Gainesville Nursing

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to protect all residents from misappropriation of resident property when staff could not account for 19 missing narcotics tablets for 10 residents (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9 and Resident #10). The facility census was 43. Review of the facility policy titled Abuse, Prevention and Prohibition Policy, revised 10/22, showed the following information:-Should a specific employee be suspected of or have allegations made of misappropriation, the facility will follow the investigation protocol set forth in this policy;-The facility will educate staff on the policy and procedure for prevention of misappropriation of resident property and of investigation reporting and staff responsibility.Review of the facility policy titled, Medication Administration-General Guidelines, dated 01/01/18, showed the following information:-If a medication with a current, active order cannot be located in the medication cart/drawer, other areas of the medication cart, medication room, and facility are searched, if possible. If the medication cannot be located after further investigation, the pharmacy is contacted, or medication removed from the night box/emergency kit (I-STAT - an automated dispensing cabinet used to securely store and track medications);-When medications are administered, the mobile medication cart is taken to the resident's location (room, dining area, etc).Review of the facility policy titled Controlled Substance Policy, revised 10/22, showed the following information:-Controlled substances are subject to special handling, storage, disposal, and record-keeping requirement. The facility will maintain compliance with these special provisions;-The Director of Nursing (DON) is responsible for the control of such drugs;-Controlled drugs are to be stored under double-lock conditions;-The key must remain in the possession of the licensed nurse or certified medication technician (CMT) that completed the count at all times during their shift;-Should it be necessary to give the keys to another licensed practical nurse (LPN) or CMT, a count will be done to verify the inventory;-All controlled substances are to be counted every shift;-Any discrepancy in the inventory of controlled substance is to be reported to the DON immediately. 1. Review of the facility's investigation report, undated, showed the following information:-On 02/26/26, at 7:00 A.M., Registered Nurse (RN) B gave off going shift report to oncoming RN A;-RN B then saw RN A standing in the medication room in front of the I-STAT logging into the machine to dispense medication;-RN B asked CMT C if he/she asked RN A to withdraw any medication from the I-STAT. CMT C said that he/she did not;-RN B then saw RN A walking from the bathroom. RN A said to RN B Well, I feel alive again. RN B said I didn't know you were dead. RN A said, You know, just not ready for the day.;-RN B immediately went to his/her car and notified the DON of the behavior;-The DON immediately notified the Administrator;-The DON and Administrator pulled up the I-STAT records and discovered that on 02/26/27, at 6:57 A.M., RN A had signed out an oxycodone (opiate used to treat moderate to severe pain) IR (immediate release) 10 milligram (mg) tablet under Resident #1's name;-On 02/26/27, at 8:00 A.M., the Administrator interviewed Resident #1. The resident could not remember the last time he/she received a pain pill. He/she thought it had been about three hours prior. The resident did remember that it was a female that gave him/her the medication;-The DON and Administrator interviewed RN A;-RN A said that he/she had not assessed Resident #1. RN A pulled the oxycodone IR 10 mg tablet for Resident #1 because he/she knew the resident would need the medication;-RN A said that he/she went to the bathroom immediately after pulling the medication from the I-STAT because he/she had diarrhea;-The DON told RN A that his/her behavior was very suspicious due to the fact that the medication had not been documented, the CMT covering the hall had not asked RN A to pull the medication, the resident had not been assessed nor asked for the medication, the Medication Administration Record (MAR) had not been checked to confirm when the last pain medication was given, and RN A had not looked for the medication in the medication cart. RN A went straight to the I-STAT and there was no proof that the medication was given;-RN A told the DON and the Administrator that he/she had not taken the medication;-The DON and Administrator told RN A that he/she was suspended pending an investigation;-RN A tossed his/her keys on the DON's desk and left the building;-On 02/26/26, at 9:17 A.M., the Administrator reported the incident to the Department of Health and Senior Services (DHSS);-On 02/26/26, at 9:29 A.M., the Administrator reported the incident to the Sheriff's office;-The Medical Director and Nurse Practitioner were also notified;-The DON printed a report of all the narcotics RN A had pulled from the I-STAT machine for the past six months. The report showed that on sixteen separate occasions, RN A pulled narcotics from the I-STAT without documenting on the MAR;-The DON asked CMT D, CMT E, and CMT F if they had ever asked a nurse to pull medication for them from the I-STAT machine. CMT D, CMT E, and CMT F said that they had never asked a nurse to pull a narcotic from the I-STAT;- Medication cards for the above narcotics were available in the medication carts.2. Review of Resident #1's face sheet (a brief resident profile sheet) showed the following information:-admission date of 03/16/17;-Diagnoses included multiple sclerosis (a chronic autoimmune disease disrupting communication between the brain and body), chronic obstructive pulmonary disease (COPD - lung disease), atrial fibrillation (irregular heart rate and rhythm) and dementia.Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 01/06/26, showed the following information:-Moderately impaired cognitive skills;-Reported moderate pain intensity;-Pain frequently was constantly.Review of the resident's current care plan, last updated 01/22/26, showed staff to ensure the resident was assessed for pain.Review of the resident's current Physician Order Sheet (POS) showed an order, dated 12/01/25, for oxycodone IR 10 mg, one tablet every four hours as needed for pain.Review of the I-STAT documentation of medications that were removed by RN A showed on 12/25/25, at 8:18 A.M., RN A withdrew oxycodone IR 10 mg tablet for the resident. Review of the resident's electronic medical record (EHR) and MAR showed RN A did not document administration of the oxycodone IR removed from the I-STAT on 12/25/25. Review of the I-STAT documentation of medications that were removed by RN A showed on 12/29/25, at 3:59 P.M., RN A withdrew oxycodone IR 10 mg tablet for the resident. Review of the resident's EHR and MAR showed RN A did not document administration of the oxycodone IR removed from the I-STAT on 12/29/25.Review of the I-STAT documentation of medications that were removed by RN A showed on 01/12/26, at 3:04 P.M., RN A withdrew oxycodone IR 10 mg tablet for the resident. Review of the I-STAT documentation of medications that were removed by RN A showed on 01/12/26, at 7:23 P.M., RN A withdrew oxycodone IR 10 mg tablet for the resident. Review of the resident's EHR and MAR showed RN A did not document administration of the oxycodone IR removed from the I-STAT on 01/12/26.Review of the I-STAT documentation of medications that were removed by RN A showed on 01/26/26, at 3:03 P.M., RN A withdrew oxycodone IR 10 mg tablet for the resident. Review of the resident's EHR and MAR showed RN A did not document administration of the oxycodone IR removed from the I-STAT on 01/26/26.Review of the I-STAT documentation of medications that were removed by RN A showed on 02/26/26, at 6:57 A.M., RN A withdrew oxycodone IR 10 mg tablet for the resident. Review of the resident's EHR and MAR showed RN A did not document administration of the oxycodone IR removed from the I-STAT on 02/26/26.3. Review of Resident #2's face sheet showed the following information:-admission date of 08/21/25;-Diagnoses included brain cancer, COPD, and Type 2 Diabetes.Review of the resident's admission MDS, dated [DATE], showed the following information:-Moderately impaired cognition;-Reported moderate pain intensity.Review of the resident's care plan, dated 08/21/25, showed staff to assess the resident for pain.Review of the resident's current POS showed an order, dated 08/21/25 , for tramadol (used to treat moderate to severe and/or chronic pain) 50 mg, one tablet every six hours as needed for pain. Review of the I-STAT documentation of medications that were removed by RN A showed on 09/03/25, at 12:48 A.M., RN A withdrew tramadol 50 mg tablet for the resident. Review of the resident's EHR and MAR showed RN A did not document administration of the tramadol removed from the I-STAT on 09/03/25.4. Review of Resident #3's face sheet showed the following information:-admission date of 09/19/25;-Diagnoses included rhabdomyolysis (severe muscle damage), heart attack, hip pain, and history of falls.Review of the resident's quarterly MDS, dated [DATE], showed the following information:-Normal cognition;-Reported severe pain intensity. Review of the resident's care plan, last updated 01/03/26, showed staff to ensure the resident is assessed for pain.Review of the resident's current POS showed an order, dated 09/19/25, for hydrocodone- acetaminophen (APAP) (medication used to treat moderate to severe pain) 10-325 mg, one tablet every six hours as needed for pain.Review of the I-STAT documentation of medications that were removed by RN A showed on 09/27/25, at 7:54 A.M., RN A withdrew hydrocodone-acetaminophen (APAP) 10/325 mg tablet for the resident. Review of the resident's EHR and MAR showed RN A did not document administration of the hydrocodone-APAP removed from the I-STAT on 09/27/25.5. Review of Resident #4's face sheet showed the following information:-admission date of 03/22/23;-Diagnoses included Parkinson's disease (neurodegenerative disease primarily of the central nervous system), dementia, Alzheimer's disease, and heart failure. Review of the resident's quarterly MDS, dated [DATE], showed the following information:-Moderately impaired cognition;-Frequently reported pain.Review of the resident's care plan, last updated on 01/06/26, showed staff to assess the resident for pain.Review of the resident's current POS showed an order, dated 12/01/25, for hydrocodone-APAP 5-325 mg, one tablet every six hours as needed for pain.Review of the I-STAT documentation of medications that were removed by RN A showed on 12/29/25, at 4:00 P.M., RN A withdrew hydrocodone-APAP 5/325 mg tablet for the resident. Review of the resident's EHR and MAR showed RN A did not document administration of the hydrocodone-APAP removed from the I-STAT on 12/29/25.Review of the I-STAT documentation of medications that were removed by RN A showed on 01/12/26, at 3:06 P.M., RN A withdrew hydrocodone-APAP 5/325 mg tablet for the resident. Review of the resident's EHR and MAR showed RN A did not document administration of the hydrocodone-APAP removed from the I-STAT on 01/12/26.6. Review of Resident #5's face sheet showed the following information:-admission date of 12/14/22;-Diagnoses included atrial fibrillation (abnormal heart rate and rhythm), type 2 diabetes, COPD, morbid obesity, and right knee pain.Review of the resident's quarterly MDS, dated [DATE], showed the following information:-Normal cognition;-Occasionally reported pain.Review of the resident's care plan, last updated on 01/06/26, showed staff to assess the resident for painReview of the resident's current POS showed an order dated 01/01/26, for hydrocodone-APAP 5-325 mg, one tablet every six hours as needed for pain.Review of the I-STAT documentation of medications that were removed by RN A showed on 01/03/26, at 10:01 A.M., RN A withdrew hydrocodone-APAP 5/325 mg tablet for the resident. Review of the resident's EHR and MAR showed RN A did not document administration of the hydrocodone-APAP removed from the I-STAT on 01/03/26.7. Review of Resident #6's face sheet showed the following information:-admission date of 07/11/24;-Diagnoses included dementia, high blood pressure, anxiety, and unspecified pain. Review of the resident's quarterly MDS, dated [DATE], showed the following information:-Severely impaired cognition;-Reported occasional pain frequency.Review of the resident's care plan, last updated on 11/21/25, showed staff to ensure the resident was assessed for pain.Review of the resident's current POS showed an order, dated 12/20/25, for hydrocodone-APAP 5-325 mg, one tablet every six hours as needed for pain.Review of the I-STAT documentation of medications that were removed by RN A showed on 01/12/26, at 3:05 P.M., RN A withdrew hydrocodone-APAP 5/325 mg tablet for the resident. Review of the resident's EHR and MAR showed RN A did not document administration of the hydrocodone-APAP removed from the I-STAT on 01/12/26.8. Review of Resident #7's face sheet showed the following information:-admission date of 09/30/18;-Diagnoses included Alzheimer's disease, dementia, morbid obesity, and high blood pressure. Review of the resident's quarterly MDS, dated [DATE], showed the following information:-Severely impaired cognition;-Reported occasional pain frequency.Review of the resident's care plan, last updated on 06/12/25, showed staff to ensure the resident was assessed for pain.Review of the resident's current POS showed an order, dated 12/20/25, for hydrocodone-APAP 5-325 mg, one tablet every four hours as needed for pain.Review of the I-STAT documentation of medications that were removed by RN A showed on 01/12/26, at 7:24 P.M., RN A withdrew hydrocodone-APAP 5/325 mg tablet for the resident. Review of the resident's EHR and MAR showed RN A did not document administration of the hydrocodone-APAP removed from the I-STAT on 01/12/26.9. Review of Resident #8's face sheet showed the following information:-admission date of 07/29/24;-Diagnoses included high blood pressure, encopresis (leaking of stool from the rectum), and cachexia (severe weight and muscle loss).Review of the resident's quarterly MDS, dated [DATE], showed the following information:-Normal cognition;-Reported frequently having pain.Review of the resident's care plan, last updated on 08/12/25, showed staff to ensure the resident is assessed for pain.Review of the resident's current POS showed an order, dated 12/23/25, for hydrocodone-APAP 5-325 mg, one tablet every six hours as needed for pain.Review of the I-STAT documentation of medications that were removed by RN A showed on 01/12/26, at 7:24 P.M., RN A withdrew hydrocodone-APAP 5/325 mg tablet for the resident. Review of the resident's EHR and MAR showed RN A did not document administration of the hydrocodone-APAP removed from the I-STAT on 01/12/26.Review of the resident's EHR and MAR showed RN A did not document administration of the hydrocodone-APAP removed from the I-STAT on 01/12/26.10. Review of Resident #9's face sheet showed the following information:-admission date of 07/21/24;-Diagnoses included heart failure, atrial fibrillation (irregular heart rate and rhythm), dementia, anxiety, and stroke.Review of the resident's quarterly MDS, dated [DATE], showed the following information:-Severely impaired cognition;-Reported frequently having pain.Review of the resident's care plan, last updated on 06/12/25, showed staff to ensure the resident is assessed for pain.Review of the resident's current POS showed an order, dated 01/30/26, for tramadol 50 mg, one tablet every six hours for pain.Review of the I-STAT documentation of medications that were removed by RN A on 02/02/26, at 9:57 P.M., RN A withdrew tramadol 50 mg tablet for the resident. Review of the resident's EHR and MAR showed RN A did not document administration of the tramadol removed from the I-STAT on 02/02/26.10. Review of Resident #10's face sheet showed the following information:-admission date of 02/07/26;-Diagnoses included congestive heart failure, right lower extremity amputation, high blood sugar and peripheral vascular disease (narrowing blood vessels).Review of the resident's admission MDS, dated [DATE], showed the following information:-Normal