a cleaning agent for staff use when staff emptied her catheter bag and if any urine spilled onto the floor.
On 04/09/24 a 11:46 AM, observation of R1's bathroom revealed a bottle of Fabuloso cleaning agent with the manufacturer label documented Keep out of reach of children. The cleanser sat on the counter next to mouthwash and personal hygiene products.
On 04/10/24 at 10:13 AM, observation of R1's bathroom revealed a bottle of Fabuloso cleaning agent with the manufacturer label of Keep out of reach of children. The cleanser was next to mouthwash and other personal hygiene products.
On 04/10/24 at 01:23 PM, Licensed Nurse (LN) AA entered R1's room to perform cares and removed a gait belt (a thick belt made from semi-rigid plastic or thick semi-rigid fabric used to help transfer a person from one place to another) that was looped around the door knob of the door and a wall-mounted wire glove box holder that restricted door movement and held the door in the open position.
On 04/11/24 at 02:00 PM, observation of R1's room revealed a bottle of air-freshener on the bed in reach of R1 with manufacturer label that with manufacturer labels documented keep out of reach of children.
On 04/15/24 at 07:45 AM, observation of R1's bathroom revealed a bottle of air-freshener with manufacturer label to Keep out of reach of children and was on the counter next to the mouthwash and other personal hygiene products.
On 04/15/24 at 07:55 AM, an observation of R25's room revealed a can of hair spray and three other items with manufacturer labels documented Keep out of reach of children sat on R25's bedside table.
On 04/10/24 at 01:30 PM, LN AA confirmed that door movement should not be restricted with any device (door stop or otherwise) due to accident/fire hazard concerns.
On 04/10/24 at 01:50 PM, Certified Nurse Aide (CNA) D revealed that no chemicals could be stored in resident's rooms and if discovered, the chemicals would be removed and taken to the LN.
On 04/10/24 at 02:05 PM, Certified Nurse Aide (CNA) N revealed that chemicals were not allowed to be stored in resident's rooms and if discovered, the chemicals should be moved out of the resident's reach and to notify the Licensed Nurse (LN).
On 04/10/24 at 02:10 PM, LN E revealed that chemicals were prohibited in resident rooms and if discovered, they would be removed from the resident's room and turned over to Housekeeping Supervisor J for proper storage.
On 04/15/24 at 08:55 AM, Administrative Nurse B confirmed that chemicals should not be stored in resident's rooms under any circumstances but should be kept somewhere secured with a lock that requires a key. Door movement or operation could not be restricted with any mechanical device due to fire/safety hazard concerns.
The facility failed to provide a policy related to prevention of accident hazards as requested on 04/15/24.
The facility failed to keep hazardous chemicals out of reach for the 11 confused, mobile residents of the facility. Furthermore, the facility failed to maintain a safe environment when staff utilized a gait belt to secure R1's door to remain in the open position.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 64 residents with 16 residents included in the sample. Based on observation, interview, and record review, the facility failed to provide necessary services to decrease the risk of a urinary tract infection when staff failed to use proper hand hygiene and Enhanced Barrier precautions (EBP) when providing urinary catheter care for resident (R)1 and R25.
Findings included:
- R1's Electronic Medical Record (EMR) revealed diagnoses that included acute kidney failure (a sudden decline in kidney function that occurs within a few hours or days), neuromuscular dysfunction of bladder (the muscles that control the flow of urine out of the body do not relax and prevent the bladder from fully emptying), and urinary tract infection ([UTI] infection of any part of the urinary system, including kidneys, ureters, bladder, and urethra).
R1's Annual Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The resident required extensive to total assistance for all cares. R1 had an indwelling urinary catheter (insertion of a catheter into the bladder to drain the urine into a collection bag).
The Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA) dated 06/22/23, documented risk factors included recurrent UTI's and injury from use of the catheter.
The Bladder/Bowel care plan, dated 01/27/23, revealed R1 required a urinary catheter, and guided staff to provide catheter care policy.
Observation on 04/09/24 at 11:19 AM revealed R1's catheter bag stored top of a dignity bag that was stored directly on the floor.
Observation on 04/10/24 at 10:13 AM, revealed R1's catheter bag hung from the edge of her bed, with dark amber colored urine in the drainage bag, and clear yellow urine with sediment in the tubing.
Observation of 04/10/24 at 01:23 PM, revealed Licensed Nurse (LN) AA donned a gown and pushed the gown sleeves above her wrists. She then washed her hands with soap and water, removed a gait belt from the back of door handle, then donned her gloves and pulled the gown sleeves back down to her wrists. LN AA wiped the catheter tubing with a no-rinse foam soap-soaked gauze, and removed and reapplied a new pair of gloves without performing hand hygiene, removed the spigot from the catheter collection system, emptied the urine from the collection bag into a urinal, then washed the spigot with a no-rinse foam soap-soaked gauze, then saline soaked gauze, then alcohol wipes. She removed her gloves, emptied the urinal into the commode and rinsed the urinal with tap water from the resident's sink. She pulled her sleeves up on her arms, washed her hands with soap and water and removed her gown.
On 04/09/24 at 02:09 PM, R1 reported that she required a urinary catheter because she was unable to urinate.
On 04/10/24 at 01:32 PM, LN AA confirmed no hand hygiene was done when changing her gloves and carrying the urinal to the bathroom and improper infection control techniques.
Interview on 04/10/24 at 02:35 PM, Administrative Nurse B reported wipes should be used for one wipe per swipe for either peri or catheter care. Hand hygiene should be performed with either alcohol-based hand rub (ABHR) or soap/water before the procedure and with every glove change, and with soap/water only at the end of a procedure.
The facility's policy for Catheter care, dated 08/22, revealed the purpose of this procedure is to prevent urinary catheter -associated complications including urinary tract infections. Use aseptic technique when handling or manipulating the drainage system.
The facility's policy for Enhanced Barrier Precautions, dated 08/22 revealed EBPs are used in conjunction with standard precautions and expand the use of Personal Protective Equipment to donning of gown and gloves during high contact resident care activities that provide opportunities for transfer of Multi Drug Resistant Organisms (MDRO) to staff hands or clothing.
The facility failed to provide necessary services to decrease the risk of a urinary tract infection when the staff failed to use proper hand hygiene and Enhanced Barrier Precautions when providing catheter care for resident (R)1.
- Resident (R) 25's diagnoses included neuromuscular dysfunction of bladder (dysfunction of the urinary bladder caused by a lesion of the nervous system), and urinary tract infection (Infection of any part of the urinary system, including kidneys, ureters, bladder, and urethra).
The Significant Change Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The resident was dependent for all cares and had an indwelling urinary catheter (insertion of a catheter into the bladder to drain the urine into a collection bag).
The 11/03/23 Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA), dated 11/03/23, revealed the resident required a urinary catheter.
The care plan, dated 10/13/23, revealed the resident required a urinary catheter.
Revision of the care plan revealed on 04/10/2024, the resident required Enhanced Based Precautions (EBP) related to wound and catheter. Staff were to wear gloves and gowns for all dressing, changing brief, catheter care, emptying catheter, transfers, toileting, peri care, bathing/showering, hygiene, changing linens, and wound care.
The Physician Orders included to check and verify catheter securement was in place and the tubing was free of kinks, two times a day, ordered 04/12/2024.
Observation on 04/10/24 at 10:55 AM revealed Licensed Nurse (LN) M provided urinary catheter care with the assistance of Certified Nursing Aide (CNA) D. CNA D performed hand hygiene upon entry to the room and donned gloves, LN M failed to perform hand hygiene and donned gloves when entering the room. CNA D left the resident's room to retrieve the full body mechanical lift outside the room with neither staff member engaged in enhanced barrier precautions. Staff transferred the resident with the mechanical lift to her bed. CNA D went to the bathroom to retrieve warm/soapy wash cloth while LN M removed the resident's brief at the front and assisted the resident to hold her legs apart. The resident was incontinent of bowels. CNA D wiped the front of the resident, then discarded the soiled washcloth and changed gloves without performing hand hygiene. CNA D retrieved incontinence wipes from the bedside table drawer and initiated peri-care. Staff assisted the resident and the resident positioned to her left side. LN M started cleaning up feces with multiple swipes with the same wipe, LN M changed her gloves without hand hygiene. CNA D removed her gloves and left the resident room for additional supplies and failed to perform hand hygiene. When CNA D returned to the resident's room, CNA D donned new gloves and took the washcloth to the bathroom to make a warm/soapy wash cloth, then walked to bedside and cleaned resident's genitals, then cleaned around the resident's catheter, then wiped the resident's genitals a second time, then cleaned the resident's catheter a second time, folding and /refolding the same washcloth with each pass. CNA D then disposed of the washcloth and changed gloves but failed to perform hand hygiene. LN M removed gloves and left the resident's room to obtain additional supplies and failed to perform hand hygiene. CNA D replaced resident's brief and LN M returned to the room and failed to perform hand hygiene. LN M attempted to place a commercially available adhesive catheter securement device to the resident, but the resident declined this as she had a documented history of adverse reaction to the adhesive. LN M removed her gloves and performed hand hygiene with an alcohol-based hand solution, then left the room. CNA D collected the soiled supplies and removed gloves, then exited the room without performing hand hygiene.
On 04/10/24 at 09:38 AM, R25 stated staff have not put on any full personal protective equipment (PPE) when emptying her catheter bag. She reported she did not have a tubing anchoring/securement device because she was allergic to the anchor, and the facility was to get her a harness type securement device but had not done that yet.
Interview on 04/10/24 at 11:20 AM, CNA D stated she would not have changed anything with the procedure as observed except that staff may have needed extra supplies to prevent having to leave to go get additional supplies. CNA D confirmed that no EBP were in place at the time of catheter/peri care.
On 04/10/24 at 11:18 AM, LN M stated she would not have changed anything with the procedure as observed.
Interview on 04/10/24 at 02:06 PM with LN M confirmed that no EBP was in place at the time of catheter/peri care, and reported it was acceptable to wipe/fold/reuse with wash cloth but not with wipes, confirmed that she had reused wipe to remove BM from resident's skin. Stated that CNA D should not have re-wiped a second time of genitals or catheter with wash cloth because it presented as an infection control concern.
Interview on 04/10/24 at 02:35 PM, Administrative Nurse B reported an expectation for staff that wash cloths should not be used for peri care or catheter care, only for bathing. Wipes should be used for one wipe per swipe for either peri or catheter care. Hand hygiene should be performed with either alcohol-based hand rub (ABHR) or soap/water before procedure, and with every glove change and with soap/water only at the end of a procedure. Residents with catheters should have some sort of securement device for the tubing to be secured to the resident's leg. It is never acceptable for resident to have a catheter without it being secured to the leg.
Interview on at 04/10/24 at 04:05 PM, CNA CC reported there were no special orders in progress for a foley securement device. Walk through with CNA CC of the facility's supply room revealed leg securement straps in house stock.