cognition;-Reported frequently having pain.Review of the resident's care plan, last updated on 02/09/26, showed staff to ensure the resident was assessed for pain.Review of the resident's current POS showed an order, dated 02/07/26, for tramadol 50 mg, two tablets every six hours as needed for pain.Review of the I-STAT documentation of medications that were removed by RN A showed on 02/15/26, at 12:10 P.M., RN A withdrew tramadol 50 mg tablet for the resident. Review of the resident's EHR and MAR showed RN A did not document administration of the tramadol removed from the I-STAT on 02/15/26.11. During an interview on 03/12/26, at 9:47 A.M., CMT C said the following:-He/she counted the narcotics with the oncoming and off going CMT every shift;-Staff should notify the DON immediately if the narcotic count was off;-He/she signed out the narcotic in the narcotic book log and on the MAR;-He/she would only pull medications from the I-STAT if the medication was not in the medication cart;-He/she has never had to pull a narcotic from the I-STAT;-Misappropriation means stealing resident medications. During an interview on 03/12/26, at 11:06 A.M., RN G said the following:-He/she did a narcotic count with the off going nurse every shift;-Notify the DON of any discrepancy immediately;-Any missing narcotics is considered misappropriation;-All scheduled and PRN narcotics are located in the medication carts under double locks;-Narcotics should be signed out on the narcotic log and the MAR;-I-STAT is available to override any medication that is needed;-Each nurse has a personalized long in and passcode to get into the I-STAT machine;-If pulling medications from the I-STAT, staff must sign off as administering the medication on the MAR.During an interview on 03/12/26, at 11:25 A.M, CMT D said the following:-He/she did a narcotic count with the off going nurse every shift;-He/she signed out all narcotics in the narcotic log and on the MAR;-All narcotics were double locked;-He/she never gives his/her keys to anyone at any time during his/her shift;-He/she would notify the DON immediately with any narcotic discrepancy;-He/she considered missing medications misappropriation.During an interview on 03/12/26, at 11:39 A.M., the Pharmacist Consultant said the following:-Medications are delivered daily from the pharmacy to the facility;-The pharmacy runs a report of controlled medications daily;-The I-STAT does not account for the medication being administered, only how many narcotics are in the I-STAT machine, so if the count is correct, it will not create a discrepancy.During an interview on 03/12/26, at 11:46 A.M., the DON said the following:-He/she knew that RN A had a history of medication diversion in the past;-RN A was told not to administer any narcotics to residents. RN A was told that CMT's administer all medications;-It was discovered that RN A was pulling medication from the I-STAT;-The DON was running a discrepancy report weekly on the I-STAT and was doing a monthly narcotic count with the Pharmacist Consultant, however, what the RN A was doing, did not create a discrepancy;-The DON ran a report by each nurse's name, that showed every medication that the nurse pulled from the I-STAT. That list was then compared against the EHR MAR and the narcotic log;-RN A had been pulling medications and not administering them to the residents;-The DON is now completing a weekly audit of narcotics, comparing the medications pulled from the I-STAT against the medications administered in the EHR MAR;-The DON said he/she should have been completing the weekly audit and comparing the medications against the EHR MAR every week then he/she would had known immediately that RN A was diverting medications.During an interview on 03/12/26, at 4:30 P.M., the Administrator said the following:-On 02/26/26, the DON notified him/her of a potential medication diversion;-The DON and the Administrator immediately started an investigation and discovered that RN A had been removing narcotics from the I-STAT machine and not administering the medications to residents;-The DON and the Administrator have been monitoring and auditing weekly since the diversion;-The Administrator expected staff to administer medication to the residents and document the medication administration appropriately;-The Administrator expected the DON to monitor medication administration and documentation of administration weekly;-The Administrator said that missing narcotics is considered misappropriation of property.Complaint #2789239

Based on interview and record review, the facility failed to protect all resident from misappropriation of property when one facility staff member (Environmental Services Employee A) used one resident's (Resident #1) debit card without consent. The facility census was 46.On 12/26/25, the Social Services Worker became aware of the misappropriation. The facility immediately began their investigation, including multiple interviews of other residents and staff. The facility began education on abuse, neglect, and misappropriation of resident's property. The facility removed Environmental Services Employee A from the facility. The facility reviewed all other resident's accounts with a debit card, as well as educated the residents on the process for debit card transactions. The facility reported the misappropriation to the Department of Health and Senior Services (DHSS) and local law enforcement. The noncompliance was corrected on 12/27/25. Review of the facility policy titled, Abuse, Prevention and Prohibition Policy, revised 10/22, showed, the following:-The facility prohibits misappropriation of resident property;-Misappropriation of resident property was defined as the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent.1. Review of Resident #1's face sheet showed the following:-admission date of 01/30/25;-Diagnoses included chronic obstructive pulmonary disease (COPD - lung condition that blocks airflow, making it hard to breathe), chronic respiratory failure (lungs can't effectively get enough oxygen into the blood or remove the carbon dioxide), myocardial infarction (blood flow to part of the heart muscle is blocked, causing tissue to die), and atrial fibrillation (upper changes of the heart quiver chaotically instead of beating effectively).Review of the resident's quarterly minimum Data Set (MDS - a federally mandated comprehensive assessment completed by facility staff), dated 10/08/24, showed the following:-Cognitively intact;-No behavioral symptoms exhibited;-Resident is independent with oral hygiene, toileting hygiene, upper and lower body dressing and personal hygiene;-Resident requested supervision with showers. Review of the resident's care plan, last revised on 10/28/25, showed the following:-Resident had impaired cognitive function or impaired thought process;-Resident had impaired visual function, ensure resident uses glasses and other supports.Review of the resident's bank statement, dated 11/28/25, showed on 11/03/25, a withdrawal, in the amount of $103.25, plus a $2.00 ATM fee. Review of Resident #1's bank statement, dated 12/24/25, showed the following:-On 12/04/25, withdrawals of $123.25 and $306.00, plus $4.00 in ATM fees;-On 12/15/25, Venmo (mobile payment application that lets users send and receive money instantly) payments to Environmental Services Employee A, in the amounts of $10.00, $25.00, $50.00, $60.00, and $100.00;-On 12/17/25, Venmo payments to Environmental Services employee A in the amounts of $5.00, $10.00, $50.00, $50.00, $50.00, $100.00, $100.00, and overdraft fees totaling $125;-On 12/17/25, overdraft fee of $25.00.Review of the facility's investigation summary, dated 12/26/25, showed the following:-On 12/26/25, at 1:50 P.M., the resident reported to the Social Services Director (SSD) eh/she had received an insufficient funds notice from his/her bank, and he/she suspected Environmental Services Employee A of taking money out of his/her account without permission;-The resident and SSD contacted the bank to request a printout of December's bank statement and to report the resident's debit card as stolen and freeze the account;-The resident already had his/her November bank statement, and it showed an ATM withdrawal that he/she stated he/she did not authorize on the same day he/she had given Environmental Services Employee A his/her card to withdraw money for the resident;-Administrator contacted the Environmental Services Employee A, to let him/her know of the allegations and suspension pending investigation;-On 12/26/25, SSD met with the resident. Resident believed that Environmental Services Employee A, stole money from him/her. Resident stated he/she had Environmental Services Employee A, withdraw money from the ATM before and the resident had given Environmental Services Employee A his/her pin number to the debit card. When reviewing the November bank statement, the resident found two ATM withdrawals on the day he/she had requested Environmental Services Employee A, to withdraw money for the resident;-On 12/26/25, the Administrator met with the resident. Resident stated he/she had given his/her card to Environmental Services Employee A on 11/01/25 and 12/01/25 to make withdrawals from his/her account. Resident believed Environmental Services Employee A, took money from his/her account because he/she gave his/her debit card and pin number to Environmental Services Employee A. Resident said Environmental Services Employee A told him/her at one point that if the resident didn't have money, it was okay, the resident could give Environmental Services Employee A his/her debit card and he/she would take care of it. The resident stated that he/she should have never given Environmental Services Employee A his/her card and pin number and that he/she was aware that all purchases should go through the business office;-On 12/26/25, the Administrator spoke to Environmental Services Employee A by phone. Administrator made Environmental Services Employee A aware of allegations and suspension pending investigation. He/she stated I don't know what to tell you, I don't have any money. My dad is dying. I asked people for gas money, and nobody would help me out.-Summary of findings, Resident's November 2025 Bank Statement, ending 11/28/25, showed an ATM withdrawal of $103.25 and an ATM withdrawal of $510 on 11/03/25. Resident stated he/she asked Environmental Services Employee A to withdrawal $500.00 from the account but he/she did not authorize the $103.25. The December 2005 bank statement, dated 12/24/25, showed three ATM withdrawals on 12/03/25. Resident stated he/she asked Environmental Services Employee A, to withdrawal $500.00 on 12/01/25 but did not authorize the ATM withdrawals in the amounts of $123.25 or $306.00 withdrawn the same day. The December2025 bank statement also showed multiple Venmo payments to Environmental Services Employee A between 12/15/25 and 12/17/25. Total Venmo transfer of $610.00;-Resident stated the following transfers were not authorized;-On 11/03/25, ATM transfer of $103.25;-On 12/03/25, ATM transfer of $123.25;-On 12/03/25, ATM transfer of $306.00;-On 12/15/25 through 12/17/25, total of $610.00 of Venmo transfers;-Resident was charged overdraft fees in the amount of $150.00. Review of the county sheriff's department report showed the following:-Report made by the facility to the sheriff's department on 12/26/25;-Sheriff's department interviewed the resident regarding the unauthorized charges. Resident said he/she provided Environmental Services Employee A his/her debit and pin number when the employee asked for it so that the employee could obtain money from the ATM for the resident;-Resident said he never authorized Environmental Services Employee A to take any money from his/her account;-Total unauthorized charges, including overdraft fees were $1012.50;-On 12/27/25, Sheriff's office made contact with Environmental Services Employee A. Environmental Services Employee A acknowledged the authorized $503.00 withdrawal at the Gainesville gas station on 12/03/25. He/she admitted adding the resident's card to his/her Venmo account but claimed he/she did not initially realize it belonged to the resident. Environmental Services Employee A showed the officer several transactions on his/her Venmo account that he/she acknowledged were linked to the resident's card after he/she became aware of the association. Environmental Services Employee A confirmed the card had since been removed from the Venmo account. Officer photographed the credit card used by Environmental Services Employee A without permission and it showed the resident's name on the front and again on the back showing a reasonable person to believe who the owner of the card to be;-Based on the resident's bank statements, bank records, and Environmental Services Employee A's admission, probable cause exits to believe Environmental Services Employee A committed financial exploitation of an elder person, fraud involving unauthorized use of a credit card, and stealing. During an interview on 01/06/26, at 10:30 A.M., the resident said the following:-Environmental Services Employee A came to his/her room one day and asked the resident if he/she needed anything from the store. He/she gave the resident cash that day to pick up a sub sandwich for him/her, another resident, and Environmental Services Employee A. Environmental Services Employee A brought back the receipt and nothing was missing. The resident doesn't remember when this was, but prior to the incidents of missing money;-On 11/03/25, Environmental Services Employee A, asked him/her again if he/she needed anything and the resident said he/she needed money withdrawn from his/her account. The resident said he/she did not have cash and Environmental Services Employee A said he/she could take the resident's debit card and get the cash. He/she gave Environmental Services Employee A his/her debit card and pin number. He/she asked Environmental Services Employee A to withdrawal $500 from his/her account. He/she did not give Environmental Services Employee A permission to get him/herself any money. At that time Environmental Services Employee A also withdrew $103.25;-On 12/04/25, Environmental Services Employee A, asked the resident if he/she needed anything in the community. The resident said he/she needed some money from the ATM, so Environmental Services Employee A, took the resident's debit card. The resident had Environmental Services Employee A, withdraw $503.00 for the resident. The resident did not give Environmental Services Employee A, permission to withdraw other money. Environmental Services employee A, also withdrew $123.25 and $306.00;-The resident received the insufficient funds notice from the bank on 12/26/25. That's when he/she found Environmental Services Employee A, had been taking money from the resident's account; -The resident doesn't know what Venmo was, and he/she wasn't aware Environmental Services Employee A had used his/her card to obtain $610.00 through Venmo as the Resident said he/she never gave permission for this.During an interview on 01/07/26, at 11:55 A.M., Environment Services Employee A said the following:-Only the Activity Director was allowed to shop for the residents, no other staff;-He/she had pulled money out of the ATM for the resident. He/she didn't remember the dates or how much money. He/she took money out of the ATM a couple of times for the resident;-The resident asked him/her to take money out of the ATM. He/she believed the first time it was $500, and he/she wasn't sure about the other time;-The resident had given him/her money before. The resident offered the money. The resident gave him/her $100 to help pay for the electric and just before Christmas the resident gave him/her $100 and said Merry Christmas. It was the week of Christmas;-He/she said the resident's card was mistakenly put on the Venmo account;-It is not acceptable to take money from a resident and that could be misappropriation of funds.During an interview on 01/06/26, at 11:07 A.M., Environmental Services Employee B said the following:-The Activity Director and administration does the shopping for residents; no other staff are allowed to;-Staff aren't allowed to take debit or credit cards and can't accept money from residents;-If staff used a resident's debit card and withdrew money from the resident's account