Interview on at 04/10/24 at 04:25 PM with Administrative Nurse B, informed of above and was unable to provide an explanation as to why a securement device had not been in place prior to location of the device in the facility's supply room.
The facility's policy for Catheter care, dated 08/22, revealed the purpose of this procedure was to prevent urinary catheter -associated complications including urinary tract infections. Use aseptic technique when handling or manipulating the drainage system.
The facility's policy for Enhanced Barrier Precautions, dated 08/22, revealed EBPs are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high contact resident care activities that provide opportunities for transfer of Multi Drug Resistant Organisms (MDRO) to staff hands or clothing.
The facility failed to provide necessary services to decrease the risk of a urinary tract infection when the staff failed to use proper hand hygiene, catheter cleansing, and Enhanced Barrier Precautions when providing catheter care for resident (R)25.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** - Review of Resident (R)27's undated Physician Orders, (POS) revealed diagnoses which included heart failure and chronic respiratory failure.
The admission Minimum Data Set, (MDS), dated [DATE], included the Brief Interview for Mental Status (BIMS) score of BIMS 10, indicating moderate cognitive impairment. She received Oxygen (O2) as a special care and treatment.
The Quarterly MDS, dated 03/25/24, documented the resident with BIMS score of 11, indicating continued moderate cognitive impairment. She received oxygen, as special care and treatment .
The Care Plan, (CP) dated 02/07/24, lacked address of special care and treatment related to oxygen.
The POS documentation included an order to apply oxygen to keep oxygen saturation rate (percentage of oxygen content in the blood) greater than or equal to 90 percent (% ) as needed, ordered on 07/12/2023.
On 04/09/24 at 11:06 AM, the resident sat on the side of the bed with oxygen administered at two liters per minute by way of nasal cannula. The tubing, cannula, and humidifier bottle did not have a date indicating placement. An undated 2/3rd full gallon container of distilled water sat directly on the resident's bed side commode. The resident stated the staff used the distilled water to fill the humidifier bottle to keep her nasal passages from drying out.
On 04/09/24 11:45 AM, Certified Medication Aide (CMA) I verified the above findings. She stated the oxygen tubing, cannula, humidifier bottle and distilled water should be labeled to indicate the date it was placed into service to ensure routine changes to prevent the spread of infection. Additionally, CMA I reported the distilled water should be stored in the resident's room in a location other than the bedside commode to prevent cross contamination.
On 04/10/24 at 11:04 AM, CMA I stated the night shift was to change the oxygen tubing and cannulas weekly to prevent infection. The staff should label the tubing with the date at the time the change was made. The distilled water should be dated when opened.
On 04/11/24 at 09:46 AM, Licensed Nurse (LN) P stated oxygen equipment including tubing cannula and humidifier bottles should be marked when changed. The protocol for changing the set up includes night shift on Sundays, and as needed to prevent cross contamination.
On 04/15/24 02:48 PM , Administrative Nurse B stated the nursing staff were responsible for maintain the oxygen equipment in a manner to prevent cross contamination and the spread of infection. The oxygen tubing, cannula, humidifier bottle, and distilled water should be labeled when initiated or changed. The oxygen supplies should be stored in a manner to prevent cross contamination and the spread of infection.
The facility lacked a policy to address of maintain oxygen equipment to prevent the spread of infection.
The facility failed to provide appropriate respiratory care related to maintaining respiratory equipment to prevent the spread of infection for the resident.
The facility reported a census of 64 residents with 16 residents sampled, including three residents reviewed for respiratory care. Based on observations, record reviews, and interviews, the facility failed to properly clean and store a nebulizer (a device for administering inhaled medications) for Resident (R)28 and R11 in accordance with the standards of care. In addition, the facility failed to place a date label on the oxygen tubing for R27. This deficient practice placed the residents at risk of respiratory complications that could also have a negative impact on the resident's psychosocial wellbeing.
Findings included:
- R28's Electronic Health Record (EHR) documented pertinent diagnoses of atherosclerotic (buildup of plaques in the blood vessels) heart disease, history of pulmonary embolism (a blood clot in the blood vessels of the lungs), asthma (a chronic disorder of narrowed airways that caused wheezing and shortness of breath), generalized weakness, difficulty in walking and respiratory failure (a condition in which respiratory function is inadequate to maintain the body's need for oxygen supply and/or carbon dioxide removal while at rest).
The Significant Change Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The resident was dependent on staff for all cares except eating which was performed independently and received oxygen.
The Activities of daily living (ADL's such as walking, grooming, toileting, dressing and eating) Functional / Rehabilitation Potential Care Area Assessment (CAA), dated 02/07/24, documented that R28 had impaired functional abilities due in part to diagnoses of respiratory failure and asthma.
The Psychosocial Well-Being CAA, dated 02/07/24 documented that R28 had little interest or pleasure in doing things due in part to diagnoses of respiratory failure and asthma.
The Quarterly MDS, dated 12/22/23, documented a BIMS score of 15, which indicated intact cognition. The resident was dependent on staff for all cares except eating which was performed independently, and R28 received oxygen.
The 04/10/24 Care Plan documented R28 received nebulizer medications and the care plan lacked guidance related to care of the nebulizer equipment.
The EHR Physician Orders included an order, dated 03/21/23, for Ipratropium-Albuterol solution (two medications used to relax airway muscles to ease the work of breathing), 0.5 milligrams (mg), and 2.5 mg in three milliliters (mL) to inhale orally via nebulizer once per day for shortness of breath or wheezing. The order lacked orders specific instructions to care or maintenance of the nebulizer or the nebulizer equipment.
On 04/09/24 at 11:52 AM, observation of R28's room revealed a nebulizer intact sitting on top of a nebulizer machine with an unknown clear liquid in the nebulizer chamber.
On 04/15/24 at 12:55 PM, Certified Medication Aide (CMA) K revealed that only Licensed Nurses (LN) give nebulized medications and LN staff were responsible for the care and maintenance of nebulizer equipment.
On 04/15/24 at 12:55 PM, LN X revealed that after a nebulized medication was administered, nursing staff should disassemble the nebulizer and rinse it with tap water and then set the components on a paper towel to dry. Then, after the components were dry, staff would reassemble the pieces and the set would be placed in a clear plastic bag and left on top of the nebulizer machine until the next use.
On 04/15/24 at 03:00 PM, Administrative Nurse B revealed that her expectation at the end of a breathing treatment that the LN would disassemble the nebulizer device and rinse with tap water and then set the components to dry on a clean paper towel. Once the components were dry, staff were to reassemble them and place them in a clean plastic bag until the next use.
The facility's undated Administering Medications through a Small Volume (Handheld) Nebulizer) policy documented after a treatment was completed, staff were to rinse and disinfect the nebulizer equipment per facility protocol or wash with warm soapy water, rinse with hot water, and allow to air dry on a paper towel. When the equipment was completely dry, staff were instructed to store in a plastic bag or other plastic container.
The facility failed to provide respiratory care consistent with professional standards of care for R28, regarding the use and cleaning of the nebulizer equipment.
- The Electronic Health Records (EHR) for Resident (R)11 included diagnoses of diabetes mellitus type 2 (DM2 - when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), generalized weakness, aphasia (condition with disordered or absent language function) following cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain) and rheumatoid arthritis (RA - a chronic inflammatory disease that affected joints and other organ systems).
The 12/23/23 admission Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 15, which indicates intact cognition. R11 required substantial assistance from staff for all cares except eating, which required setup and supervision.
The 12/23/23 Activities of daily living (ADL's such as walking, grooming, toileting, dressing and eating) Functional / Rehabilitation Potential Care Area Assessment (CAA), documented R11 had an ADL self-care deficit related to impaired balance during transfers, functional impairment during activity, generalized weakness, and decreased safety awareness.
The 12/23/23 Falls CAA documented R11 was at increased risk for falls due to impaired gait (manner or style of walking), impaired mobility, weakness, and physical performance limitations.
The 03/05/24 Quarterly MDS documented a BIMS score of 15, which indicated intact cognition and R11 required substantial/maximum assistance for all cares except eating which required supervision and setup.
The 04/10/24 Care Plan lacked instructions for staff related to care of nebulizer equipment.
The EHR Physician Orders included an order, dated 03/26/24, for Ipratropium-Albuterol solution (two medications used to relax airway muscles to ease the work of breathing), 0.5 milligrams (mg) and 2.5 mg in three milliliters (mL) to inhale orally, via nebulizer, every four hours, as needed (PRN) for shortness of breath or wheezing. The orders lacked instructions specific for the care or maintenance of the nebulizer or the nebulizer equipment.
On 04/09/24 at 01:34 PM, observation of R11's room revealed a nebulizer intact sitting on a windowsill.
On 04/15/24 at 12:55 PM, Certified Medication Aide (CMA) K revealed that only Licensed Nurses (LN) give nebulized medications and LN staff were responsible for the care and maintenance of nebulizer equipment.
On 04/15/24 at 12:55 PM, LN X revealed that after a nebulized medication was administered, nursing staff should disassemble the nebulizer and rinse it with tap water and then set the components on a paper towel to dry. Once the components were dry, staff was to reassemble the pieces and place it in a clear plastic bag and left on top of the nebulizer machine until the next use.
On 04/15/24 at 03:00 PM, Administrative Nurse B revealed that her expectation at the end of a breathing treatment that the LN would disassemble the nebulizer device and rinse with tap water and then set the components to dry on a clean paper towel. Once the components were dry, staff were to reassemble them and place them in a clean plastic bag until the next use.
The facility's undated Administering Medications through a Small Volume (Handheld) Nebulizer) policy documented that after a treatment was completed that staff were to rinse and disinfect the nebulizer equipment per facility protocol or wash with warm soapy water, rinse with hot water then allow to air dry on paper towel. When the equipment was completely dry, staff were instructed to store in a plastic bag or other plastic container.
The facility failed to provide respiratory care consistent with professional standards of care for R28, regarding the use and cleaning of the nebulizer equipment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** - Resident (R) 25's diagnoses included neuromuscular dysfunction of bladder (dysfunction of the urinary bladder caused by a lesion of the nervous system), and urinary tract infection (Infection of any part of the urinary system, including kidneys, ureters, bladder, and urethra).
The Significant Change Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The resident was dependent for all cares and had an indwelling urinary catheter (insertion of a catheter into the bladder to drain the urine into a collection bag).
The 11/03/23 Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA), dated 11/03/23, revealed the resident required a urinary catheter.
The care plan, dated 10/13/23, revealed the resident required a urinary catheter.
Revision of the care plan revealed on 04/10/2024, the resident required Enhanced Based Precautions (EBP) related to wound and catheter. Staff were to wear gloves and gowns for all dressing, changing brief, catheter care, emptying catheter, transfers, toileting, peri care, bathing/showering, hygiene, changing linens, and wound care.
The Physician Orders included to check and verify catheter securement was in place and the tubing was free of kinks, two times a day, ordered 04/12/2024.
Observation on 04/10/24 at 10:55 AM revealed Licensed Nurse (LN) M provided urinary catheter care with the assistance of Certified Nursing Aide (CNA) D. CNA D performed hand hygiene upon entry to the room and donned gloves, LN M failed to perform hand hygiene and donned gloves when entering the room. CNA D left the resident's room to retrieve the full body mechanical lift outside the room with neither staff member engaged in enhanced barrier precautions. Staff transferred the resident with the mechanical lift to her bed. CNA D went to the bathroom to retrieve warm/soapy wash cloth while LN M removed the resident's brief at the front and assisted the resident to hold her legs apart. The resident was incontinent of bowels. CNA D wiped the front of the resident, then discarded the soiled washcloth and changed gloves without performing hand hygiene. CNA D retrieved incontinence wipes from the bedside table drawer and initiated peri-care. Staff assisted the resident and the resident positioned to her left side. LN M started cleaning up feces with multiple swipes with the same wipe, LN M changed her gloves without hand hygiene. CNA D removed her gloves and left the resident room for additional supplies and failed to perform hand hygiene. When CNA D returned to the resident's room, CNA D donned new gloves and took the washcloth to the bathroom to make a warm/soapy wash cloth, then walked to bedside and cleaned resident's genitals, then cleaned around the resident's catheter, then wiped the resident's genitals a second time, then cleaned the resident's catheter a second time, folding and /refolding the same washcloth with each pass. CNA D then disposed of the washcloth and changed gloves but failed to perform hand hygiene. LN M removed gloves and left the resident's room to obtain additional supplies and failed to perform hand hygiene. CNA D replaced resident's brief and LN M returned to the room and failed to perform hand hygiene. LN M attempted to place a commercially available adhesive catheter securement device to the resident, but the resident declined this as she had a documented history of adverse reaction to the adhesive. LN M removed her gloves and performed hand hygiene with an alcohol-based hand solution, then left the room. CNA D collected the soiled supplies and removed gloves, then exited the room without performing hand hygiene.
On 04/10/24 at 09:38 AM, R25 stated staff have not put on any full personal protective equipment (PPE) when emptying her catheter bag. She reported she did not have a tubing anchoring/securement device because she was allergic to the anchor, and the facility was to get her a harness type securement device but had not done that yet.
Interview on 04/10/24 at 11:20 AM, CNA D stated she would not have changed anything with the procedure as observed except that staff may have needed extra supplies to prevent having to leave to go get additional supplies. CNA D confirmed that no EBP were in place at the time of catheter/peri care.
On 04/10/24 at 11:18 AM, LN M stated she would not have changed anything with the procedure as observed.
Interview on 04/10/24 at 02:06 PM with LN M confirmed that no EBP was in place at the time of catheter/peri care, and reported it was acceptable to wipe/fold/reuse with wash cloth but not with wipes, confirmed that she had reused wipe to remove BM from resident's skin. Stated that CNA D should not have re-wiped a second time of genitals or catheter with wash cloth because it presented as an infection control concern.
Interview on 04/10/24 at 02:35 PM, Administrative Nurse B reported an expectation for staff that wash cloths should not be used for peri care or catheter care, only for bathing. Wipes should be used for one wipe per swipe for either peri or catheter care. Hand hygiene should be performed with either alcohol-based hand rub (ABHR) or soap/water before procedure, and with every glove change and with soap/water only at the end of a procedure. Residents with catheters should have some sort of securement device for the tubing to be secured to the resident's leg. It is never acceptable for resident to have a catheter without it being secured to the leg.
Interview on at 04/10/24 at 04:05 PM, CNA CC reported there were no special orders in progress for a foley securement device. Walk through with CNA CC of the facility's supply room revealed leg securement straps in house stock.
Interview on at 04/10/24 at 04:25 PM with Administrative Nurse B, informed of above and was unable to provide an explanation as to why a securement device had not been in place prior to location of the device in the facility's supply room.
The facility's policy for Catheter care, dated 08/22, revealed the purpose of this procedure was to prevent urinary catheter -associated complications including urinary tract infections. Use aseptic technique when handling or manipulating the drainage system.
The facility failed to ensure certified staff had appropriate competencies and skill sets to provide nursing related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This placed the resident at risk for decreased quality of care.
- The Electronic Health Records (EHR) for Resident (R)11 included diagnoses of diabetes mellitus type 2 (DM2 - when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), generalized weakness, aphasia (condition with disordered or absent language function) following cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain) and rheumatoid arthritis (RA - a chronic inflammatory disease that affected joints and other organ systems).
The 12/23/23 admission Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 15, which indicates intact cognition. R11 required substantial assistance from staff for all cares except eating, which required setup and supervision.
The 12/23/23 Activities of daily living (ADL's such as walking, grooming, toileting, dressing and eating) Functional / Rehabilitation Potential Care Area Assessment (CAA), documented R11 had an ADL self-care deficit related to impaired balance during transfers, functional impairment during activity, generalized weakness, and decreased safety awareness.
The 12/23/23 Falls CAA documented R11 was at increased risk for falls due to impaired gait (manner or style of walking), impaired mobility, weakness, and physical performance limitations.
The 03/05/24 Quarterly MDS documented a BIMS score of 15, which indicated intact cognition and R11 required substantial/maximum assistance for all cares except eating which required supervision and setup.
The 04/10/24 Care Plan, documented an intervention dated 12/28/23 for staff to place R11's call light within his reach.
Review of the call light log from 03/01/24 to 03/14/24 revealed 345 call light entries with 47 entries greater than 15 minutes, which included entries of 45.23 minutes, 32.5 minutes, 34.3 minutes, 33.3 minutes, 32.8 minutes, 37.8 minutes, 35.8 minutes, 36 minutes, 43 minutes, and 39 minutes.
On 04/11/24 at 08:34 AM, Interview with Certified Nursing Aide (CNA ) D revealed R167 will complain about the length of the call light response. Several residents complain about the response time of the call lights. There is enough staff, but it depends on the staff working.
On 04/11/24 at 01:35 PM, Licensed Nurse LN F revealed staff have pagers that notify the nurses how long a call light has been initiated.
On 04/11/24 at 10:09 AM, Administrative Nurse B revealed staff needs are determined by the acuity of the residents and or the census. When staff do not answer the call lights timely, and if the call light response was longer than 10 minutes, then Administrative Nurse B was to conduct audits, investigate the staff working, interview the resident, and provide 1:1 counseling with the staff .
The facility failed to provide a policy regarding call lights as requested on 04/15/24.
The facility failed to ensure certified staff had appropriate competencies and skill sets to provide nursing related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This placed all residents at risk for decreased quality of care.
- The Electronic Health Records (EHR) for Resident (R)3 revealed diagnoses that included muscle weakness, history of falls, reduced mobility.
The Annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition.
The Activities of Daily Living (ADL)/Functional/Rehabilitation Potential Care area Assessment (CAA), dated 03/22/24, documented R3 had reduced mobility.
Review of the call light log from 03/01/24 to 03/14/24, revealed 149 call light entries with 24 entries greater than 15 minutes which included one entry each for 37.7 minutes, 35.55 minutes, 34.3 minutes, 47 minutes, 63.6 minutes and 33.2 minutes.
On 04/09/24 at 02:59 PM, R3 reported staff do not answer her call lights quick enough and she has to wait sometimes over 45 minutes for someone to answer her call light. Because of the delay of call light response, she will at times become incontinent. She reported she also had to be hospitalized because of a urinary tract infection, and felt it was because she would try to hold her urine while waiting for staff to assist her.
On 04/11/24 at 08:34 AM, Interview with Certified Nursing Aide (CNA ) D revealed R167 will complain about the length of the call light response. Several residents complain about the response time of the call lights. There is enough staff, but it depends on the staff working.
On 04/11/24 at 01:35 PM, Licensed Nurse LN F revealed staff have pagers that notify the nurses how long a call light has been initiated.
On 04/11/24 at 10:09 AM, Administrative Nurse B revealed staff needs are determined by the acuity of the residents and or the census. When staff do not answer the call lights timely, and if the call light response was longer than 10 minutes, then Administrative Nurse B was to conduct audits, investigate the staff working, interview the resident, and provide 1:1 counseling with the staff .
The facility failed to provide a policy regarding call lights as requested on 04/15/24.
The facility failed to ensure certified staff had appropriate competencies and skill sets to provide nursing related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This placed all residents at risk for decreased quality of care.
The facility had a census of 64 residents. The sample included 16 residents with five residents sampled. Based on observation, record review, and interview, the facility failed to ensure certified nursing staff had appropriate competencies and skill set to provide nursing related services to assure resident safety and to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This placed Resident (R) 3, R11, and R165 at risk of injury during call light response and R25, R50 for proper catheter care which placed all residents at risk for decreased quality of care.
Findings included:
- The Physician Orders for Resident (R)50, dated 03/22/24, indicated diagnoses that included retention of urine unspecified (Lack of ability to urinate and empty the bladder) and urinary catheter (insertion of a catheter into the bladder to drain the urine into a collection bag).
The admission Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of three, indicating severely impaired cognition. The Activities of Daily Living (ADL's) indicated Resident R 50 required extensive assistance with two or more persons for bed mobility, transfers, and toilet use.
The Quarterly MDS dated [DATE], indicated a BIMS score of 12, indicating moderately impaired cognition. R50 required an indwelling urinary catheter.
The Care Plan dated 08/11/23 revealed F50 required the need of a indwelling urinary catheter for terminal illness and urinary retention. Staff were to ensure the catheter bag remained below the level of the bladder to minimize the risk of infection. Staff were to provide catheter care per facility policy.
R50 required Enhanced Barrier Precautions dated 04/10/24, due to wound and urinary catheter. Staff were to wear gloves and gowns for all dressing, changing brief, transfer, toileting, peri-care, catheter care/ bathing/showering, hygiene, changing lines and wound care.
On 04/10/24 at 10:32 AM, observed R50 in his bed and the urinary catheter bag hung off of his wheelchair. The urinary collection bag lacked a privacy bag.
On 04/10/24 at 10:58 AM, Certified Nurse Aide (CNA) C provided catheter care. CNA C did not wash her hands prior to applying gloves and did not apply a gown before starting the cleaning of R50's catheter. CNA C used wipes to clean R50's penis and catheter. CNA C placed the soiled wipes on top of the package of the clean wipes. CNA C finished the catheter care. CNA C failed to wash her hands between the soiled gloves. CNA C also failed to wash her hands after removing her soiled gloves and before leaving R50's room.
On 04/10/24 at 11:04 AM, interview with CNA C revealed she was not aware of the guidelines for proper catheter care and was unaware of the guidelines for the Enhanced Barrier protection.
On 04/11/24 at 01:30 PM, Interview with Licensed Nurse F revealed the staff now have to follow the Enhanced Barrier Precautions of wearing a gown and gloves while providing care of residents with a catheter.