for their personal use it would be misappropriation of a resident's money;-He/she has received in-services on this and would tell his/her supervisor if it happened.During an interview on 01/06/26, at 11:17 A.M., Certified Medication Technician (CMT) C said the following:-SSD or activities does all of the shopping for residents;-Staff are not allowed to take a resident's debit card and get cash for residents;-It would not be appropriate for staff to take money from a resident's debit card for personal use, this would be misappropriation of resident's money;-He/she would report misappropriation to the charge nurse or DON. During an interview on 01/06/26, at 11:20 A.M., Licensed Practical Nurse (LPN) D said the following:-The Business Office Manager goes shopping for the residents;-Staff are not allowed to take a resident's debit card to an ATM to withdraw money;-Staff are not allowed to take money off from a debit card for their personal use, that would be misappropriation of funds, and it's not allowed;-Staff aren't allowed to accept gifts;-If he/she suspects misappropriation, he/she reports to the DON or administration.During an interview on 01/06/26, at 11:27 A.M., Certified Nurse Aide (CNA) E said the following:-People in charge do the resident shopping, aides are not allowed to;-No staff are allowed to take a resident's debit card and withdraw money;-If a staff takes money from a resident's debit card for personal use it would be misappropriation;-Abuse or misappropriation would be reported to the charge nurse, Director of Nursing (DON) or the Administrator.During an interview on 01/06/26, at 11:30 A.M., CNA F said the following: -All shopping is done by the higher ups, he/she is not allowed to shop for the residents;-No staff are allowed to take a resident's debit card to withdraw money from the ATM;-Staff are not allowed to use a resident's debit card for their personal use, that would be misappropriation of resident funds;-If he/she became of aware of misappropriation, he/she would report to the charge nurse and administrator.During an interview on 01/06/26, at 11:33 A.M., SSD said the following:-The resident shopping is done by the front office or the Activity Director;-Staff are not allowed to take a resident's debit card and withdraw money;-All residents are told on admission the process for resident shopping and no staff uses resident's debit cards;-When the appointed staff does the shopping, he/she has receipts and logs that are kept;-If staff withdraw money from a resident's account for their own person use with debit card, it is misappropriation of funds;-Not appropriate to take a resident's debit card and withdraw money for a resident or themselves;-He/she would report to the Administrator if he/she knows of misappropriation of resident property.During an interview on 01/06/26, at 11:36 A.M., the Activity Director said the following:-He/she or upper management are the only staff that does shopping for residents;-The/she gets a list from the resident and the sign the list agreeing to what they want;-He/she gets a facility check and picks up the items for each resident. When he/she goes over the receipt and shows the receipt to the resident, and they sign off saying they received the items and the total cost. This is then taken out of their account. He/she never takes a resident's personal debit cards;-It would be misappropriation to withdraw money from atm for personal use;-He/she would report suspected misappropriation to the Administrator.During an interview on 01/06/26, at 11:40 A.M., the MDS Coordinator said the following:-All shopping was done by the Activities director, the Administrator, and sometimes the BOM;-If a staff takes resident money for their use, it's wrong and would be misappropriation and abuse;-He/she would report suspected abuse or misappropriation to the DON and the Administrator.During an interview on 01/06/26, at 12:10 P.M., the BOM said the following:-Only the BOM, Administrator, and Activity Director goes shopping for residents;-The residents have a shopping list that's a designated from, staff check to see if residents have funds to cover the items, and the facility writes one check for all of the items purchased. Once the employee returns, they go over the items with the resident's and they resident's sign off and those funds are removed from the resident accounts;-Staff are not allowed to take money from a resident or take debit card and withdraw money from ATM. If a staff takes money from a resident's account for their personal use, it's misappropriation of resident funds;-He/she reports misappropriation to the Administrator.During an interview on 01/06/26, at 11:45 A.M., the DON said the following:-The Activity Director and front office does the shopping for residents;-Staff are not allowed to take a resident's debit card;-If staff takes money from a resident or gets money out of an ATM for their personal use, it's abuse and misappropriation and it's not appropriate;-Staff should report any suspected abuse or misappropriation to the Administrator or him/her;-When staff go shopping for the residents the residents make a list and sign the list of items they're requesting. The Activities Director gets the items and once he/she delivers them to the resident's the residents verify and sign off on the items they're receiving and the amount. The money is then taken from the resident's trust account;-What Environmental Services Employee A did is misappropriation of a resident's money.During an interview on 01/06/26, at 11:50 A.M., the Administrator said the following:-The BOM, Activities Director, or the Administrator are the only staff to do shopping for the residents;-The staff that shop for the residents ensure the residents have the money for the items the residents have chosen, and the residents sign their list of things they want. Once the staff returns, they go over the list and items with the resident and the resident's sign off again and the money is taken from the resident's trust account;-Staff are not allowed to take a debit card from a resident; -Environmental Services Employee A took money from the resident and it was misappropriation. Complaint #2701720

1. Please refer to Event ID B3N912, exit date 11/14/24.
Based on interview and record review, the facility failed to ensure all allegation of possible neglect were reported within two hours to the State Survey Agency (Department of Health and Senior Services - DHSS) when the facility Administrator received an allegation of possible neglect involving one resident (Resident #1) in a facility and failed to report it to DHSS. The facility census was 43.
Review of the facility policy titled, Abuse, Prevention, and Prohibition Policy, dated October 2022, showed the following:
-The facility Administrator will be designated as the facility Abuse Coordinator and will be responsible for overseeing the Abuse Prevention and Prohibition Program and directing any abuse investigation.
-Resident abuse must be reported immediately to the Administrator. The facility Administrator will ensure a thorough investigation of alleged violations of individual rights and document appropriate action. While a facility investigation is under way, steps will be taken to prevent further abuse. Initiate investigation including initial notifications of all listed on the notification form, documenting on the form. This includes the State Agency and law enforcement if this is reasonable suspicion of a crime;
-Complete a report of alleged resident abuse within the required timelines;
-The facility employee or agent, who becomes aware of abuse on neglect, shall immediately report the matter to the facility Administrator or his/her designated representative in his/her absence;
-The Administrator will notify the Corporate Nurse;
-The facility Administrator shall report to the mandated state agency per reporting criteria;
-All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property will be reported immediately to the Administrator. The person made aware of the allegation of abuse or neglect of the Administrator will report the allegation of abuse and neglect to the mandated state agency and law enforcement;
-The allegation will be reported no later that two hours after the allegation is made if the events involve abuse or result in serious bodily injury;
-Neglect means failure to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress.
1. Review of the Resident #1's face sheet showed the following:
-admission date of 07/09/24;
-Diagnoses included acute kidney failure (AKF), severe dementia with agitation, repeated falls, need for assistance with personal cares, and weakness.
Review of the resident's admission Minimum Data Set (MDS - a federally mandated, comprehensive assessment tool completed by facility staff), dated 07/22/24, showed the following:
-Severely cognitively impaired;
-Required set up or clean up assistance of staff with eating;
-Dependent on staff for toileting hygiene, personal hygiene, mobility, and transfers;
-Required substantial or maximum assistance of staff for showers.
Review of the resident's progress note dated 10/14/24, at 9:45 A.M., showed the facility Administrator documented the following:
-A visitor said the Administrator was letting the resident die. The resident had lost 25% of his/her body weight and the Administrator was fine with the resident lying in bed, dying. The Administrator asked the visitor how he/she knew the resident's weight. The visitor said he/she saw the resident when entering the facility to pick up other residents. The Administrator informed the visitor per the request of the resident's durable power of attorney (DPOA), the visitor should not seek out the resident while in the facility. The visitor said he/she saw the resident while he/she was in the facility conducting business. The visitor stated that on the previous day, 11/13/24, the resident had food on his/her clothes and was dirty. The visitor again told the Administrator that he/she (the Administrator) was just going to let the resident lay in bed and die. The Administrator told the visitor that their conversation was over and he/she did not appreciate what the visitor was accusing the Administrator of and that any further information needed, he/she would need to get the information from the DPOA, from Adult Protective Services (APS), or he/she could hire a lawyer and file for guardianship. After the visitor left, he/she went to the resident's room. The resident was resting in bed. The Administrator had assisted the resident back to his/her room after breakfast and he/she was doing fine. The resident had fresh ice water and snacks available on his/her overbed table. The Activity Director was present during the conversation.
Review of DHSS records showed the facility did not file a self-report regarding the allegation of possible neglect.
During an interview on 11/14/24, at 4:30 P.M., Certified Nurse Aide (CNA) D said the following:
-He/she would instantly report any allegation of resident abuse or neglect to the nurse, the Director of Nursing (DON), or Administrator;
-The facility must notify DHSS within two hours of any allegation of resident abuse or resident neglect;
-If someone alleged the facility staff were letting a resident lay there and die, he/she would consider that to be an allegation of neglect and would immediately report the allegation to his/her charge nurse.
During an interview on 11/14/24, at 4:40 P.M., [NAME] E said the following:
-Facility staff members were required to immediately report any allegation of resident abuse or neglect to their supervisors;
-The facility was required to notify DHSS within two hours of any allegation of resident abuse or neglect;
-If someone accused a facility staff member of letting a resident lay in bed and die, he/she would consider that to be an allegation of neglect and would immediately report that information to his/her supervisor or charge nurse.
During interviews on 11/14/24, at 4:35 P.M., and 11/15/24, at 2:30 P.M., the Activity Director (AD) said the following:
-Examples of resident neglect would be staff leaving a resident alone or not tending to a resident's needs;
-If anyone made an allegation or resident abuse or neglect, he/she would immediately notify the Administrator;
-The facility was required to notify DHSS within two hours of any allegation of abuse or neglect;
-If someone accused the staff of allowing a resident to lay there and die, the AD would consider that to be an allegation of neglect and would immediately report to the Administrator;
-He/she overheard the conversation on 10/14/24 between the Administrator and the visitor in regards to the resident;
-The visitor accused the facility of neglecting the resident;
-The facility should have called in the allegation of neglect to within two hours to DHSS.
During an interview on 11/14/24, at 2:33 P.M., the DON said the following:
-He/She was unaware of the specifics of the situation with the resident and a visitor who had become involved in his/her care;
-He/She would be concerned of an allegation of the facility letting a resident lay in bed and die;
-He/She could see how an allegation of this nature would be considered an allegation of possible neglect;
-Staff should notify DHSS within two hours with any allegation or resident abuse or neglect.
During an interview on 11/14/24, at 3:13 P.M., the Administrator said the following:
-On 10/14/24, at that time he/she did not consider what the visitor said about the resident to be an allegation of abuse or neglect;
-He/She should have notified DHSS of the possible allegation;
-The facility was required to notify DHSS of any allegation of abuse or neglect within two hours;
-He/she did not notify DHSS of the allegation of neglect.
MO00243241

1. Please refer to Event ID B3N912, exit date 11/14/24.
Based on interviews and record review, the facility failed to ensure all allegations of possible neglect were investigated by the facility and the investigation submitted to the State Survey Agency (Department of Health and Senior Services - DHSS) within five days when a staff member received an allegation of possible neglect of one resident (Resident #1) and the facility failed to complaint a full investigation. The facility census was 43.
Review of the facility policy titled, Abuse, Prevention, and Prohibition Policy, dated October 2022, showed the following:
-The facility prohibits mistreatment, neglect, or abuse of residents. This includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychological wellbeing.
-The facility Administrator will be designated as the facility Abuse Coordinator and will be responsible for overseeing the Abuse Prevention and Prohibition Program and directing any abuse investigation.
Investigation.
-The facility Administrator will ensure a thorough investigation of alleged violations of individual rights and document appropriate action. While a facility investigation is under way, steps will be taken to prevent further abuse.
-Utilize Resident Abuse Investigation Forms for completing investigation;
-A licensed professional nurse will assess the resident for signs of injury and notify the resident's physician and responsible party of any injuries noted;
-Complete a thorough investigation. Two management level staff will conduct interviews with witnesses or other staff, residents or visitors who could have knowledge of the allegation. Witnesses will be asked to assist with completing a questionnaire and statements if indicated that will be attached to the Abuse Investigation Format;
-Every employee will be interviewed who was working on the specific hall/wing that the affected resident resides on. If the allegation occurred on a specific shift, all staff for the identified shift only will complete a questionnaire and complete a statement if indicated;
-Interview the resident if they are cognitively able to answer questions in private setting free from any intimidating factors;
-Complete the investigative summary and statements within five business days;
-Neglect means failure to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress.
1. Review of the Resident #1's face sheet showed the following:
-admission date of 07/09/24;
-Diagnoses included acute kidney failure (AKF), severe dementia with agitation, repeated falls, need for assistance with personal cares, and weakness.