The policy Catheter Care Urinary dated 2001 revealed the purpose of the procedure is to prevent urinary catheter-associated complication, including urinary tract infections. The Routine Perineal Hygiene guidance is to place the clean equipment on the bedside stand or overbed table. Perform hand hygiene with the non-dominant hand and retract the foreskin of uncircumcised male residents. Maintain the position of this hand throughout the procedure. Cleanse the glans using circular strokes from the meatus outward with a clean washcloth or wipe, rinse using the about technique, and return the foreskin to normal the position. Perform hand hygiene after finishing catheter care.
The facility failed to ensure certified staff had appropriate competencies and skill sets to provide nursing related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This placed the resident at risk for decreased quality of care.
- The Physicians Orders for R165, dated 04/04/24, included the diagnosis for after care following surgery for pacemaker (implanted device to regulate the beating of the heart).
The admission Minimum Data Set (MDS dated [DATE]) revealed a Brief Interview for Mental Status (BIMS) score of 15, revealing intact cognition, and R165 required assistance with bathing.
The Care Area Assessment (CAA) dated 04/10/24 indicated staff were to wear gloves and gowns for all dressing, changing brief, transfers, toileting, pericare, catheter care, bathing/showering, hygiene, changing linens, and wound care.
The Care Plan dated 04/04/24, documented R 165 required the assistance of one staff member for bathing, personal hygiene, and dressing.
Review of the call light log for R165 room from 04/02/24 to 04/09/24 indicated the call light remained unanswered for 18 occurrences ranging from 15 minutes to 30 minutes before staff answered the call light.
On 04/10/24 at 11:48 AM, R165 revealed that she sometimes had to wait at least 45 minutes for a staff member to answer the call light.
On 04/11/24 at 08:34 AM, Interview with Certified Nursing Aide (CNA ) D revealed R167 will complain about the length of the call light response. Several residents complain about the response time of the call lights. There is enough staff, but it depends on the staff working.
On 04/11/24 at 01:35 PM, Licensed Nurse LN F revealed staff have pagers that notify the nurses how long a call light has been initiated.
On 04/11/24 at 10:09 AM, Administrative Nurse B revealed staff needs are determined by the acuity of the residents and or the census. When staff do not answer the call lights timely, and if the call light response was longer than 10 minutes, then Administrative Nurse B was to conduct audits, investigate the staff working, interview the resident, and provide 1:1 counseling with the staff .
The facility failed to provide a policy regarding call lights as requested on 04/15/24.
The facility failed to ensure certified staff had appropriate competencies and skill sets to provide nursing related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This placed all residents at risk for decreased quality of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 64 residents and identified 11 residents as confused and self-mobile. Based on observations, interviews, and record review, the facility failed provide a safe environment for 11 residents by the failure to ensure that Resident (R)25 and R1's rooms remained free of unsecured medications, when the facility failed to secure medications in both residents' rooms. This deficient practice had the potential to create an accidental ingestion of medications to these confused, mobile residents.
Findings included:
- The Electronic Health Records (EHR) for Resident (R)25 included diagnoses of generalized muscle weakness, reduced mobility, incomplete paraplegia (paralysis characterized by motor or sensory loss in the lower limbs and trunk) and muscle wasting with atrophy (wasting or decrease in size of a part of the body).
R25's Significant Change Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. R25 was dependent on staff for all cares except eating and oral care which required supervision.
The Activities of daily living (ADL's such as walking, grooming, toileting, dressing and eating) Functional / Rehabilitation Potential Care Area Assessment (CAA), dated 11/30/23, documented that R25 required ADL assistance due to functional impairment in activity from generalized weakness and incomplete paraplegia.
The 04/10/24 Care Plan lacked information related to self-administration of medications.
The EHR Evaluations tab lacked a self-administration assessment.
The EHR Physician's Orders lacked a self-administration order for any medications.
On 04/15/24 at 07:55 AM, an observation of R25's room revealed bottle of generic antacid tablets on the bathroom counter next to personal hygiene items.
On 04/10/24 at 02:05 PM, Certified Nurse Aide (CNA) N revealed that medications were not allowed to be stored in resident's rooms and if discovered, the medications should be moved out of the resident's reach and to notify the Licensed Nurse (LN).
On 04/10/24 at 02:10 PM, LN E revealed that medications were prohibited in resident rooms unless the resident had been assessed for self-administration safety and had a physician's order specific to the self-administration of each medication.
On 04/15/24 at 08:55 AM, Administrative Nurse B confirmed that medications should not be stored in resident's rooms unless the resident had a self-administration safety assessment and a physician's order for self-administration for each medication. Administrative Nurse B then confirmed the lack of self-administration safety assessment and physician's order for self-administration.
The facility's undated Storage of Medications policy documented that medications were stored in safe, secure and orderly manner and lacked instructions related to self-administration of medications.
The facility failed provide a safe environment for 13 residents by the failure to ensure that R25's room remained free of unsecured medications. This deficient practice had the potential to create an accidental ingestion of medications to these confused, mobile residents.
- The Electronic Health Records (EHR) for Resident (R)1 included diagnoses of generalized anxiety disorder (a disorder characterized by chronic free-floating anxiety and such symptoms as tension or sweating or trembling or lightheadedness or irritability etc. that has lasted for more than six months), major depressive disorder (a serious mood disorder involving one or more episodes of intense psychological depression or loss of interest or pleasure that lasts two or more weeks) and generalized muscle weakness.
R1's Annual Minimum Data Set (MDS), dated 06/22/23, documented a Brief Interview of Mental Status (BIMS) score of 15 which indicated intact cognition. R1 required extensive or total assistance for all cares except eating which was performed independently and R1 had a urinary catheter (insertion of a catheter into the bladder to drain the urine into a collection bag).
R1's Activities of daily living (ADL's such as walking, grooming, toileting, dressing and eating) Functional / Rehabilitation Potential Care Area Assessment (CAA), dated 06/22/23, documented that R1 had impaired functional impairment in activity due to decreased safety awareness.
R1's Quarterly MDS, dated 03/09/24, documented a BIMS score of 15 which indicated intact cognition. R1 required extensive or total assistance for all cares except eating which was performed independently.
The 04/10/24 Care Plan lacked information related to medication self-administration.
The EHR Evaluations tab lacked a self-administration assessment.
The EHR Physician's Orders lacked a self-administration order for any medications.
On 04/09/24 at 11:44 AM, an observation of R1's room revealed a bottle of refresh eyedrops (an over the counter [OTC - available without a prescription] medication used to lubricate the eyes and harmful to humans if swallowed) on the over-the-bed-table sitting on top of an insulated cup with a lid, Ciclopirox (a prescription antifungal medication used to treat fungal infections of fingernails and toenails and harmful to humans if swallowed) drops and Restasis (a prescription medication used to lubricate and reduce inflammation on the surface of the eye and harmful to humans if swallowed) drops on over-the-bed table.
On 04/10/24 at 10:13 AM, observation of R1's room revealed a bottle of refresh eye drops on the insulated cup with lid, Ciclopirox drops and Restasis drops on the resident's over-the-bed table.
On 04/11/24 at 09:15 AM, observation of R1's room revealed R1 resting in bed watching TV with a breakfast tray present on over-the-bed table with ciclopirox drops, Restasis and refresh drops also present on over-the-bed table.
On 04/11/24 at 02:00 PM, observation of R1's room revealed ciclopirox drops, Restasis and refresh drops present on over-the-bed table.
On 04/15/24 at 07:45 AM, observation of R1's room revealed ciclopirox drops, Restasis and refresh drops remained on over-the-bed table.
On 04/10/24 at 02:05 PM, Certified Nurse Aide (CNA) N revealed that medications were not allowed to be stored in resident's rooms and if discovered, the medications should be moved out of the resident's reach and to notify the Licensed Nurse (LN).
On 04/10/24 at 02:10 PM, LN E revealed that medications were prohibited in resident rooms unless the resident had been assessed for self-administration safety and had a physician's order specific to the self-administration of each medication.
On 04/15/24 at 08:55 AM, Administrative Nurse B confirmed that medications should not be stored in resident's rooms unless the resident had a self-administration safety assessment and a physician's order for self-administration for each medication. Administrative Nurse B then confirmed the lack of self-administration safety assessment and physician's order for self-administration.
On 04/17/24 at 11:15 AM, according to the Poison Control Center (1-800-222-1222 https://www.poison.org ) reported ciclopirox, Restasis and refresh medications were harmful and would cause gastrointestinal distress that included nausea, vomiting and diarrhea.
The facility's undated Storage of Medications policy documented that medications were stored in safe, secure, and orderly manner and lacked instructions related to self-administration of medications.
The facility failed provide a safe environment for 13 residents by the failure to ensure that R1's room remained free of unsecured medications. This deficient practice had the potential to create an accidental ingestion of medications to these confused, mobile residents.

The facility reported a census of 64 residents. The facility identified one central kitchen with two satellite kitchens and two dining areas. Based on observation, interview, and record review, the facility failed to provide food that was palatable, attractive and at a safe and appetizing temperature.
Findings included:
- On 04/11/24 at 09:00 AM, test trays were requested from Dietary Staff H for the noon meal service, one from each of the satellite kitchens.
On 04/11/24 at 12:24 PM Dietary Staff H provided surveyors with a meal tray from the west kitchen with all foods measured by Dietary Staff H above appropriate temperature of 135 degrees Fahrenheit (°F) for food service. All foods were sampled for palatability, and all were acceptable except for the tater-tots which tasted stale and freezer burnt.
On 04/11/24 at 12:48 PM Dietary Staff Z provided surveyors with a meal tray from the east kitchen with all foods measured by Dietary Staff Z. The tater-tots measured at 130.9 °F and popcorn shrimp measured at 132 °F. Dietary Staff Z stated that all foods were to be served at 135°F or higher. All foods were sampled for palatability, and all were acceptable except for the tater-tots which were cool and tasted stale and freezer burnt and the shrimp which was cool and unpalatable.
On 04/11/24 at 01:10 PM, Dietary Staff H confirmed that all hot foods should be served at a minimum of 135 °F.
The facility failed to provide a policy related to food palatability and food service temperatures as requested on 04/11/24.
The facility failed to provide food that was palatable, attractive and at a safe and appetizing temperature. This deficient practice had the potential to lead to resident's not eating appropriate portion sizes and causing foodborne illnesses due to improper serving temperature.

The facility reported a census of 64 residents. The facility identified one central kitchen with two satellite kitchens and two dining areas. Based on observation, interview, and record review, the facility failed to provide sanitary food preparation and storage of food to prevent the spread of food borne illness to the residents of the facility.
Findings included:
- Initial tour of the kitchen on 04/09/24 at 09:05 AM with Dietary Staff H, revealed the following areas of concerns:
1. In the west kitchen, Dietary Staff Y performed tasks in the kitchen and had long hair exposed below the level of her buttocks with hair restraint device covering only the top of her head.