Review of the resident's admission Minimum Data Set (MDS - a federally mandated, comprehensive assessment tool completed by facility staff), dated 07/22/24, showed the following:
-Severely cognitively impaired;
-Required set up or clean up assistance of staff with eating;
-Dependent on staff for toileting hygiene, personal hygiene, mobility, and transfers;
-Required substantial or maximum assistance of staff for showers.
Review of the resident's progress note dated 10/14/24, at 9:45 A.M., showed the facility Administrator documented the following:
-A visitor said the Administrator was letting the resident die. The resident had lost 25% of his/her body weight and the Administrator was fine with the resident lying in bed, dying. The Administrator asked the visitor how he/she knew the resident's weight. The visitor said he/she saw the resident when entering the facility to pick up other residents. The Administrator informed the visitor per the request of the resident's durable power of attorney (DPOA), the visitor should not seek out the resident while in the facility. The visitor said he/she saw the resident while he/she was in the facility conducting business. The visitor stated that on the previous day, 11/13/24, the resident had food on his/her clothes and was dirty. The visitor again told the Administrator that he/she (the Administrator) was just going to let the resident lay in bed and die. The Administrator told the visitor that their conversation was over and he/she did not appreciate what the visitor was accusing the Administrator of and that any further information needed, he/she would need to get the information from the DPOA, from Adult Protective Services (APS), or he/she could hire a lawyer and file for guardianship. After the visitor left, he/she went to the resident's room. The resident was resting in bed. The Administrator had assisted the resident back to his/her room after breakfast and he/she was doing fine. The resident had fresh ice water and snacks available on his/her overbed table. The Activity Director was present during the conversation.
Review of facility records showed the facility did not provide documentation of a full investigation completed regarding the allegation of neglect.
Review of DHSS records showed an investigation report related to the allegations of neglect was not received.
During an interview on 11/14/24, at 4:30 P.M., Certified Nurse Aide (CNA) D said if someone alleged the facility staff were letting a resident lay there and die, he/she would consider that to be an allegation of neglect and would immediately report the allegation to his/her charge nurse.
During an interview on 11/14/25, at 4:40 P.M., [NAME] E said if someone accused a facility staff member of letting a resident lay in bed and die, he/she would consider that to be an allegation of neglect and would immediately report that information to his/her supervisor or charge nurse.
During an interview on 11/14/24, at 4:35 P.M., the Activity Director (AD) said the following:
-Examples of resident neglect would be staff leaving a resident alone or not tending to a resident's needs;
-If anyone made an allegation or resident abuse or neglect, he/she would immediately notify the Administrator;
-If someone accused the staff of allowing a resident to lay there and die, the AD would consider that to be an allegation of neglect and would immediately report to the Administrator.
During an interview on 11/14/24, at 2:33 P.M., the Director of Nursing (DON) said the following:
-He/She was unaware of the specifics of the situation with the resident and a visitor who had become involved in his/her care;
-He/She would be concerned of an allegation of the facility letting a resident lay in bed and die;
-He/She could see how an allegation of this nature would be considered an allegation of possible neglect;
-The Administrator is in charge of investigating allegations of resident abuse or neglect.
During an interview on 11/14/24, at 3:13 P.M., the Administrator said the following:
-He/she was responsible for facility abuse/neglect investigations;
-He/she had five days to investigate allegations of resident abuse/neglect and submit the completed investigations;
-On 10/14/24, at that time he/she did not consider what the visitor said about the resident to be an allegation of abuse or neglect;
-After the visitors left, he/she went to the resident's room to check on the resident;
-He/she did not conduct a full investigation of the allegation;
-He/she did not interview other residents or staff about the allegations of resident neglect.
MO00243241

Based on observation, interview, and record review, the facility failed to develop complete a person centered care plan for each resident when staff failed to care plan related to side rails use for one resident (Resident #13) and wandering/elopement risks for one resident (Resident #36) of 21 sampled residents.
Review of the facility's Care Planning - Interdisciplinary Team policy, dated January 2017 showed the following:
-Upon completion of comprehensive assessments care areas of concern will be triggered to be addressed in the plan of care for that resident.
-Each triggered care area will be reviewed by designated staff to determine if a triggered condition affects the resident's function and quality of life.
-Staff will document whether or not a care plan is needed to address the triggered area.
1. Review of the facility policy titled Proper Use of Side Rails, reviewed 02/2021, showed the use of side rails will be addressed in the resident's care plan.
Review of Resident #13's admission Record, located in the electronic medical record (EMR) under the Profile tab, showed the following:
-admission date of 03/03/23;
-Diagnoses that included history of frequent repeated falls and unsteadiness on feet.
Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment completed by facility staff), located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 06/16/24, showed the resident was cognitively intact.
Review of the resident's EMR under the Misc tab, showed the following:
-Consent for Side Rail Usage, dated 05/24/24, for bilateral (both sides) half side rails to assist with bed mobility and repositioning.
Review of the resident's EMR, under the Progress Notes tab, a Progress Note,, dated 06/19/24 showed bilateral half side rails continued for mobility assist and repositioning assist while in bed.
Observation and interview on 09/09/24, at 11:13 A.M., showed the resident in bed with half side rails on both sides of the bed. The resident said the rails were on the bed at his/her request to assist in positioning and support when he/she gets out of bed.
Review of the resident's EMR, under the Care Plan tab, showed staff did not care plan the use of side rails.
During an interview on 09/12/24, at 11:32 P.M., the MDS Coordinator confirmed staff did not care plan the resident's use of side rails that were installed on 04/21/23. The use of side rails should have been care planned.
During an interview on 09/12/24, at 12:14 P.M., the Director of Nursing (DON) confirmed residents with side rails should have a care plan for side rails and confirmed the staff did not care plan the resident's use of side rails.
2. Review of Resident #36's admission Record, located in the Profile tab of the EMR, showed the following:
-admission date of 08/12/24;
-Diagnoses included Alzheimer's disease.
Review of the resident's Elopement Assessment - V3, dated on 08/12/24 and located under the Assmnts tab of the EMR, showed the following:
-At risk for elopement;
-Interventions included frequent visual monitoring and provided with distracting activity.
Review of the resident's Behavior Note, dated 08/19/24 and located in the Prog Note tab of the EMR, showed the resident was exit seeking at the end door of 600 hall and required redirection.
Review of the resident's admission MDS assessment, with an ARD of 08/25/24, located in the resident's EMR under the MDS tab, showed the following:
-The resident had severely impaired cognition.
-The resident walked with supervision or touching assistance.
-The resident had daily wandering behavior and did not utilize a wander/elopement device.
-The resident had dementia and would get up and wander if not busy. Staff should give resident tasks to do, games to play, magazines to peruse, etc. Family visits also helps keep the resident busy.
-The behavior CAA stated wandering would be on the Care Plan.
Review of the resident's Care Plan, located in the resident's EMR under the Care Plan tab of the EMR, showed staff did not care plan regarding the resident's identified wandering and elopement risk.
Review of the resident's Behavior Note, dated 08/27/24 and located in the Prog Note tab of the EMR, showed the resident exited out the door at the end of 300 hall and required redirection.
During an interview on 09/09/24, at 2:21 P.M., the resident's representative said a couple of weeks ago, facility staff told him/her the resident ,had tried to get out the front door twice in one day.
During an interview on 09/11/24 at 10:56 A.M., Certified Nurse Aide (CNA) 3 said the resident was confused and had a recent room change so he/she gets turned around needed redirection.
During an interview on 09/11/24, at 2:01 P.M., the Infection Preventionist (IP) said the resident walked by himself and was confused. On 08/27/24, the resident walked by himself and pushed on the 300-hall door, which alarmed. Staff responded and redirected the resident as he reached the threshold.
During an interview on 09/12/24, at 11:14 A.M., the MDS Coordinator (MDSC) said the Social Services Director (SSD) completed the Behavior section of the MDS. The MDSC confirmed the resident wandered daily. The MDSC stated the wandering should be care planned.
During an interview on 09/12/24,at 3:00 P.M., the Director of Nursing (DON) said she expected wandering to be addressed on the Care Plan.

Based on observation, interview, and record review, the facility failed to ensure an environment as free from accident hazards as possible for all residents when staff failed to evaluate effective of interventions, care plan new interventions, and failed to complete root cause analysis after multiple elopement attempts and combativeness for one of two residents (Resident #22) reviewed for wandering.
Review of the facility's policy titled Elopement Policy, undated, showed it was the intent of the facility to maintain and enhance a resident's dignity by promoting free access in and around the facility, while safeguarding the well-being of the resident, and to monitor behavior or residents to identify potential elopers, such as excessive wandering, especially to doors.
1. Review of Resident #22's admission Record, undated, found under the Profile tab of the electronic medical record (EMR), showed the following:
-admission date of 06/15/23;
-Diagnoses included dementia.
Review of the resident's annual Minimum Data Set (MDS - federally mandated assessment completed by facility staff), with an Assessment Reference Date (ARD) of 06/28/24, showed the following:
-The resident had severe cognitive impairment;
-The resident experienced delusions, did not exhibit wandering, and used a wheelchair for mobility.
Review of the resident's Care Plan showed the following:
-Elopement risk and wanderer;
-Interventions, initiated on 06/15/23, included to distract the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, and books;
-Identify a pattern of wandering;
-An elopement wandering risk due to dementia and was independently ambulatory and able to propel wheelchair.
Review of the resident's Progress Notes, found in the EMR under the Progress Notes tab, showed the following:
-On 06/02/24, the resident exited out the hall side door two times alone. Interventions were that staff redirected and assisted resident back into the facility and offered the resident a snack and drink.
-On 07/29/24, the resident exited out 200 hall side door. The aide immediately went out to bring the resident back in. Interventions were therapeutic communication, and redirection, both were ineffective.
-On 07/30/24, the resident was repeatedly exiting the facility out 200 hall side door unsupervised. Staff assisted the resident back into the facility.
-On 08/03/24, the resident exited out 200 hall side door several times. The Certified Nursing Aide (CNA) immediately went out to bring the resident back in. The resident was hitting at staff and yelling to leave him/her alone. Staff attempts to redirect were unsuccessful.
-On 08/07/24, the resident continued to exit seek out of the 200-hall side door. The resident was monitored while he/she was outside in the fenced in area.
-On 08/21/24, the resident was exiting 200 side door during a non-smoking time.
-On 08/25/24, the resident exited out the front door while another resident was coming back into the building with family. The nurse was immediately alerted and got the resident. Resident saw nurse coming and began wheeling his/her wheelchair faster while ignoring the nurse. The nurse brought the resident back into the facility.
-On 08/27/24, the resident was exiting out 200 side door alone. Staff followed the resident out and attempted to redirect and the resident became agitated and tried to evade them. The resident hit a CNA four times. Buspirone (used to treat anxiety) was increased on 08/07/24 and has not seemed to help with behaviors.
-On 08/27/24, the resident exited out 200 hall side door, again. Resident agitated and combative. Staff redirected resident back into facility.
-On 08/29/24, the resident attempted to exit 200 hall side door unsuccessfully once this evening, but the staff caught and redirected.
-On 09/10/24, the resident was found several times trying to enter the nursing staff's break room and has now figured out how to unlock the break room door with the nearby key. The resident went around the dining room during supper touching and moving around several other resident's plates and food. The resident found throwing away several plastic cups in the dining room that are used for hot beverages. The resident was redirected several times and therapeutic communication was tried unsuccessfully. The physician was notified and the resident was transferred to a behavioral unit for evaluation and treatment.
Review of the resident's Elopement Assessment, dated 09/10/24, showed the resident was at risk for elopement, did not have a history of elopement, did have a desire to leave the facility, exit seeking with a purpose, and wandering activity.
Observation on 09/10/24, at 11:20 A.M., showed hall 200 had two exit doors, one at the end of the hall and one exit door on the right side of the hall exiting to a patio, flower/vegetable garden, and smoking area. The area was fenced from the end of hall 200 exit door to the corner of hall 300. The area had closed gates that were unlocked.
Review of the resident's medical record showed staff did not update the care plan with new interventions after the multiple elopement attempts and did not complete a root cause analysis to determine the cause of elopements and steps to be take to deter the elopement behaviors.
During an interview on 09/10/24, at 11:20 A.M., the Director of Nursing (DON) said the gates were not locked for emergency purposes. The DON confirmed the resident had not had an elopement assessment completed since June of 2024 until 09/10/24.
During an interview on 09/10/24, at 2:57 P.M., Registered Nurse (RN) 1 said that the staff keep an eye on the resident. RN 1 said that when the staff hear the alarm, they can check the monitor and know which door to go to.
During an interview on 09/10/24, at 3:06 P.M., RN 2 said all staff monitor the resident and that when the alarm sounds, they check the appropriate door.
During an interview on 09/11/24, at 10:13 A.M., the DON said a root cause analysis for the resident's exit seeking and successfully getting out hall 200 side door had not been done. When asked if the concern regarding the resident's increased wandering had been discussed in Quality Assurance, the DON stated no.
During an interview on 09/12/24,.at 2:30 P.M., with the DON and the Administrator, the DON said his/her expectations for successful supervision in the future would mean that the resident's behaviors would have to be under control. The DON said that her hope was that the cause of the resident's exacerbation of exit seeking, wandering, aggression and combativeness could be determined and treated.

Based on observation and interview, the facility failed to ensure food prepared by the facility was palatable when residents complained the food was served cold at times, the food lacked flavor/seasoning, and the meat was tough at times.
1. Observations and interview on 09/11/24, at 1:07 P.M., showed the following:
-The Dietary Manager (DM) confirmed testing the food on the last (test) tray on the cart. Prior to leaving the kitchen the temperature of the cheesy rice casserole was 120 degrees Fahrenheit (F); pork chop was 125 degrees F; and the broccoli was 115 degrees F.
-When the tray was presented after the last tray was delivered, the casserole was 110 degrees F, the pork chop was 95 degrees F, and the broccoli was 90 degrees F.
-The DM said the food was cool and should have been warmer to be palatable for the residents.
Interviews during the Resident Council Meeting on 09/11/24, at 9:15 A.M., showed the residents said the food was cold for the residents who eat in their rooms. The pancakes that morning were cold. The prior night (09/10/24) the menu said burrito with beans/rice, but what was served was tortilla chips with meat on top and unmelted cheese on the meat. The orange Jell-O was not set and watery.
During an interview on 09/09/24, at 3:42 P.M., Resident #35 said the food was not good and was overcooked. The staff overcook the meat. The breakfast was good, just cold. The oatmeal was served without butter or brown sugar.
During an interview on 09/09/24, at 12:02 P.M., Resident #39 said the food did not always taste good. He/she had no teeth so sometimes he/she just threw the food away when he/she could not chew it.
During an interview on 09/11/24, at 2:05 P.M., Resident #38 said the pork chop for lunch that day was tough and dry.
During an interview on 09/11/24, at 2:05 P.M., Resident #20 said the food lacked seasoning. The pork chops were tough and hard to cut and chew.
During an interview on 09/10/24, at 9:37 A.M., Resident #40 said the food had no taste. The pork chops were tough and not easy to chew.
During an interview on 09/12/24, at 10:10 A.M., Resident #4 said the pork chop for yesterday's lunch was hard and not easy to chew.

Based on observation, interview, and record review, the facility failed to ensure all food was prepared in a form designed to meet the needs of each resident when the facility failed to cut up meat as ordered for one resident (Resident #17).
Review of the facility policy titled Menus and Food Preparation-Nutrition Services, revised January 2018, showed the purpose of the policy was to ensure resident nutritional needs are met in conjunction with resident preferences.
1. Review of Resident #17'sadmission Record, located in the electronic medical record (EMR) under the Profile tab, showed the following:
-admission date of 10/18/21;
-readmission date of 08/09/22;
-Diagnoses included gastroesophageal reflux disease.
Review of the resident's annual Minimum Data Set (MDS - a federally mandated assessment completed by facility staff) located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 07/23/24, showed the resident was cognitively intact.
Review of the resident's Orders tab in the EMR showed a physician's order, dated 07/18/24, for regular texture, regular consistency diet with no gravy and meats to be cut small.
Review of the resident's Tray Card, printed daily by the kitchen, showed staff did not update the care to show instruction to cut up meat or to not serve gravy.
During an observation on 09/11/24, at 12:00 P.M., of lunch tray line (preparing the trays of food for the residents) the menu included pork chops. The resident's tray was served with a whole pork chop (not cut up).
During an interview on 09/11/24, at 2:00 P.M., the resident said I could not cut the meat, so I did not eat it.
During an interview on 09/11/24, at 11:10 A.M., the Director of Nursing (DON) said when a change to a diet is made by the physician, a copy of the change is given to the Dietary Manager (DM) for implementation.
During an interview on 09/12/24, at 2:15 P.M., the DON said the paperwork for the change in diet for the resident was not communicated to the DM.

Based on interview and record review, the facility failed to ensure all allegation of possible neglect were reported within two hours to the State Survey Agency (Department of Health and Senior Services - DHSS) when the facility Administrator received an allegation of possible neglect involving one resident (Resident #1) in a facility and failed to report it to DHSS. The facility census was 43.
Review of the facility policy titled, Abuse, Prevention, and Prohibition Policy, dated October 2022, showed the following:
-The facility Administrator will be designated as the facility Abuse Coordinator and will be responsible for overseeing the Abuse Prevention and Prohibition Program and directing any abuse investigation.
-Resident abuse must be reported immediately to the Administrator. The facility Administrator will ensure a thorough investigation of alleged violations of individual rights and document appropriate action. While a facility investigation is under way, steps will be taken to prevent further abuse. Initiate investigation including initial notifications of all listed on the notification form, documenting on the form. This includes the State Agency and law enforcement if this is reasonable suspicion of a crime;
-Complete a report of alleged resident abuse within the required timelines;
-The facility employee or agent, who becomes aware of abuse on neglect, shall immediately report the matter to the facility Administrator or his/her designated representative in his/her absence;
-The Administrator will notify the Corporate Nurse;
-The facility Administrator shall report to the mandated state agency per reporting criteria;
-All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property will be reported immediately to the Administrator. The person made aware of the allegation of abuse or neglect of the Administrator will report the allegation of abuse and neglect to the mandated state agency and law enforcement;
-The allegation will be reported no later that two hours after the allegation is made if the events involve abuse or result in serious bodily injury;
-Neglect means failure to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress.
1. Review of the Resident #1's face sheet showed the following:
-admission date of 07/09/24;
-Diagnoses included acute kidney failure (AKF), severe dementia with agitation, repeated falls, need for assistance with personal cares, and weakness.
Review of the resident's admission Minimum Data Set (MDS - a federally mandated, comprehensive assessment tool completed by facility staff), dated 07/22/24, showed the following:
-Severely cognitively impaired;
-Required set up or clean up assistance of staff with eating;
-Dependent on staff for toileting hygiene, personal hygiene, mobility, and transfers;
-Required substantial or maximum assistance of staff for showers.
Review of the resident's progress note dated 10/14/24, at 9:45 A.M., showed the facility Administrator documented the following:
-A visitor said the Administrator was letting the resident die. The resident had lost 25% of his/her body weight and the Administrator was fine with the resident lying in bed, dying. The Administrator asked the visitor how he/she knew the resident's weight. The visitor said he/she saw the resident when entering the facility to pick up other residents. The Administrator informed the visitor per the request of the resident's durable power of attorney (DPOA), the visitor should not seek out the resident while in the facility. The visitor said he/she saw the resident while he/she was in the facility conducting business. The visitor stated that on the previous day, 11/13/24, the resident had food on his/her clothes and was dirty. The visitor again told the Administrator that he/she (the Administrator) was just going to let the resident lay in bed and die. The Administrator told the visitor that their conversation was over and he/she did not appreciate what the visitor was accusing the Administrator of and that any further information needed, he/she would need to get the information from the DPOA, from Adult Protective Services (APS), or he/she could hire a lawyer and file for guardianship. After the visitor left, he/she went to the resident's room. The resident was resting in bed. The Administrator had assisted the resident back to his/her room after breakfast and he/she was doing fine. The resident had fresh ice water and snacks available on his/her overbed table. The Activity Director was present during the conversation.
Review of DHSS records showed the facility did not file a self-report regarding the allegation of possible neglect.
During an interview on 11/14/24, at 4:30 P.M., Certified Nurse Aide (CNA) D said the following:
-He/she would instantly report any allegation of resident abuse or neglect to the nurse, the Director of Nursing (DON), or Administrator;
-The facility must notify DHSS within two hours of any allegation of resident abuse or resident neglect;
-If someone alleged the facility staff were letting a resident lay there and die, he/she would consider that to be an allegation of neglect and would immediately report the allegation to his/her charge nurse.
During an interview on 11/14/24, at 4:40 P.M., [NAME] E said the following:
-Facility staff members were required to immediately report any allegation of resident abuse or neglect to their supervisors;
-The facility was required to notify DHSS within two hours of any allegation of resident abuse or neglect;
-If someone accused a facility staff member of letting a resident lay in bed and die, he/she would consider that to be an allegation of neglect and would immediately report that information to his/her supervisor or charge nurse.
During interviews on 11/14/24, at 4:35 P.M., and 11/15/24, at 2:30 P.M., the Activity Director (AD) said the following:
-Examples of resident neglect would be staff leaving a resident alone or not tending to a resident's needs;
-If anyone made an allegation or resident abuse or neglect, he/she would immediately notify the Administrator;
-The facility was required to notify DHSS within two hours of any allegation of abuse or neglect;
-If someone accused the staff of allowing a resident to lay there and die, the AD would consider that to be an allegation of neglect and would immediately report to the Administrator;
-He/she overheard the conversation on 10/14/24 between the Administrator and the visitor in regards to the resident;
-The visitor accused the facility of neglecting the resident;
-The facility should have called in the allegation of neglect to within two hours to DHSS.
During an interview on 11/14/24, at 2:33 P.M., the DON said the following:
-He/She was unaware of the specifics of the situation with the resident and a visitor who had become involved in his/her care;
-He/She would be concerned of an allegation of the facility letting a resident lay in bed and die;
-He/She could see how an allegation of this nature would be considered an allegation of possible neglect;
-Staff should notify DHSS within two hours with any allegation or resident abuse or neglect.
During an interview on 11/14/24, at 3:13 P.M., the Administrator said the following:
-On 10/14/24, at that time he/she did not consider what the visitor said about the resident to be an allegation of abuse or neglect;
-He/She should have notified DHSS of the possible allegation;
-The facility was required to notify DHSS of any allegation of abuse or neglect within two hours;
-He/she did not notify DHSS of the allegation of neglect.
MO00243241

Based on interviews and record review, the facility failed to ensure all allegations of possible neglect were investigated by the facility and the investigation submitted to the State Survey Agency (Department of Health and Senior Services - DHSS) within five days when a staff member received an allegation of possible neglect of one resident (Resident #1) and the facility failed to complaint a full investigation. The facility census was 43.
Review of the facility policy titled, Abuse, Prevention, and Prohibition Policy, dated October 2022, showed the following:
-The facility prohibits mistreatment, neglect, or abuse of residents. This includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychological wellbeing.
-The facility Administrator will be designated as the facility Abuse Coordinator and will be responsible for overseeing the Abuse Prevention and Prohibition Program and directing any abuse investigation.
Investigation.
-The facility Administrator will ensure a thorough investigation of alleged violations of individual rights and document appropriate action. While a facility investigation is under way, steps will be taken to prevent further abuse.
-Utilize Resident Abuse Investigation Forms for completing investigation;
-A licensed professional nurse will assess the resident for signs of injury and notify the resident's physician and responsible party of any injuries noted;
-Complete a thorough investigation. Two management level staff will conduct interviews with witnesses or other staff, residents or visitors who could have knowledge of the allegation. Witnesses will be asked to assist with completing a questionnaire and statements if indicated that will be attached to the Abuse Investigation Format;
-Every employee will be interviewed who was working on the specific hall/wing that the affected resident resides on. If the allegation occurred on a specific shift, all staff for the identified shift only will complete a questionnaire and complete a statement if indicated;
-Interview the resident if they are cognitively able to answer questions in private setting free from any intimidating factors;
-Complete the investigative summary and statements within five business days;
-Neglect means failure to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress.
1. Review of the Resident #1's face sheet showed the following:
-admission date of 07/09/24;
-Diagnoses included acute kidney failure (AKF), severe dementia with agitation, repeated falls, need for assistance with personal cares, and weakness.
Review of the resident's admission Minimum Data Set (MDS - a federally mandated, comprehensive assessment tool completed by facility staff), dated 07/22/24, showed the following:
-Severely cognitively impaired;
-Required set up or clean up assistance of staff with eating;
-Dependent on staff for toileting hygiene, personal hygiene, mobility, and transfers;
-Required substantial or maximum assistance of staff for showers.
Review of the resident's progress note dated 10/14/24, at 9:45 A.M., showed the facility Administrator documented the following:
-A visitor said the Administrator was letting the resident die. The resident had lost 25% of his/her body weight and the Administrator was fine with the resident lying in bed, dying. The Administrator asked the visitor how he/she knew the resident's weight. The visitor said he/she saw the resident when entering the facility to pick up other residents. The Administrator informed the visitor per the request of the resident's durable power of attorney (DPOA), the visitor should not seek out the resident while in the facility. The visitor said he/she saw the resident while he/she was in the facility conducting business. The visitor stated that on the previous day, 11/13/24, the resident had food on his/her clothes and was dirty. The visitor again told the Administrator that he/she (the Administrator) was just going to let the resident lay in bed and die. The Administrator told the visitor that their conversation was over and he/she did not appreciate what the visitor was accusing the Administrator of and that any further information needed, he/she would need to get the information from the DPOA, from Adult Protective Services (APS), or he/she could hire a lawyer and file for guardianship. After the visitor left, he/she went to the resident's room. The resident was resting in bed. The Administrator had assisted the resident back to his/her room after breakfast and he/she was doing fine. The resident had fresh ice water and snacks available on his/her overbed table. The Activity Director was present during the conversation.
Review of facility records showed the facility did not provide documentation of a full investigation completed regarding the allegation of neglect.
Review of DHSS records showed an investigation report related to the allegations of neglect was not received.
During an interview on 11/14/24, at 4:30 P.M., Certified Nurse Aide (CNA) D said if someone alleged the facility staff were letting a resident lay there and die, he/she would consider that to be an allegation of neglect and would immediately report the allegation to his/her charge nurse.
During an interview on 11/14/25, at 4:40 P.M., [NAME] E said if someone accused a facility staff member of letting a resident lay in bed and die, he/she would consider that to be an allegation of neglect and would immediately report that information to his/her supervisor or charge nurse.
During an interview on 11/14/24, at 4:35 P.M., the Activity Director (AD) said the following:
-Examples of resident neglect would be staff leaving a resident alone or not tending to a resident's needs;
-If anyone made an allegation or resident abuse or neglect, he/she would immediately notify the Administrator;
-If someone accused the staff of allowing a resident to lay there and die, the AD would consider that to be an allegation of neglect and would immediately report to the Administrator.