2. In the west kitchen, in the refrigerator, a bottle of orange juice with a factory expiration date of 09/29/23.
3. In the west kitchen, in the freezer, a package of hotdog buns unsealed and opened to air.
4. In the west kitchen freezer, a package of miscellaneous bread products unsealed and opened to air.
5. In the main kitchen food preparation area, four cutting boards with non-cleanable surfaces.
6. In the main kitchen, in the stand-alone freezer, four bags of various types of potatoes (chunked, whole, tater-tots, etc.) unsealed and undated.
7. In the main kitchen, in the stand-alone freezer, one bag of sliced onions undated.
8. In the main kitchen, in the stand-alone refrigerator, one large container of mayonnaise undated.
9. In the main kitchen, in the walk-in refrigerator, one large bag of raw chicken, open and undated.
10. In the main kitchen, in the walk-in freezer, one package of an unknown and unidentifiable food product unlabeled and undated.
11. In the main kitchen, in the walk-in freezer, one large bag of assorted vegetables, opened and undated.
12. In the main kitchen, in the walk-in freezer, one large box of frozen corn, opened and undated.
13. In the main kitchen, in the walk-in freezer, one bag of corn dogs, opened and undated.
14. In the main kitchen, in the walk-in freezer, one large box of hot links, opened and undated with ice crystals on the food.
On 04/09/24 at 09:53 AM, Dietary Staff H stated that all items in the refrigerators and freezers should be sealed and dated with an expiration date. All staff should have hair restraint devices on when in the kitchen areas.
The facility's undated Food Storage policy documented that all foods in the kitchen would be labeled and include the name of the food and expiration date. Additionally, documented that raw poultry should not be left uncovered or unsealed.
The facility failed to provide a policy for hair-restraint use in the kitchen areas as requested on 04/09/24,
The facility failed to provide sanitary food preparation and storage of food. This deficient practice had the potential to cause the spread of food borne illness to the residents of the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 67 residents, with three residents included in the sample. Based on observation, interview, and record review, the facility failed to provide adequate supervision and ensure a safe environment on 11/20/23, when the facility sent cognitively impaired dependent Resident (R)1 to R2's medical appointment. The facility mixed up R2 and R1's identity and dropped off R1 at the front doors of a medical clinic, alone, for R2's appointment. R1 did not have any identification on him and did not know why he was at the appointment. The facility did not know R1 was out of the facility until the medical clinic staff called the facility to point out the facility dropped off the incorrect resident.
Finding included:
- The Physician Orders for R1, dated 10/18/23, revealed a diagnosis of cognitive communication deficit (difficult recalling short-term or long-term information).
The Significant Change of Status Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview Mental Status score of three, indicating severe cognitive impairment. R1 required extensive assistance of two staff with most Activities of Daily Living (ADL), used a mechanical lift for transfers, and a wheelchair for mobility.
The Quarterly MDS dated 10/13/23, indicated a BIMS score of four, indicating severe cognitive impairment. R1 was dependent for ADLs, used a mechanical lift for transfers, and a wheelchair for mobility.
The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 10/18/23, revealed the resident had cognitive loss, change in mental status, and short-term memory loss.
The Care Plan revised 10/25/23, revealed R1 had impaired cognitive function or impaired decision making, and short-term memory loss. R1 required extensive assistance with ADLs.
The Nurses Notes dated 11/20/23 at 11:34 AM, revealed a contracted transport company transported R1 to a hospital (mistakenly, for a R2's medical appointment) due to (mistaken identity due to R1 and R2 had) identical (first) names. The staff notified R1's responsible party.
The Electronic Medical Record for R1 lacked further documentation when facility staff sent a cognitively impaired R1 to R2's clinical medical appointment.
The facility lacked an investigation following the return of R1 to the facility on [DATE] confirmed through interview with Administrative Nurse D.
Observation on 12/04/23 at 09:35 AM revealed R1 sat in a high back wheelchair. R1 observed with a lift sling (sling usually of cloth material, placed under the resident for a transfer with a full body mechanical lift) underneath him. R1 had difficulty keeping his eyes open and could not hold a conversation.
During an interview with the Medical Clinical Nursing Staff (MCN) Z on 12/04/23 at 09:45 AM, revealed the facility staff did not know R1 was not in the facility until the medical clinic called the facility. MCN Z stated R1 had paperwork for an appointment, and when the clinic nursing staff questioned R1, he could not tell the clinic staff member why he was there for an appointment. R1 was in a personal wheelchair with a mechanical lift sling underneath him. R1 did not have any identification, wallet, or cell phone on him, and when the clinic nursing staff asked his name during check-in, he replied with a different name than who was scheduled for the appointment, or his correct name. MCN Z reported the resident was very confused, and several clinic staff attempted to get information from him. There was no family or facility staff with him, so a clinic nursing staff took the appointment paperwork (R2's paperwork) and called the contact on the paperwork. MCN Z reported R2 answered the phone and informed clinic nursing staff that he was still at the facility, in his bedroom. Clinic nursing staff then notified the facility receptionist that R1 was at the medical clinic and was the wrong resident. After being placed on hold on the phone, the facility informed MCN Z there was a mix up on what resident should have been at the medical appointment. MCN Z reported the facility management they spoke with, just did a little laugh and said they were super busy with some residents that were dying and the facility had a new Certified Nurse Aide (CNA). MCN Z reported she told the facility management they needed to pick up the resident from their exam room. MCN Z said the facility should not have left a confused resident alone at the medical clinic with no one to help or no identification.
On 12/04/23 at 11:35 AM, Administrative Nurse D reported there was concern when staff transported the wrong resident to the appointment. There was a mix up of the residents. She reported she did not do an investigation and did not make a report to the State of Kansas Reporting hotline.
On 12/06/23 at 10:40 AM, Administrative Nurse D verified R1 left the faciity on [DATE] at 09:30 AM and did not return to the facility until 11:30 AM (a total of two hours).
Interview with Licensed Nurse (LN) G on 12/04/23 at 03:30 PM, revealed the facility was short staffed when the resident mix-up occurred. The wrong confused dependent resident (R1) went to the appointment. When the (facility) receptionist called the nurses station and asked for the resident (by his first name only), staff took the wrong resident to the front desk for the transport.
The facility failed to provide a policy regarding Resident Identification System as requested on 12/04/23.
The facility failed to provide adequate supervision and ensure a safe environment on 11/20/23, when the facility sent cognitively impaired dependent Resident (R)1 to R2's medical appointment. The facility mixed up R2 and R1's identity and dropped off R1 at the front doors of a medical clinic, alone, for R2's appointment. R1 did not have any identification on him and did not know why he was at the appointment. The facility did not know R1 was out of the facility until the medical clinic staff called the facility to point out the facility dropped off the incorrect resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 59 residents. The sample included 18 residents with two reviewed for hospitalization. Based on observation, interview, and record review the facility failed to provide the resident or resident representative with written information regarding the facility bed hold policy, when R18 transferred to the hospital. This placed R18 at risk for not being permitted to return and resume residence in the nursing facility.
Findings included:
- R18's Electronic Medical Record (EMR) documented the resident had diagnoses of major depressive disorder (major mood disorder), diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), muscle weakness, and altered mental status (state of awareness that was different from the normal awareness of a person).
R18's Significant Change Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview of Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS documented the resident required total staff assist with transfers and locomotion off unit, extensive staff assistance with bed mobility, dressing, toileting, locomotion on the unit, and limited staff assistance with eating and personal hygiene.
R18's Activities of Daily Living (ADL) Care Plan, dated 04/11/22, documented the resident required total staff assistance with locomotion, extensive staff assistance with bed mobility, transfers, toileting and personal hygiene, and supervision with eating.
R18's Progress Notes, dated 03/20/22 at 04:22 PM, documented the resident transferred by ambulance to the hospital.
Review of R18's Progress Notes revealed lack of documentation the facility provided the resident or representative with the facility bed hold policy regarding the 03/20/22 hospitalization transfer.
On 06/21/22 at 12:00 PM, observation revealed the resident rested in bed and ate his noon meal independently.
On 06/23/22 at 08:20 AM, Administrative Staff A stated the business office notified the resident or resident representative by telephone regarding the facility bed hold policy.
On 06/23/22 at 08:40 AM, Administrative Staff A verified the facility did not send the bed hold policy with the resident or resident representative on transfer to the hospital or go over the bed hold policy with them.
The facility's Bed-Holds and Returns Policy, revised March 2017, documented prior to transfers and therapeutic leaves, residents or resident representative would be informed in writing of the bed-hold and return policy.
The facility failed to provide R18 or his representative with the bed hold policy when he was transferred to the hospital on [DATE]. This placed the resident at risk for not being permitted to return and resume residence in the nursing facility.

The facility had a census of 59. The sample included 18 residents. Based on observation, interview, and record review the facility failed to provide care in a timely manner for Resident (R) 54 when facility staff did not answer her call light (used to request assistance) for 28 minutes. This deficient practice placed R54 at risk to not have care or assistance in a timely manner.
Findings included:
- R54's Physician Oder Sheet, dated 06/21/22, included diagnoses of 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), diabetes mellitus (condition results from insufficient production of insulin, causing high blood sugar), meningitis (infection of meninges, protective tissue of the brain that causes stiff neck, headache and fever), and myopathy (disorders in which the primary symptom is muscle weakness due to dysfunction of muscle fiber).
The Care Plan, dated 06/12/22, directed staff to anticipate and meet the resident's needs, ensure her call light remained within reach and encourage the resident to use the bell to call for assistance. The resident wanted to have the call light left on until someone provided assistance. The resident usually knew when she needed the bathroom.
On 06/21/22 at 10:09 AM, R54 stated staff come in and turn off the call light and do not come back to help for up to an hour later, sometimes.
On 06/23/22 at 08:52 AM, the surveyor entered R54's room to visit with the resident. At 09:37 AM, the surveyor activated the bedside call light. At 09:55 AM, the surveyor activated the bathroom call light. Observation revealed at 10:05 AM Licensed Nurse (LN) I and Certified Nurse Aide (CNA) P responded to the call light, 28 minutes after activating the bedside call light.
On 06/27/22 at 11:40 AM, Administrative Nurse D verified staff were expected to answer call lights promptly. She stated the facility used pagers connected to the call lights and if staff did not answer within five minutes the call would go to Certified Medication Aides (CMAs), then after no answer for another five minutes the notice would page the nurse on duty. Administrative Nurse D stated she expected staff to respond and they should leave the call light on.
The facility's policy for Answering the Call Light, dated 03/2021, documented the purpose of the procedure was to ensure timely responses to the resident's needs and requests. The policy stated staff were to ensure the call light plugged in and functioning at all times, within reach of the resident, and report all defective call lights to the nurse supervisor immediately.
The facility failed to ensure timely response to R54's call for assistance, placing R54 at risk to not have care needs met.

The facility had a census of 59 residents. The sample included 18 residents with one reviewed for pressure ulcers. Based on observation, interview, and record review, the facility failed to initiate effective interventions according to standards of care to prevent the development of a right dorsal (the back, or upper surface of the foot) foot, facility acquired Stage 3 pressure ulcer (full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue may be present) for Resident (R)2.