During an interview on 11/14/24, at 2:33 P.M., the Director of Nursing (DON) said the following:
-He/She was unaware of the specifics of the situation with the resident and a visitor who had become involved in his/her care;
-He/She would be concerned of an allegation of the facility letting a resident lay in bed and die;
-He/She could see how an allegation of this nature would be considered an allegation of possible neglect;
-The Administrator is in charge of investigating allegations of resident abuse or neglect.
During an interview on 11/14/24, at 3:13 P.M., the Administrator said the following:
-He/she was responsible for facility abuse/neglect investigations;
-He/she had five days to investigate allegations of resident abuse/neglect and submit the completed investigations;
-On 10/14/24, at that time he/she did not consider what the visitor said about the resident to be an allegation of abuse or neglect;
-After the visitors left, he/she went to the resident's room to check on the resident;
-He/she did not conduct a full investigation of the allegation;
-He/she did not interview other residents or staff about the allegations of resident neglect.
MO00243241

Based on interview and record review, the facility failed to ensure one nursing assistant (NA B) completed a state approved certified nursing assistant (CNA) training program and competency evaluation program within four months of hire. This deficient practice had the potential to affect all residents who received care from the NA. The facility's census was 48.
Record review showed the facility did not provide a written policy pertaining to Certified Nurse Aide (CNA) training and certification testing.
1. Record review of NA B's personnel file showed the following:
-Date of hire: 6/28/2022;
-Staff did not have documentation NA B had completed the nurse aide training program and passed the required certification testing.
Record review of the Missouri CNA Registry on-line verification showed the NA did not have an active CNA certification.
Observation on 11/14/2022, at 1:02 P.M., showed NA B was passing meal trays wearing a name tag with his/her name and title of NA. During the observation, he/she told the surveyor that he/she had been employed at the facility since June 2022.
Observations on 11/15/2022, at 1:32 P.M., and 11/16/2022, at 9:15 A.M., showed NA B providing direct care to residents in the facility. NA B wore an identification badge bearing his/her name and the title NA.
During an interview on 11/17/2022, at 3:25 P.M., with the Administrator and the Assistant Director of Nursing (ADON), the Administrator confirmed that NA B was hired on 6/28/2022. The ADON said NA B had finished the classroom and clinical training, but had not completed the testing for CNA certification and was not yet scheduled for the testing. The Administrator and the ADON said NA's should complete their training and pass the certification testing within four months.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the resident and/or the resident's representative in writing of a transfer or discharge to the hospital, including the reason for the transfer, for one resident (Resident #37) and failed to notify the ombudsman of transfers to the hospital for two residents (Residents #6 and #37). The facility census was 48.
Record review showed the facility did not provide a a written policy pertaining to transferring a resident to the hospital.
Record review of a facility form entitled Notice of Resident Transfer or Discharge, revised 11/2016, showed the following spaces to fill:
-Date of notice;
-Name, address, city, state, and zip (did not specify for whom);
-Salutation to addressee;
-Name of resident;
-Name and location of institution where resident to be transferred/discharged ;
-Date of transfer;
-Rationale for transfer;
-Facility contact information for appeal;
-Information regarding State Long-Term Care Appeal Agency, State Ombudsman, State Agency for the Developmentally Disabled, and State Agency for the Mentally Ill;
-Signature/Title/Date by facility;
-Signature of resident or responsible party acknowledging receipt of the notice.
1. Record review of Resident #37's face sheet (gives brief information about the resident) showed the following information:
-admission date of 8/4/2021.
Record review of the resident's progress notes showed staff documented the following:
-On 9/30/2022, at 8:29 A.M., staff rechecked blood glucose after night shift received 536 milligrams/deciliter (mg/dl) blood sugar and physician gave order for this nurse to give 10 units regular insulin. It has been about one hour since insulin was given. Staff gave resident eggs and water at breakfast. AccuCheck (used to check blood sugar levels) machine only gave high reading, no number given. Staff rechecked twice with the same reading. Staff notified physician and he/she stated to recheck in two hours, as it can take four hours for the insulin to peak. Resident left up for monitoring and encouraging water;
-On 9/30/2022, at 8:53 A.M., staff noted the resident's hand shaking. Staff rechecked glucose level and received a reading of 524 mg/dl;
-On 9/30/2022, at 10:36 A.M., staff noted blood sugar still 396 mg/dl. Staff notified physician of level and that resident's brief was also dry. The resident had not voided since 6:15 A.M. Physician ordered another 7 units of insulin and to recheck in four hours. Staff made the family aware and would like updated on rechecks and physician calls;
-On 9/30/2022, at 2:45 P.M., staff noted the resident's blood sugar down to 226 mg/dl and notified the physician;
-On 9/30/2022, at 3:34 P.M.: staff notified family notified of IV (intravenous - administered into the blood vein) fluids to be run;
-On 10/1/2022, at 11:29 P.M., staff noted resident in the hospital.
Record review of the resident's medical record showed staff did not document written notification to the resident or resident's responsible party of the resident's transfer to the hospital on 9/30/2022 or 10/1/2022.
Record review of the facility provided information showed staff did not documentation notifying the Ombudsman of the resident's transfer to the hospital.
2. Record review of Resident #6's face sheet showed the following:
-admitted on [DATE].
Record review of the resident's quarterly minimum data set (MDS - an federally mandated assessment tool completed by facility staff), dated 10/28/22, showed the following:
-Resident discharged to the hospital with anticipation to return on 7/29/22;
-Resident returned from the hospital on 7/31/22.
Record review of the resident nurses' notes showed the following information:
-On 7/29/22, at 12:45 A.M., staff documented the resident had a change in condition and had coffee brown emesis. The resident appeared restless and complained of tummy pain. The doctor was contacted and gave new orders to include Ativan (an antianxiety medication), Maalox (used to treat stomach upset), and proton pump inhibitor (used to treat the amount of stomach acid). The resident was only agreeable to take the Ativan. The resident's responsible party requested resident be sent to the hospital.
Record review of the facility provided information showed staff did not document notifying the Ombudsman of the resident's transfer to the hospital.
3. During an interview on 11/17/2022, at 10:20 A.M., the Social Services Director (SSD) said he/she did not send a written notification for hospital transfers; only for permanent transfers or discharges. The SSD said he/she sends a monthly log to the ombudsman showing admissions, discharges, and transfers.
4. During an interview on 11/17/2022, at 11:10 A.M., the Administrator said the facility's policy was to verbally notify a resident's responsible party of a transfer to the hospital. A copy of the written transfer notice should be mailed to the responsible party or given to the resident if they were self-responsible and alert and oriented. The monthly log sent to the Ombudsman should include hospital transfers.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to give written information to the resident and/or resident's representative of the facility's bed hold policy for two residents (Residents #6 and #37) who were transferred out to the hospital. The facility census was 48.
Record review of the facility's policy entitled Bed Hold Policy & Agreement Form, revised February 2014, showed the following:
-Purpose to establish policy and procedure for facility to notify the resident/responsible party of the Bed Hold Policy and Agreement To Pay Charges For Bed Hold. The facility is to execute an acknowledgement stating whether or not such resident desires to exercise his or her right to a bed hold. The policy should meet applicable regulatory, federal and state program guidelines;
-The Bed Hold Agreement is to be obtained for each occurrence - hospital or therapeutic home leave;
-When hospital or therapeutic home leave is reported on the Midnight Census, the Social Service Director (SSD)/Business Office will notify the resident/responsible party to sign the Bed Hold Agreement. The SSD/Business Office will address weekend or holiday transfers to the hospital on the next business day;
-When the resident goes to the hospital the bed may be held by paying the rate as identified in the Bed Hold Agreement;
-A telephone call may be documented as notification on the Bed Hold Agreement.
1. Record review of Resident #37's face sheet (gives brief information about the resident) showed the following information:
-admission date of 8/4/2021.
Record review of the resident's progress notes showed staff documented the following:
-On 9/30/2022, at 8:29 A.M., staff rechecked blood glucose after night shift received 536 milligrams/deciliter (mg/dl) blood sugar and physician gave order for this nurse to give 10 units regular insulin. It has been about one hour since insulin was given. Staff gave resident eggs and water at breakfast. AccuCheck (used to check blood sugar levels) machine only gave high reading, no number given. Staff rechecked twice with the same reading. Staff notified physician and he/she stated to recheck in two hours, as it can take four hours for the insulin to peak. Resident left up for monitoring and encouraging water;
-On 9/30/2022, at 8:53 A.M., staff noted the resident's hand shaking. Staff rechecked glucose level and received a reading of 524 mg/dl;
-On 9/30/2022, at 10:36 A.M., staff noted blood sugar still 396 mg/dl. Staff notified physician of level and that resident's brief was also dry. The resident had not voided since 6:15 A.M. Physician ordered another 7 units of insulin and to recheck in four hours. Staff made the family aware and would like updated on rechecks and physician calls;
-On 9/30/2022, at 2:45 P.M., staff noted the resident's blood sugar down to 226 mg/dl and notified the physician;
-On 9/30/2022, at 3:34 P.M.: staff notified family notified of IV (intravenous - administered into the blood vein) fluids to be run;
-On 10/1/2022, at 11:29 P.M., staff noted resident in the hospital.
Record review of the resident's record showed staff did not document the resident was informed in writing of the facility's bed hold policy at the time of transfer.
2. Record review of Resident #6's face sheet showed the following:
-admitted on [DATE].
Record review of the resident's quarterly minimum data set (MDS - an federally mandated assessment tool completed by facility staff), dated 10/28/22, showed the following:
-Resident discharged to the hospital with anticipation to return on 7/29/22;
-Resident returned from the hospital on 7/31/22.
Record review of the resident nurses' notes showed the following information:
-On 7/29/22, at 12:45 A.M., staff documented the resident had a change in condition and had coffee brown emesis. The resident appeared restless and complained of tummy pain. The doctor was contacted and gave new orders to include Ativan (an antianxiety medication), Maalox (used to treat stomach upset), and proton pump inhibitor (used to treat the amount of stomach acid). The resident was only agreeable to take the Ativan. The resident's responsible party requested resident be sent to the hospital.
Record review of the resident's record showed staff did not document the resident was informed in writing of the facility's bed hold policy at the time of transfer.
3. During an interview on 11/17/2022, at 10:20 A.M., the SSD said he/she did not send a written notification of hospital transfers; only for permanent transfers or discharges. The SSD said he/she had the resident or responsible party sign agreement with the Bed Hold policy upon transfer or on the next business day.
4. During an interview on 11/17/2022, at 11:10 A.M., the Administrator said the facility's policy was to verbally notify a resident's responsible party of a transfer to the hospital. A copy of the written transfer notice, which includes the Bed Hold Policy on the reverse side, should be mailed to the responsible party or given to the resident if they were self-responsible and alert and oriented.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify and coordinate with the State-designated authority following newly evident or possible serious mental illness for one resident (Resident #6) who had a negative level one Preadmission Screening and Resident Review (PASARR-a federal requirement to help ensure that individuals who have a mental disorder or intellectual disability are not inappropriately placed in nursing homes for long-term care. The PASARR requires that all applicants to a Medicaid-certified nursing facility be evaluated for a serious mental disorder and/or intellectual disability and be offered the most appropriate integrated setting for their needs (in the community, a nursing facility, or acute care setting) and receive the services they need in those settings). The facility census was 48.
Record review showed the facility did not provide a policy regarding PASARR requirements.
1. Record review of Resident #6's Level 1 Nursing Facility Pre-admission Screening for Mental Illness/Mental Retardation or related condition, dated 5/23/19, showed the following information:
-Does not show any signs of symptoms of major mental disorder;
-Had not been diagnosed as having a major mental disorder;
-Primary reason for nursing facility placement not due to dementia;
-Had never had serious problems in levels of functioning in the last six months;
-Not known or suspected to have mental retardation that originated prior to age [AGE];
-Not known or suspected to have a related condition;
-Did not qualify for a special admission category.
Record review of resident's face sheet showed the following information:
-admitted on [DATE];
-admission diagnoses included type 2 diabetes mellitus (affects body's ability to process and use glucose), bipolar disorder (disorder associated with episodes of mood swings ranging from depressive lows to manic highs), flaccid hemiplegia (severe or complete loss of motor function on one side of the body) affecting left side, atrial fibrillation (irregular and often very rapid heart rhythm that can lead to blood clots in the heart), and cerebral infarction (stroke) due to embolism (obstruction of an artery by a clot of blood);
-Diagnosis, dated 12/18/19, included paranoid schizophrenia (serious mental disorder in which people interpret reality abnormally - may result in some combination of hallucinations, delusions, and extremely disordered thinking and behavior that impairs daily functioning) and generalized anxiety disorder;
-Diagnosis, dated 10/1/22, included dementia with agitation (impaired ability to remember, think, or make decisions that interferes with doing everyday activities).
Record review of the resident's medical record showed no new Level II PASARR screening had been completed.
During an interview on 11/17/22, at 11:00 A.M., Licensed Practical Nurse (LPN) E said that after a PASARR screening is submitted, if there is a change in Medicaid status a new form may need to be completed. He/she was unsure if a new diagnosis would require the PASARR screening to be completed again.
During an interview on 11/17/22, at 2:46 P.M., the Administrator said that at the time of the resident's admission in 2019 and submission of the PASARR screening the facility was not aware of the paranoid schizophrenia diagnosis. She said that the PASARR screening should have been re-submitted with the new diagnosis.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed ensure proper care for all residents with catheters (a sterile tube inserted into the bladder to drain urine) when staff failed to obtain updated physician orders for an indwelling catheter for one resident (Resident #12). The facility census was 48.
1. Record review of Resident #12's admission Minimum Data Set (MDS - a federally mandated comprehensive assessment tool completed by facility staff), dated 9/26/22, showed the following information:
-admitted to the facility on [DATE];
-Diagnoses included history of neurogenic bladder (lack of bladder control due to a brain, spinal cord, or nerve condition);
-Cognitively intact;
-Total dependence on staff assistance for transfers, dressing, toileting, and bathing;
-Limited assistance required with bed mobility and personal hygiene;
-Always continent of bowel and bladder;
-Indwelling catheter present.
Record review of the resident's care plan, dated 9/14/22, showed the following:
-Resident has catheter and is incontinent of bowel at times;
-Monitor for signs/symptoms of urinary tract infection;
-Perform catheter care every shift and as needed.
Record review of the resident's physician order sheet (POS), active as of 11/17/22, showed the following information:
-Catheter 20 French indwelling catheter with 30 milliliter(mL) in balloon on admission 9/14/22;
-Discontinue catheter on 9/27/22;
-Change catheter drainage bag as needed for leaking until 09/27/2022;
-Remove catheter per original orders for on day, if resident still needs catheter, call the doctor for a new order;
-No new orders documented for catheter after 9/27/22.
Record review of the resident's nurse progress notes showed the following:
-On 9/27/22, at 2:38 P.M., staff removed the 20 French Foley per doctor's order. The resident stated that he/she had a catheter for over 10 years and that we will have to put one back. Educated on increased risk of infection associated with catheter use. He/she expressed understanding, but stated that every time it gets discontinued they have to put another one in because he/she cannot control his/her voiding. The resident stated, Be ready to be changing me and my bed all the time because I am just going to wet all the time. Educated resident to notify staff by turning on call light whenever he/she voids;
-On 9/27/22, at 9:40 P.M., staff replaced the catheter with size 18 French, resident tolerated well, urine flowing light yellow, will continue to monitor.
Observation and interview on 11/15/22, at 11:42 A.M., showed the resident seated in a recliner with the Foley catheter collection bag tucked into the recliner side pocket. The resident said that his/her bladder does not work and he/she has had a catheter for several years.
Observation on 11/16/22, at 1:00 P.M., showed the resident in his/her recliner and the Foley catheter bag was tucked into the recliner pocket.
During an interview on 11/17/22, at 2:40 P.M., Licensed Practical Nurse (LPN) F said that the order for the catheter was to be discontinued, but that was a hospice order and that when the doctor found out he did not want the catheter to be discontinued. The catheter was re-inserted due to neurogenic bladder diagnosis.
During an interview on 11/17/22, at 2:55 P.M., the Director of Nursing (DON) said that the order to discontinue the catheter on 9/27/22 should have been completed off the order sheet. She said that the facility prefers not to have catheters in the facility if possible. She said that she did not know if the catheter was removed or if the resident refused to have it removed. She said that if the staff did remove the catheter there should have been a new order to re-insert catheter. The order should be up to date.
During an interview on 11/17/22, at 4:00 P.M., the Administrator said that staff should follow physician orders and request new orders for catheters when needed to keep the order sheet up to date.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to complete a risk/benefit review and document alternatives attempted prior to bed rail use for five residents (Residents #8, #12, #27, #31, and #199); failed to obtain informed consent prior to the use side rails for one resident (Resident #31); failed to address the use bed rails in residents' care plans for four residents (Residents #8, #12, #31, and #199); and failed to obtain physician's orders for bed rail use for two residents (Resident #12 ad #199); and failed to ensure staff conducted periodic safety rechecks of all bed rails in use. The facility census was 48.
Record review of a facility policy entitled Proper Use of Side Rails, reviewed 2/2021, showed the following:
-Side rails are only permissible if they are used to treat a resident's medical symptoms or to assist with mobility and transfer of residents;
-An assessment will be made to determine the resident's symptoms or reason for using side rails and will be reviewed quarterly;
-The use of side rails will be addressed in the resident care plan;
-The risks and benefits of side rails will be considered for each resident;
-Consent for side rail, when used as a restraint, will be obtained from the resident or representative, after presenting potential benefits and risks.
1. Record review of Resident #31's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 11/14/2022, showed the following information:
-admission date of 1/29/2020;
-Severely impaired cognition;
-Diagnoses included progress neurological conditions, high blood pressure, renal insufficiency (poor function of the kidneys that may be due to a reduction in blood-flow to the kidneys), Type 2 diabetes (a chronic health condition that affects how the body turns food into energy), dementia, and schizophrenia (a mental disorder in which people interpret reality abnormally);
-Independent for bed mobility, transfers, ambulation with walker or cane, locomotion using wheelchair, and toileting;
-Required set up only for eating, dressing, and personal hygiene;
-Bed rails not used as a restraint.
Observation on 11/15/2022, at 1:40 P.M., showed the resident's bed had a u-shaped side rail attached to his/her right side of the bed in a fixed upright position. During the observation, the resident was unable to understand or respond appropriately to the surveyor's questions regarding the side rail.
Record review of the resident's electronic medical record (EMR) conducted on 11/17/2022, at 8:48 A.M., showed the following:
-Staff documented completion of a Device/Restraint Evaluation on 5/13/2022. The evaluation did not reference the use of a bed side rail;
-Staff did not document a pre-use risk evaluation/assessment or informed consent for the use of side rails.
Record review of the resident's care plan, last updated 8/17/2022, showed the following:
-Resident was able to turn him/herself in bed;
-Staff did not document information pertaining to the use of a side rail.
During an interview on 11/17/2022, at 11:40 A.M., the Director of Nursing (DON) said he/she was unable to locate a signed consent for the resident's use of a side rail.
2. Record review of Resident #8's admission MDS, dated [DATE], showed the following:
-admission date of 9/30/2022;
-Moderately impaired cognition;
-Diagnoses included fractures of the hip and sacrum (large, triangular bone at the base of the spine), high blood pressure, neurogenic bladder (lack of bladder control due to a brain, spinal cord or nerve problem), urinary tract infection (UTI) in previous 30 days, Type 2 diabetes, and arthritis;
-Total dependence on staff for bed mobility, transfers, toileting, and bathing;
-Required extensive assistance from staff for dressing, personal hygiene, and bathing;
-Bed rails not used as a restraint.
Observation on 11/14/2022, at 1:42 P.M., showed the resident's bed had a half rail on his/her right side, in the upright position and padded with foam tubing.
Observation on 11/16/2022, at 10:06 A.M., showed the resident's bed had a padded half rail on his/her right side toward window. The resident grasped the rail during personal care and turning by staff.
Record review of the resident's EMR, showed the following:
-Staff documented informed consent for the use of side rails for bed mobility on 9/30/2022;
-Staff documented completion of the Nursing admission Data Collection, dated 10/1/2022. Staff documented the resident did use or request to use side rails;
-Staff did not document a pre-use risk evaluation/assessment for the use of side rails.
Record review of the resident's care plan, last updated 11/17/2022, showed the following information:
-Resident totally dependent on staff for positioning and turning in bed;
-Staff did not document information pertaining to the use of bed rails.
3. Record review of Resident #27's admission MDS, dated [DATE], showed the following:
-admission date of 8/15/2022;
-Cognitively intact;
-Diagnoses included anemia (lack enough healthy red blood cells to carry adequate oxygen to the body's tissues), congestive heart failure (CHF - occurs when the heart muscle doesn't pump blood as well as it should), atrial fibrillation (irregular heart rhythm), chronic obstructive pulmonary disease (COPD - breathing disorder), high blood pressure, peripheral vascular disease (a slow and progressive circulation disorder), renal insufficiency, recent UTI, depression, thyroid disorder, and morbidly obese;
-Totally dependent on staff for bed mobility, transfers, and bathing;
-Required extensive assistance for dressing and personal hygiene;
-Bed rails not used as a restraint.
Record review of the resident's care plan, last updated 9/12/2022, showed the resident required the use of bed rails and the assistance of two staff to reposition and turn in bed.
Observation on 11/15/2022, at 2:28 P.M., showed the resident's bed had square side rails, approximately 10 inches by 10 inches, in an upright, fixed position on both sides.
Record review of the resident's EMR showed the following:
-Staff documented informed consent for the use of side rails for bed mobility on 8/15/2022;
-Staff documented completion of the Nursing admission Data Collection, dated 8/15/2022. Staff documented the resident did use or request to use side rails to promote independence with bed mobility and positioning;
-Staff did not document a pre-use risk evaluation/assessment for the use of side rails.
4. Record review of Resident #12's face sheet showed the following:
-admission date of 9/13/2022;
-Diagnoses included COPD, chronic kidney disease (CKD - kidneys are damaged and can't filter blood the way they should), type 2 diabetes mellitus, anxiety disorder, CHF, history of falling, and neurogenic bladder.
Record review of the resident's admission MDS, dated [DATE], showed the following information:
-Cognitively intact;
-Extensive assistance required for transfers, mobility, dressing, and toilet use;
-Limited assistance required for bed mobility, personal hygiene, and eating;
-Indwelling catheter (sterile tube used to drain urine).
Observation and interview on 11/14/2022, at 2:00 P.M., showed one-half side rails on the both sides of the resident's bed in the up position. The resident was seated in his/her recliner and said that he/she used the side rail to assist with repositioning in bed. He/she did not remember any assessment or forms required to be signed for the side rail.
Observation on 11/16/2022, at 11:00 A.M., showed the resident seated in his/her recliner. The bed had side rails in the up position.
Record review of the resident's care plan, dated 9/22/2022, showed the following information:
-The resident had an activities of daily living self-care deficit;
-The resident will demonstrate the appropriate use of adaptive devices to increase ability in bed mobility, transfers, eating, dressing, toilet use and personal Hygiene;
-Required one staff assistance to reposition and turn in bed;
-The care plan showed no other information related to the side rails.
Record review of the resident's November 2022 physician order sheet (POS) showed staff did not document any physician order pertaining to bed rails.
Record review of the resident's EMR, showed the following:
-Staff documented informed consent for the use of side rails for bed mobility on 9/14/2022;
-Staff did not document a pre-use risk evaluation/assessment for the use of side rails.
5. Record review of Resident #199's face sheet showed the following:
-admission date of 11/10/2022;
-Diagnoses included Parkinson's disease (disorder of the central nervous system that affects movement, often including tremors), broken internal left knee prosthesis (knee joint with a man-made artificial joint), and presence of artificial knee joint - bilateral.
Record review of the resident's admission MDS, dated [DATE], showed the following information:
-Cognitively intact;
-Extensive assistance required for transfers, mobility, dressing, personal hygiene, and toilet use;
-Set up assistance for eating.
During observation and interview on 11/15/22, at 11:25 A.M., resident's bed had bilateral one-half size side rails in the up position. The resident was seated in the bedside chair. He/she said that he/she used the side rails to assist with repositioning in bed.
Observation on 11/16/2022, at 8:30 A.M., the resident rested in bed with his/her eyes closed and the side rails in the up position.
Record review of the resident's November 2022 POS showed staff did not document any physician order pertaining to bed rails.
Record review of the resident's EMR, showed the following:
-Staff documented informed consent for the use of side rails for bed mobility on 11/10/2022;
-Staff did not document a pre-use risk evaluation/assessment for the use of side rails.
Record review of the resident's care plan, dated 11/12/2022, showed the following information:
-The resident had an activities of daily living self-care deficit;
-Required two staff assistance to reposition and turn in bed;
-The care plan showed no information related to the side rail use.
6. During an interview on 11/17/2022, at 10:20 A.M., the Social Services Director (SSD) said the nurse assesses a resident for the need or request for side rails or requests that therapy do an evaluation and recommend a side rail. The nurse obtains signed consent for the use of side rails and requests Maintenance to install the rails.
7. During an interview on 11/17/2022, at 10:30 A.M., Maintenance said he was responsible for installing bed rails when requested by nursing staff. He installs rails according to manufacturer's guidelines for the type of bed and completes the initial safety gap measurements. He did not do further periodic bed rail safety checks, unless someone asked him to do so.
8. During an interview on 11/17/2022, at 10:50 A.M., the Administrator said staff should obtain informed consent for the use of side rails on a resident's bed. Maintenance installs the bed rails and completes the safety gap measurements.
9. During an interview on 11/17/2022, at 3:45 P.M., the Administrator said staff should complete a Device Evaluation for each resident on admission and quarterly. A pre-use evaluation should also be done if a resident or responsible party requests side rails after admission. Maintenance should complete periodic safety checks on all bed rails.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to protect food from possible contamination when staff failed to follow proper hand hygiene when handling food items and food contact surfaces; when staff failed to properly wear facial hair nets and hair nets; when staff failed to ensure that the warewasher was working properly; and when staff failed to keep open drinks out of the kitchen. The facility had a census of 49 residents.
1. Record review of the 2013 Food and Drug Administration (FDA) Food Code showed the following information:
-Food employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles;
-After touching bare human body parts other than clean hands and clean, exposed portions of arms;
-During food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks;
-Before donning gloves to initiate a task that involves working with food;
-After engaging in other activities that contaminate hands.
Record review of the facility's (undated) policy titled, Handwashing, showed staff to wash hands whenever they are soiled and before food preparation.
Record review of facility records showed the facility did not provide a policy for glove usage for the kitchen or food preparation area.