Findings included:
- R2's Physician Order Sheet dated 06/21/22, included diagnoses of anxiety (mental or emotional reaction characterized by apprehension), diabetes mellitus Type 2 (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), hyponatremia (greater than normal concentration of sodium in the blood), and right-side hemiplegia (paralysis of one side of the body).
R2's Quarterly Minimum Data Set (MDS) assessment, dated 04/21/22, documented R2 had severely impaired cognition and required extensive assistance with two staff for bed mobility, transfers, dressing, toileting, and personal hygiene. The MDS further documented the resident had no skin issues.
The 10/18/21 Pressure Ulcer Care Area Assessment (CAA) documented the resident had a 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) that placed him at risk for impaired skin and had impaired mobility, incontinence, and not able to communicate his needs to the staff. The CAA documented the resident had no skin issues or pressure ulcers.
The Braden Scale Assessment for predicting pressure ulcer risk, dated 10/01/21 and 02/01/21 documented a score of 10 which indicated the resident a high risk for pressure ulcer development.
The Activities of Daily Living (ADL) Care Plan, dated 03/08/22 directed the staff to monitor the resident for skin break down, turn and reposition at least every two hours, more often as needed or if he/she displayed discomfort. The ADL Care Plan documented the resident had impaired mobility, was at risk for pressure ulcer development, and directed staff to use off-loading boots to prevent skin breakdown.
The Physician Order, dated 10/12/21 ordered the staff to obtain weekly skin assessments.
The Physician Order, dated 02/23/22 directed the staff to apply the Prevalon (a boot designed with an open, floated-heel design which means the heel is completely floated. This provides continuous pressure relief.) boots when the resident was in bed.
The Skin Alteration Assessment, dated 05/30/22 documented a wound on the resident's lateral 5th toe, that measured 1.2 centimeters (cm) by 1.1 cm, with no drainage.
The Wound Care Plus Skin Assessment, dated 06/02/22, documented R2 had one open area on his right dorsal foot, measuring 2.0 cm by 1.2 cm by 0.1 cm depth with a moderate amount of yellow drainage. The nurse practitioner ordered the staff to cleanse the wound with wound cleanser and use to irrigate or scrub the wound bed (mechanical debride). Protect the peri wound with Skin Prep Protectant (forms protective film), cover with a border gauze, and change the dressing every other day and as needed for soiling, saturation, or unscheduled removal.
The Wound Care Plus Skin Assessment, dated 06/09/22, documented R2 had one open area on his right dorsal foot, and the Nurse Practitioner debrided the area measuring 1.5 cm by 1.5 cm by 0.1 cm with moderate amount of yellow drainage. The nurse practitioner ordered the staff to apply a skin protectant around the wound, apply a cut to fit Calcium Alginate (a dressings are highly absorptive, non-occulsive dressings made of soft, non-woven calcium alginate fibers derived from brown seaweed or kelp) dressing to the wound base and cover with a silicone border foam gauze and change every Tuesday, Thursday, and Saturday and as needed.
The Skin Alteration Assessment, dated 06/09/22, documented a wound on the resident's lateral 5th toe, that measured 1.5 cm by 1.5 cm by 0.1 cm, with moderate drainage.
The Skin Alteration Assessment, dated 06/16/22, documented a wound on the resident's right toes, measuring 1.5 cm by 1.5 cm by 0.1 with moderate drainage.
The Physician Order, dated 06/18/22, documented to apply Calcium Alginate to the wound area, cover with Opti foam (a foam dressing that has silicone adhesive border, waterproof backing that can stay in place for 7 days) border, and change every Tuesday, Thursday and Saturday.
The Skin Alteration Assessment, dated 06/23/22, documented a wound on the resident's right toes, that measured 1.2 cm by 1.2 cm by 0.1 with moderate drainage.
The Wound Care Plus Skin Assessment, dated 06/23/22, documented R2 had one open area noted on his right dorsal foot, measuring 1.2 cm centimeters by 1.2 cm, with 0.1 cm depth with maceration. The nurse practitioner ordered the staff to cleanse the wound with wound cleanser, use to irrigate or scrub the wound bed (mechanical debride), apply Skin Prep Protectant (a liquid film-forming dressing that, upon application to intact skin, forms a protective film to help reduce friction during removal of tapes and films) around the wound, apply a cut to fit dressing to the wound base, cover with a silicone border foam gauze, and change every Tuesday, Thursday, and Saturday and as needed.
On 06/22/22 at 03:30 PM, observation revealed R2 lying on their back in bed with the lights off and eyes closed. R2 laid on a low air loss mattress with protective boots on both feet.
On 06/23/22 at 10:20 AM, observation revealed R2 lying on their back in bed when Licensed Nurse (LN) H removed the protective boot and gauze dressing from R2's right dorsal foot. Continued observation revealed the dressing was embedded into the wound and LN H pulled the dressing off and the resident winced and shook his head as he was having pain. LN H cleansed the wound with wound cleanser, applied a cut-to-fit calcium alginate dressing to the open area, and covered with an Opti foam dressing on top of the dressing.
On 06/23/22 at 10:40 AM interview with LN H, facility wound nurse, verified R2 developed a pressure ulcer on his right dorsal foot on 05/30/22. LN H said R2 wore a Prevalon boot when in bed and the boot caused a sore on his toes. LN H verified the resident refused to get out of bed.
On 06/27/22 at 01:45 PM, Administrative Nurse D verified the resident developed the facility acquired Stage 3 pressure ulcer on his right dorsal foot on 05/30/22. Administrative Nurse E verified the resident had pressure relieving boots since 02/2022 and would cross his legs at the ankle area and developed the area on the foot from positioning.
The facility Skin and Wound Management policy, dated January 2021, documented the policy was to prevent the development of pressure injury unless clinically unavoidable. The policy documented all residents are screened to determine their risk of development of pressure injury using the Braden Scale. A licensed nurse would perform a visual head to toe skin review upon admission or readmission to determine general skin condition and identify any pre-existing skin concerns and/or wounds. All wounds are monitored at least weekly by a licensed nurse.
The facility failed to initiate timely interventions to prevent the development of a Stage 3 facility acquired pressure ulcer for R2, placing the resident at risk for further skin breakdown.

The facility had a census of 59 residents. The sample included 18 residents with two reviewed for pain. Based on observation, interview, and record review the facility failed to provide interventions during wound care to manage Resident (R) 2's distress and pain. This placed the resident at risk for prolonged and unnecessary pain or distress.
Findings included:
- R2's Physician Order Sheet dated 06/21/22, included diagnoses of anxiety (mental or emotional reaction characterized by apprehension), diabetes mellitus type 2 (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), hyponatremia (greater than normal concentration of sodium in the blood), and right-side hemiplegia (paralysis of one side of the body).
R2's Quarterly Minimum Data Set (MDS) assessment, dated 04/21/22, documented R2 had severely impaired cognition and required extensive assistance with two staff for bed mobility, transfers, dressing, toileting, and personal hygiene. The MDS further documented the resident had no skin issues, and received scheduled pain medication
The 10/18/21 Pain Care Area Assessment (CAA) documented the resident had a 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 documented the resident was not able to be interviewed, due to aphasia (condition with disordered or absent language function) however, staff noted some facial grimacing when the resident moved. R2 did not express any vocal expression of pain but had the potential for pain due to his impaired mobility. The CAA documented staff would observe for pain during routine care.
The Pain Care Plan, dated 03/08/22, documented the resident had signs of pain due to a recent stroke and directed the staff to monitor the resident for pain, provide pain relief, and respond immediately to any signs of pain. The Care Plan directed the staff to evaluate the effectiveness of pain interventions within 45 minutes of administering, review for compliance, alleviated the symptoms, dosing schedules, and resident satisfaction with results, impact on functional ability and impact on cognition. Continued Care Plan directed the staff to monitor the resident for non-verbal signs of pain including changes in breathing, moaning, yelling out, mood and behavior changes, face grimacing, rocking, and thrashing.
On 06/22/22 at 03:30 PM, observation revealed R2 lying on their back in bed with the lights off and eyes closed. R2 rested on a low air loss mattress with protective boots on both feet.
On 06/23/22 at 10:20 AM, observation revealed R2 lying on their back in bed when Licensed Nurse (LN) H removed the protective boot and gauze dressing from R2's right dorsal foot. Continued observation revealed the dressing was embedded into the wound and when LN H pulled the dressing off, the resident winced and shook his head as he was having pain. LN H cleansed the wound with wound cleanser and applied the physician ordered dressing.
On 06/23/22 at 08:50 AM, LN G verified the resident had discomfort during the wound dressing change and cares. LN G said she normally does not give the resident pain medication during dressing changes.
On 06/27/22 at 01:45 PM, Administrative Nurse D verified she expected nursing staff to administer pain medication 30 minutes prior to wound care and to notify her if the resident's complaints of pain during the wound care continued.
The facility's Pain Assessment and Recognition policy, dated March 2018, documented the nursing staff would assess each individual's pain upon admission to the facility, at the quarterly review. Whenever there is a significant change in condition, and when there is onset of a new pain or worsening of existing pain. The nursing staff would identify any situations or interventions where an increase in the resident's pain may be anticipated; for example, wound care, ambulation, or repositioning. The physician would order appropriate non-pharmacological and medications interventions to address the individual's pain. Pain medication should be selected based upon pertinent treatment guidelines.
The facility failed to provide interventions during wound care to manage R2's distress and pain. This placed the resident at risk for prolonged and unnecessary pain and discomfort.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 59 residents. The sample included 18 residents with one reviewed for dialysis (blood purifying treatment given when kidney function is not optimum). Based on observation, interview, and record review the facility failed to obtain communication from the dialysis center regarding Resident (R) 33's health status with each procedure. This deficient practice placed R33 at risk for unmet needs due to lack of information regarding the resident's health status during the dialysis procedures.
Findings included:
- R33's Physician Order Sheet (POS), dated 06/21/22, documented diagnoses of end stage renal disease (condition where the kidney reaches advanced state of loss of function), and type 2 diabetes mellitus (condition from insufficient production of insulin, causing high blood sugar).
The admission Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The MDS documented the resident was independent with eating, required two staff assistance for all other activities of daily living, and received dialysis.
The Dialysis Care Plan, dated 04/12/22, documented R33 had end stage renal disease, received dialysis Monday, Wednesday, and Friday at a local dialysis center, had a dialysis catheter to his right upper chest, and a fistula (dialysis access) to his right wrist. The care plan directed staff to obtain thrill and bruit (rumbling or swooshing sound and feel of a dialysis fistula every shift, notify the physician of any abnormalities, and observe for bleeding, or signs of infection. The care plan directed staff to monitor, document every shift, and report to the physician any signs of infection to the access site, such as redness, swelling, warmth, coolness, or drainage. The care plan documented the facility would assist, as needed, to coordinate services and care with the dialysis clinic and communication with the dialysis center will be done pre/post each visit using a communication sheet or via phone and documented. The care plan documented R33 may require more assistance on dialysis days.
The Dialysis Book contained forms completed by facility staff relating information to the dialysis center, but no resident information returned by the dialysis staff.
The Dialysis Agreement, dated 06/22/22, signed by a dialysis representative and the facility lacked responsibilities of each entity.
On 06/22/22 at 09:35 AM, observation revealed R33 self-propelled his wheelchair to the nurse's desk and requested to be weighed, which staff did. R33 requested a pain pill and Licensed nurse (LN) I administered the pain pill and completed a pre-dialysis evaluation of the resident.
On 06/22/22 at 03:32 PM, LN I stated the resident just got back from dialysis and was eating. She stated he ate breakfast and staff saved lunch for when he returned between 3 and 4 PM. LN I stated R33 received dialysis with an access port and the physician created a dialysis fistula on his right wrist last week. LN I stated the facility sent the pre dialysis information with him, but dialysis staff had not sent any information back unless it was a new physician's order.
On 06/23/22 at 01:35 PM, Administrative Nurse D stated the dialysis center only sent changes in medications, and stated she encouraged facility nurses to request labs from them. Administrative Nurse D verified she expected dialysis staff to send information regarding the resident's status during the procedure.
The facility's End-Stage Renal Disease Care of a Resident policy, dated 09/2010, documented agreements between this facility and the contracted dialysis facility would include all aspects of how the resident's care would be managed, including how information would be exchanged between the facilities.
The facility failed to obtain communication from the dialysis center regarding R33's health status with each procedure, placing R33 at risk for unmet needs due to lack of information regarding the resident's health status during the dialysis procedures.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 59 residents. The sample included 18 residents. Based on observation, interview, and record review the facility staff failed to treat Resident (R) 4 and R16 with dignity when staff checked their blood pressure (test measures the pressure in your arteries as your heart pumps) and administered their insulin (a medication used to regulate blood sugar levels) at the dining room table, with nine other residents able to view them during meal service and dining. The staff also failed to close the bedroom curtain to promote dignity and privacy, while R8 sat on a bed pan.
Findings included:
- On 06/22/22 at 08:10 AM, observation revealed Licensed Nurse (LN) G checked R4's and R16's blood pressure and administered their insulin at the dining room table with nine other residents able to view the procedures.
On 06/22/22 at 08:12 AM, LN G stated sometimes she checked R4 and R16's blood pressure and administered their insulin at the dining room table because they wanted her too.
On 06/27/22 at 09:15 AM, LN H stated she would not administer R4 and R16's insulin or take their blood pressure at the dining room table, she would take them to the spa room or parlor and close the doors.
On 06/22/22 at 08:15 AM, Administrative Nurse D stated staff should not check residents' blood pressure and administer insulin at the dining room table, they should take them to the room or to a private area.
The facility's Dignity Policy, revised February 2021, documented each resident should be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self -worth and self-esteem.
The facility staff failed to treat R4 and R16 with dignity when staff checked their blood pressure and administered their insulin at the dining room table during meals.
- R8's documented diagnoses included anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), constipation (difficulty passing stool), Diabetes Mellitus type 2 (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), and incontinence (loss off bladder control/urine).
R8's Quarterly Minimum Data Set (MDS), dated [DATE], recorded R8 had a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. The assessment revealed R8 required extensive staff assistance of two for bed mobility, personal hygiene, dressing, repositioning, and transfers.
The Activities of Daily Living Care Area Assessment (CAA), dated 07/13/21, recorded the resident had actual self-care performance deficits.
The Activities of Daily Living Care Plan, dated 05/12/22, documented the resident required two staff for toileting, and had a performance deficit due to activity intolerance. The care plan lacked any documentation the resident used a bedpan.
On 06/22/22 at 11:00 AM, observation revealed R8's room door open and Licensed Nurse (LN) J entered the resident's room to administer her medications. Further observation revealed the resident had her dress up, sitting on the bed pan, with the lower part of her body exposed. Continued observation revealed the resident's windows had the blind's half up and visualization to the parking lot.
On 06/23/20 at 11:30 AM, observation revealed R8's sitting on the bed pan with her dress up and the lower part of her body exposed. Continued observation revealed the resident's window had the blinds half up and visualization of the parking lot.
On 06/27/22 at 10:30 AM, Administrative Nurse D verified the resident should have the window blinds closed when she used the bed pan. Administrative Nurse D verified it was not appropriate for the resident to be exposed when in her bed.
The facility's Dignity policy, dated February 2021, documented each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level or satisfaction with life, and feelings of self-worth and self-esteem. Th e policy documented resident would always be treated with dignity and respect and staff would promote, maintain and protect residence privacy, including bodily privacy during assistance with personal cares and during treatment procedures.
The facility failed to provide dignity for R8 when using the bedpan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 59 residents. The sample included 18 residents with five reviewed for unnecessary medications. Based on observation, interview, and record review the facility failed to follow up on the Consultant Pharmacist request for an appropriate diagnosis for the use of Seroquel, an antipsychotic (a drug used to treat psychotic disorders) medication for Resident (R) 13. This deficient practice placed R13 at risk for adverse effects related to the use of antipsychotic medication.
Findings included:
- R13's Physician Order Sheet (POS), dated 06/16/22, documented diagnoses of cerebral infarction (stroke), atherosclerosis (condition where the arteries become narrowed and hardened due to buildup of plaque (fats), dementia (group of symptoms that affects memory, thinking and interferes with daily life), vertigo (sense of spinning experienced even when someone is perfectly still), myoclonus (spasmodic jerky contraction of groups of muscles), hallucinations (experience in which you see, hear, feel, or smell something that does not exist), metabolic encephalopathy (abnormalities of the water, electrolytes, vitamins, and other chemicals that adversely affect brain function), and cerebral infarction (stroke).
The admission Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental status (BIMS) score of 12, indicating moderately impaired cognition. The MDS documented R13 did not have mood or behavior issues, was independent with bed mobility, and required supervision for most other activities of daily living. The MDS documented R13 had one non-injury fall and received antipsychotic medication four days of the lookback period.
The Psychotropic Care Area Assessment (CAA), dated 04/07/22, documented the resident was at risk for side effects related to the use of Seroquel (antipsychotic) and Cymbalta (antidepressant), and had a history of hallucinations and dementia.
The Cognitive/Dementia CAA was blank.
The Medication Care Plan, dated 04/5/22, documented R13 used Seroquel related to a diagnosis of dementia with behavior disturbance and directed staff to administer medications as ordered, monitor for side effects and effectiveness. The care plan directed staff to consult with pharmacy and the physician to consider dosage reduction when clinically appropriate, discuss with the physician and family any ongoing need for use of medication and risks, benefits and the side effects or toxic symptoms of Seroquel. The care plan directed staff to monitor and record occurrences of for target behavior symptoms (not specified) and document per facility protocol, monitor and report to the physician side effects and adverse reactions of psychoactive medications. Arrange for psych consult and follow up as indicated. Monitor, document, and report to the nurse signs of depression and provide a pharmacy review monthly.
The Physician's Order, dated 04/20/22, directed staff to administer Seroquel, 25 milligrams (mg), at bedtime for a diagnosis of dementia.
Review of Nursing Notes and the May and June 2022 Medication Administration Record (MAR) revealed no abnormal behaviors of yelling, agitation, or hallucinations noted by staff.
The Consultant Pharmacist Review, dated 04/15/22, documented an inappropriate diagnosis for the use of Seroquel and requested a risk versus benefit statement. The physician response stated done.
The Healthcare Provider Note, dated 04/19/22, documented the patient doing well on current dosing, but given her history, would recommend continue Seroquel at this time as benefit outweighs risk.
The Consultant Pharmacist Review, dated 06/16/22, noted an inappropriate diagnosis for the use of Seroquel and requested a risk versus benefit statement. The physician response stated, risk outweighs benefit and did not address the inappropriate diagnosis.
On 06/23/22 at 08:08 AM, observation revealed R13 independently ambulated to the dining room with a walker where Licensed Nurse (LN) K obtained her blood pressure and administered R13's medications.
On 06/27/22 at 01:17 PM, LN K sated R13 obsessed about her eye drops, but had no hallucinations or abnormal thoughts. LN K verified the diagnosis of dementia for Seroquel was not appropriate and stated the medication was started when the resident was in the hospital.
On 06/27/22 at 01:30 PM, LN I verified dementia was an inappropriate diagnosis for the use of Seroquel.
On 06/27/22 at 02:00 PM, Administrative Nurse D verified the diagnosis of dementia for the use of Seroquel was inappropriate and she did not realize the consultant pharmacist requested an appropriate diagnosis.
The Pharmacy Services Role of the Consultant pharmacist policy, dated 04/2019, documented the consultant pharmacist would review the medication regimen of each resident monthly, provide communication to prescribers and community leadership about potential or actual problems related to any aspect of medications or pharmacy services including medication irregularities.
The facility failed to follow up on the Consultant Pharmacist request for an appropriate diagnosis for the use of Seroquel, an antipsychotic (a drug used to treat psychotic disorders) medication for R13. This deficient practice placed R13 at risk for adverse effects related to the use of antipsychotic medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 59 residents. The sample included 18 residents with five reviewed for unnecessary medications. Based on observation, interview, and record review the facility failed to ensure Resident (R) 13 did not receive antipsychotic (a drug used to treat psychotic disorders) medication without an appropriate diagnosis. This deficient practice placed R13 at risk for adverse effects related to the use of antipsychotic medication.
Findings included:
- R13's Physician Order Sheet (POS), dated 06/16/22, documented diagnoses of cerebral infarction (stroke), atherosclerosis (condition where the arteries become narrowed and hardened due to buildup of plaque (fats), dementia (group of symptoms that affects memory, thinking and interferes with daily life), vertigo (sense of spinning experienced even when someone is perfectly still), myoclonus (spasmodic jerky contraction of groups of muscles), hallucinations (experience in which you see, hear, feel, or smell something that does not exist), metabolic encephalopathy (abnormalities of the water, electrolytes, vitamins, and other chemicals that adversely affect brain function), and cerebral infarction (stroke).
The admission Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental status (BIMS) score of 12, indicating moderately impaired cognition. The MDS documented R13 did not have mood or behavior issues, was independent with bed mobility, and required supervision for most other activities of daily living. The MDS documented R13 had one non-injury fall and received antipsychotic medication four days of the lookback period.
The Psychotropic Care Area Assessment (CAA), dated 04/07/22, documented the resident was at risk for side effects related to the use of Seroquel (antipsychotic) and Cymbalta (antidepressant), and had a history of hallucinations and dementia.
The Cognitive/Dementia CAA was blank.
The Medication Care Plan, dated 04/05/22, documented R13 used Seroquel related to a diagnosis of dementia with behavior disturbance and directed staff to administer medications as ordered, monitor for side effects and effectiveness. The care plan directed staff to consult with pharmacy and the physician to consider dosage reduction when clinically appropriate, discuss with the physician and family any ongoing need for use of medication and risks, benefits and the side effects or toxic symptoms of Seroquel. The care plan directed staff to monitor and record occurrences of for target behavior symptoms (not specified) and document per facility protocol, monitor and report to the physician side effects and adverse reactions of psychoactive medications. Arrange for psych consult and follow up as indicated. Monitor, document, and report to the nurse signs of depression and provide a pharmacy review monthly.
The Physician's Order, dated 04/20/22, directed staff to administer Seroquel, 25 milligrams (mg), at bedtime for a diagnosis of dementia.
Review of nursing notes and the May and June 2022 Medication Administration Record (MAR) revealed no abnormal behaviors of yelling, agitation or hallucinations noted by staff.
The Consultant Pharmacist Review, dated 04/15/22, documented an inappropriate diagnosis for the use of Seroquel and requested a risk versus benefit statement. The physician response stated done.
The Healthcare Provider Note, dated 04/19/22, documented the patient doing well on current dosing, but given her history, would recommend continue Seroquel at this time as benefit outweighs risk.
On 06/23/22 at 08:08 AM, observation revealed R13 independently ambulated to the dining room with a walker where Licensed Nurse (LN) K obtained her blood pressure and administered R13's medications.
On 06/27/22 at 01:17 PM, LN K sated R13 obsessed about her eye drops, but had no hallucinations or abnormal thoughts. LN K verified the diagnosis of dementia for Seroquel was not appropriate and stated the medication was started when the resident was in the hospital.
On 06/27/22 at 01:30 PM LN I verified dementia was an inappropriate diagnosis for the use of Seroquel.
On 06/27/22 at 02:00 PM, Administrative Nurse D verified the diagnosis of dementia for the use of Seroquel was inappropriate.
The facility's Antipsychotic Medication Use policy, dated 12/2016, documented residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective. Residents who are admitted for m the community or hospital already receiving antipsychotics will be evaluated for the appropriateness and indication for use and diagnosis alone does not warrant the use of antipsychotic mediation. All antipsychotic medications should be used within the dosage guidelines and the regulations, or clinical justification would be documented. The physician shall respond appropriately by changing or stopping problematic medications or clearly documenting why the benefits of the medication of outweigh the risks.
The facility failed to ensure R13 did not receive antipsychotic medication without an appropriate diagnosis or clinical justification for its use, placing R13 at risk for adverse side effects related to the use of Seroquel.

- On 06/21/22 at 11:54 AM, observation revealed Certified Nurse Aide (CNA) N picked up Resident (R) 21's used glass and refilled it with lemonade. Continued observation revealed she did not use hand gel or wash her hands before she touched the wheelchair handles of R111, filled a clean glass with ice and water for R 116, handled clean glasses for another resident, wiped her hands on her uniform, and obtained a glass of juice for another resident.
On 06/21/22 at 12:03 PM, observation revealed CNA N picked up three soiled glasses from R54, refilled them and served them, picked up R54's soiled plate, wiped hands on her uniform, picked up R21's soiled dishes, and touched the handles of R116's wheelchair when she assisted him out of the dining room without washing or disinfecting her hands.
On 06/27/22 at 02:20 PM, Administrative Nurse D verified staff should disinfect or wash their hands after touching contaminated items and prior to handling residents' clean glasses.
The facility's Preventing Foodborne Illness-Employee Hygiene and Sanitary Practices policy, dated 10/2017, documented employees must wash their hands after engaging in activities that contaminate the hands.
The facility failed to perform sanitary practices during the meal services, placing residents at risk for communicable illnesses.
The facility had a census of 59 residents. The sample included 18 residents. Based on observation, record review, and interview the facility failed to store, distribute and serve food in accordance with professional standards for food service safety for the 59 residents who resided in the facility and received their food from the facility kitchen and two kitchenettes, when staff failed to use safe food handling, failed to dispose of expired food items, failed to disinfect a thermometer between food items when checking the temperatures of the food, and failed to wear a hair net in the kitchen during the preparation a meal.
Findings included:
- On 06/21/22 at 08:18 AM, observation revealed the kitchen freezer had the following undated or expired food items:
1/2 bag of French fries
1/4 bag of French fries
1/4 bag of chicken strips
1/4 bag of tater tots
On 06/22/22 at 11:10 AM, observation revealed in the kitchen, during the preparation of the noon meal, Dietary Staff (DS) CC without a hair net.
On 06/21/22 at 08:10 AM, DS BB verified the items in the kitchen freezer and discarded the items in the trash. DS BB stated staff should label and date food items when they open them.
On 06/22/22 at 11:37 AM, observation revealed DS DD applied gloves, touched the oven door, the prep table, and pans, with the same contaminated gloves on, picked up slices of garlic bread and some in another pan, then placed two slices into a bowl for the pureed diet .
On 06/27/22 at 11:48 AM, observation in the west hall kitchenette, DS EE reheated the mechanical soft pork chops in the microwave, placed a thermometer in them, placed the thermometer on the counter underneath the microwave, then placed it (without disinfecting it) into a bowl of gravy. At 12:00 PM DS EE wiped the thermometer off with her apron, placed it back on the counter, then, without disinfecting it, placed it in a ham and cheese sandwich. Further observation revealed at 12:14 PM DS EE picked up a pork chop with tongs, placed it on a resident's plate, then used the same tongs to pick up a sweet potato and placed it on the plate.
On 06/22/22 at 11:59 AM, DS CC verified he was not wearing a hair net and stated it must have fallen off when he went to break. He reached outside the front entrance door and grabbed a hair net and placed it on.
On 06/27/22 at 12:34 PM, DS EE verified she wiped the thermometer with her apron and did not disinfect the thermometer in-between each item she reheated in microwave. DS EE verified she used the same tongs to place a pork chop and sweet potato on a resident's plate.
On 06/22/22 at 11:59 AM, DS BB verified DS CC did not have a hair net on and stated should staff wear one when in the kitchen. DS BB stated staff should use tongs to pick up food items.
On 06/27/22 12:36 PM, DS BB stated when staff checked the temperatures of food items they should disinfect the thermometer between them.
The facility's Food Receiving and Storage Policy, revised October 2017, documented all foods stored in the refrigerator or freezer would be covered, labeled, and dated (use by date).
The facility staff failed to use safe food handling, failed to dispose of expired food items, failed to disinfect a thermometer between food items when checking the temperatures of the food, and failed to wear a hair net in the kitchen during the preparation a meal.

The facility had a census of 59 residents. The sample included 18 residents. Based on observation, interview, and record review the facility failed to provide thorough infection control during a wound dressing change for Resident (R) 21 and failed to update their Infection Control policies annually. This deficient practice placed R21 at increased risk for infection.
Findings included:
- On 06/22/22 at 10:55 AM, observation revealed R21 laid in bed, on his right side. Licensed Nurse (LN) GG placed a clean bed pad under R21's left leg and unwrapped the wound dressing. The gauze wound dressing had a large amount red/yellow drainage, with slough (dead tissue). After LN GG removed the soiled wound dressings and her gloves, she washed her hands and applied new gloves. LN GG set the wound care supplies on the bedside table without first cleaning or disinfecting the table and she did not place a clean towel on the contaminated surface. Observation revealed the same bedside table held a urinal with dark yellow fluid and an empty, used urinal.
On 06/22/22 at 11:05 AM, LN GG verified she should have placed a clean barrier on the bedside table for the wound care items.
On 06/27/22 at 11:50 AM, Administrative Nurse D verified staff should place a clean barrier to set wound care supplies on during wound care.
The Wound Care policy, dated 10/2010, documented during the provision of wound care staff were to use disposable cloth or paper towel to establish a clean field on the resident's overbed table and place all items to be used during the procedure on the clean field.
The facility failed to provide a clean field for wound care supplies during a wound dressing change for Resident (R) 21. This deficient practice placed R21 at increased risk for infection.
- Review of the facility's Infection Control policies revealed the following areas included and dated of revision:
Infection Control Policy, revised 04/2020
Antibiotic Stewardship policy, revised 04/2020
Pneumococcal Vaccine, revised 08/2016
Influenza August, revised 2014
On 06/27/22 at 11:50 AM, Administrative Nurse D verified the facility's infection control policies were not updated or reviewed at least annually.
The facility's Infection Control Policy and Practices statement, dated 07/2014, did not address the Center for Medicaid/Medicare Services (CMS) required annual review of infection control policies.
The facility failed to update their Infection Control policies annually.

The facility had a census of 59 residents. The sample included 18 residents. Based on observation and interview the facility failed to provide sufficient space in one of two dining areas to accommodate residents' needs.
Findings included:
- On 06/21/22 at 11:57 AM, observation in the east dining room revealed residents seated at dining room tables, other residents entered the dining room, some with wheelchairs, others with walkers, and staff moved residents away from their tables so other residents entering could get to the tables for the noon meal.
On 06/22/22 at 11:30 AM, observation revealed residents seated at the dining room tables. The staff had to move residents currently seated at the dining room tables, away from their tables, so other residents could get to the tables for the noon meal.
On 06/27/22 at 02:04 PM, Administrative Nurse D stated she could see how the east dining room was crowded and they needed to try to rearrange the tables to make more room, because not all of the residents on that end come out for dining at this time.
On 6/27/22 at 03:31 PM, Administrative Staff A stated when the facility was first built, (three years ago) the facility dining areas were approved for having space for 35 residents. Administrative Staff A verified the facility now had more residents with wheelchairs and foot extensions who used the east hall dining room.
The facility failed to provide sufficient space in the east dining area to accommodate the residents needs who ate their meals in the east dining room.

The facility had a census of 59 residents. The sample included 18 residents. Based on observation, interview, and record review, the facility failed to post the actual scheduled working hours for nursing staff directly responsible for resident care per shift.
Findings included:
- On 06/21/22 at 08:00 AM, upon entrance into the facility, observation revealed the facility lacked a Daily Nurse Staffing Report posted in the facility.
On 06/22/22 at 07:30 AM, observation revealed the facility lacked a Daily Nurse Staffing Report posted in the facility.
On 06/23/22 at 07:30 AM, observation revealed the facility lacked a Daily Nurse Staffing Report posted in the facility.
On 06/23/22 at 09:30 AM, Administrative Staff A verified the facility had not posted the Daily Nurse Staffing Report since her employment at the facility. Administrative Staff A verified she was told the facility no longer needed to post the staffing and it was not a requirement.
The facility's Posting Direct Care Daily Staff Numbers policy, dated 07/2016, documented the facility would post, daily for each shift, the number of nursing personnel responsible for providing direct care to residents. Within two hours of the beginning of each shift, the number of licensed nurses, Registered Nurse (RN), Licensed Registered Nurse (LPN), and the number of unlicensed personnel Certified Nurse Aides (CNAs) directly responsible for resident care would be posted in a prominent location)accessible to residents and visitors) and in a clear and readable format. The completed Daily Staffing Records would be maintained for a minimum of 18 months or as required by state law.
The facility failed to post the daily staffing schedule with the nursing personnel directly responsible for resident care per shift.