Observation of the kitchen on 10/23/19, beginning at 9:58 A.M., showed the following information:
-Cook G exited the kitchen into the main dining room and re-entered the kitchen;
-Cook G touched a trash can liner inside of the dishwashing area with his/her right hand;
-Cook G entered the dry goods room, picked up a paper cover, and placed the paper cover over the open, upright water pitchers;
-Cook G exited the dry goods room, entered the kitchen, picked up a clear plastic pitcher, went to the ice machine, and used the scoop to fill the pitcher with ice;
-Cook G exited the kitchen with the pitcher filled with ice;
-During this timeframe, [NAME] G did not wash his/her hands or utilize gloves.
Observation of the kitchen on 10/23/19, beginning at 9:58 A.M., showed the following information:
-Dietary Aide (DA) F washed hands and put on gloves;
-DA F began to fill 8 ounce plastic cups with milk and put plastic, disposable lids on the cups to cover them;
-DA F ran out of milk, exited the kitchen prep area, opened the door to the milk cooler and obtained a gallon of milk, opened the gallon of milk, and proceeded to fill the remaining plastic cups and place plastic, disposable lids on the cups;
-DA F opened the reach-in cooler in the kitchen preparation area, retrieved individual dietary shake cartons from the cooler, opened them, poured them into 8 ounce plastic cups, and placed plastic, disposable lids on them;
-During this timeframe, DA F did not change gloves or wash hands after touching other non-food contact surfaces with the gloves.
Observation of the kitchen on 10/24/19, beginning at 11:23 A.M., showed the following information:
-Cook G entered the kitchen from the dining room and sanitized his/her hands with sanitizer on the way in;
-Cook G exited the kitchen preparation area and put away his/her personal belongings in the lockers;
-Cook G did not wash his/her hands;
-Cook G entered the preparation area, retrieved salad items from the reach-in cooler, placed them on a prep area by the sink, and put on gloves that were in a box on the shelf above the sink area (potentially contaminating the gloves);
-Cook G reached into the bag of lettuce and removed lettuce from the bag with his/her gloved hand and placed it into two plastic salad bowls;
-Cook G opened the bag of cheese and removed cheese with gloved hands and placed it on top of the lettuce in the two plastic salad bowls;
-Cook G opened the bag of diced meat and removed the diced meat with gloved hands and placed it on top of the cheese in the two plastic salad bowls;
-Cook G diced one tomato and placed it on top of the salad in the two plastic salad bowls;
-Cook G did not change gloves or wash hands during this timeframe.
During an interview on 10/24/19, at 2:01 P.M., [NAME] C said the following:
-Wash hands upon entering the kitchen after putting away your personal belongings;
-Wash hands between glove changes and gloves should be changed when you go from clean to dirty or dirty to clean, touch anything outside of the food prep like door handles or the dishwasher;
-Staff should wash hands all the time.
During an interview on 10/24/19, at 2:18 P.M., the Certified Dietary Manager (CDM) said the following:
-Hand hygiene should be performed all the time;
-When staff enter the kitchen, if staff open a cooler or freezer door to get something, after going to the dry goods room to do or get something, going from dirty to clean, and with every glove change;
-Kitchen staff have been trained and in-services have been completed on hand hygiene;
-They should not use only sanitizer upon entering the kitchen, they must still wash hands;
-They should wash their hands after touching a trash can liner, cooler or freezer doors, or taking dirty dishes to the dish area;
-They should wash hands after exiting the dry goods room;
-They should wash hands after changing gloves and gloves should be changed after they have touched any other surface besides the food they are preparing.
During an interview on 10/24/19, at 7:30 P.M., the administrator said the following:
-Staff should wash hands upon entering the kitchen, going from dirty to clean, and after touching non-food areas;
-They cannot touch everything with their gloves and if they do touch something gloves should be changed, hands washed, and new gloves put on;
-He/she expects kitchen staff to follow the facility hand washing and glove usage policies.
2. Record review of the 2013 FDA Food Code showed the following information:
-Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed to be worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single-service and single-use articles.
Record review of facility records showed the facility did not provide a policy for for hair restraints or beard restraints.
Record review of the facility's employee in-service, dated 9/16/19, showed the following information:
-Employees received an in-service that hair nets and beard nets must be worn at all times when in the kitchen;
-Cook C signed the attendance form.
Observation of the kitchen on 10/21/19, beginning at 10:05 A.M., showed [NAME] C had a full beard and did not wear a beard restraint.
Observation of the kitchen on 10/23/19, beginning at 9:58 A.M., showed the following information:
-Cook C had a hair net on his/her head;
-Cook C had a pony tail that was exposed and hung below the hair net down his/her back about six inches;
-Cook C continued to prepare food with the pony tail exposed outside of the hair net.
During an interview on 10/24/19, at 2:01 P.M., [NAME] C said the following:
-Hair nets and beard nets are required at all times in the kitchen;
-Beard nets are to be worn with any facial hair;
-He/she should have had a beard net on his/her face on 10/21/19;
-His/her pony tail should have been covered by the hair net on 10/23/19.
During an interview on 10/24/19, at 2:18 P.M., the CDM said the following:
-If a facility employee has facial hair, they must wear a beard net while working in any area of the kitchen;
-Hair nets should cover all of the hair and are required for any employee working in any area of the kitchen;
-Cook C should have worn a beard net and his/her pony tail should have been covered by the hair net.
During an interview on 10/24/19, at 7:30 P.M., the administrator said she expects facility employees to follow the facility policy and wear hair and beard nets at all times while working in the kitchen.
3. Record review of the 2013 FDA Food Code showed the following information:
-Warewashing machines require the presence of a temperature measuring device in each tank of the warewashing machine and is based on the importance of temperature in the sanitization step;
-In hot water machines, it is critical that minimum temperatures be met at various cycles so that the cumulative effect of successively rising temperatures causes the surface of the item being washed to reach the minimum temperature for sanitization;
-When chemical sanitizers are used, specific minimum temperatures must be met because of the effectiveness of chemical sanitization is directly affected by the temperature of the solution.
Record review of the facility's [NAME] Warewashing Machine Wash and Rinse Cycle tag showed the following information:
-Wash cycles must be at a minimum of 150 degrees Fahrenheit (F) or higher;
-Rinse cycles must be at a minimum of 180 degrees F or higher.
Observation of the kitchen on 10/22/19, beginning at 9:15 A.M., showed the following information:
-DA F started the warewasher with a tray of miscellaneous kitchen utensils;
-The rinse cycle registered at 174 degrees F.
Observation of the kitchen on 10/23/19, beginning at 9:58 A.M., showed the the warewasher rinse cycle registered at 176 degrees F.
Observation of the kitchen on 10/23/19, beginning at 11:48 A.M., showed the following information:
-DA E placed the puree bowl into a tray and began the warewasher;
-The warewasher rinse cycle registered at 174 degrees F.
Observation of the kitchen on 10/23/19, beginning at 5:54 P.M., showed the warewasher rinse cycle temperature ranged from 159 degrees F to 161 degrees F.
Observation of the kitchen on 10/24/19, beginning at 12:01 P.M., showed the warewasher rinse cycle temperature registered at 166 degrees F.
During an interview on 10/22/19, at 9:15 A.M., DA F said the following:
-The warewasher wash cycle has to be at 150 degrees F or higher and the rinse cycle has to be at 180 degrees F or higher;
-If it does not reach those temperatures, then you have to wash the items again.
During an interview on 10/24/19, at 2:01 P.M., [NAME] C said the following:
-The warewasher wash cycle must be at 150 degrees F or higher;
-The rinse cycle can range from 176-180 degrees F or higher;
-They record the temperatures daily for each shift on the clipboard;
-He/she did not know the rinse cycle must be at 180 degrees F or higher;
-He/she has not told the CDM the warewasher is not rinsing at the correct temperature.
During an interview on 10/24/19, at 2:18 P.M., the CDM said the following:
-The warewasher wash cycle should be at 150 degrees F or higher;
-The rinse cycle should be at 180 degrees F or higher;
-They test the warewasher daily and record the temperatures on the clipboard;
-He/she did not know the temperature for the rinse cycle registered below 180 degrees F.
During an interview on 10/24/19, at 7:30 P.M., the administrator said the following:
-The warewasher should be utilized per the manufacturer's recommendations;
-The wash and rinse cycles should be completed at the recommended temperatures or higher;
-If the warewasher did not work correctly, she would expect facility staff to tell the CDM or herself of the problem.
4. Record review of the 2013 (FDA) Food Code showed the following information:
-An employee shall not eat, drink, or use any form of tobacco only in designated areas where the contamination of exposed food; clean equipment, utensils, and lines; unwrapped single-service and single-use articles; or other items needing protection cannot result.
Observation of the kitchen on 10/21/19, beginning at 10:05 A.M., showed the following information:
-An open water pitcher filled with a dark liquid sat on the prep table while staff prepared lunch;
-Cook C took the pitcher with him/her on break.
Observation of the kitchen on 10/22/19, beginning at 9:15 A.M., showed the following information:
-An open water pitcher filled with a dark liquid sat on the prep table where staff prepared lunch;
-Cook C picked up the water pitcher, took a drink, and moved it to the sink area.
Observation of the kitchen on 10/23/19, beginning at 9:58 A.M., showed the following information:
-An open water pitcher filled with a dark liquid sat on the prep table by the puree machine and sink;
-Cook C picked up the water pitcher, took a drink, and sat it back down by the sink.
Observation of the kitchen on 10/24/19, beginning at 11:23 A.M., showed the following information:
-An open water pitcher filled with a dark liquid sat on the prep table where staff prepared lunch;
-Cook C left the area to go on break and took the open water pitcher with him/her.
During an interview on 10/24/19, at 2:01 P.M., [NAME] C said the following:
-There should be no open food or drinks kept in the kitchen prep area;
-They should be kept in the lockers and employees should go back there for a drink or snack.
During an interview on 10/24/19, at 2:18 P.M., the CDM said the following:
-There are to be no open food or drinks in the kitchen area;
-All food and drinks for staff are to be kept in their lockers or in the employee break room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents' end of life wishes reflected throughout the medical record remained consistent for two residents (Resident #4 and #246) out of a sample of 18 residents. The facility census was 49.
Record review of the American Heart Association website, showed the following information regarding Advance Directives:
-Advance directives, also referred to as living wills, can address a number of issues, such as whether a patient wants to receive artificial respiration, dialysis, tube feeding or artificial hydration, or donate an organ in the event of death. The document may also include a do-not-resuscitate-order, which instructs doctors not to perform cardiopulmonary resuscitation (CPR- an emergency procedure that is performed when a person's heartbeat or breathing has stopped) if the patient stops breathing or their heart stops.
-An advance directive provides a clear statement by the patient of his or her wishes with respect to his or her health care. This helps to avoid disputes that can arise among family members concerning how to treat an incapacitated relative and gives direction to healthcare providers concerning the level of care to provide the patient.
-An advance directive may also include a durable power of attorney for health care or healthcare proxy, in which the patient names another person to make healthcare decisions for them if they are unable to do so.
-Advance directives are available to any adult, regardless of health status. However, no one is required to create advance directives, and advance directives can be revoked at any time at the patient's request.
-Before providing care, hospitals are required by law to ask patients if they have an advance directive and provide guidance and necessary documents if the patient chooses to create one.
-If a patient is unable to make healthcare decisions and does not have an advance directive, healthcare providers will consult with the patient's spouse, adult children, parents, siblings or other adult relatives, among others, as required by state law.
1. Record review of Resident #4's face sheet (basic resident profile sheet), showed the following information:
-readmitted to the facility on [DATE];
-It did not show the resident's end of life wishes;
-Diagnoses included peripheral vascular disease (is a disease that causes restricted blood flow to the arms, legs, or other body parts), Parkinson's disease, and anxiety disorder.
Record review of the facility's acknowledgement of receipt, advance directives/medical treatment decisions form, showed the following information:
-Other advance directives: No vents or tubes, CPR only;
-The resident signed and dated the form on [DATE].
Record review of the resident's care plan, revised on [DATE], showed the following information:
-Resident was full code (wants CPR);
-The resident has chosen full code status. He/she has chosen no vents or tubes. This is to be reviewed annually and updated as needed.
Record review of the facility's acknowledgement of receipt, advance directives/medical treatment decisions form, showed staff reviewed the resident's wishes to be CPR only on [DATE] and documented no changes.
Record review of the resident's physician order sheet (POS), dated [DATE] through [DATE], showed the resident's code status as do not resuscitate (DNR-withhold CPR).
Record review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, dated [DATE], showed the following information:
-Cognitively intact;
-Independent with bed mobility, transfers, dressing, toilet use, and personal hygiene.
Record review of the facility's acknowledgement of receipt, advance directives/medical treatment decisions form, showed staff reviewed the resident's wishes of CPR only and documented no changes on [DATE].
Record review of the resident's POS, dated [DATE] through [DATE], showed the resident's code status as DNR.
Record review of the resident's POS, dated [DATE] through [DATE], showed the resident's code status as DNR.
Record review of the resident's POS, dated [DATE] through [DATE], showed the resident's code status as DNR.
2. Record review of Resident #246's face sheet, showed the resident admitted to the facility on [DATE]. It did not show the resident's end of life wishes.
Record review of the resident's admission evaluation and interim care plan, admission date [DATE], showed the following information:
-Resident had a living will;
-Advance directives explained;
-Staff did not document the resident's end of life wishes.
Record review of the resident's admission POS, showed the following information:
-Admit to skilled nursing;
-Code Status: full code (wants CPR);
-Diagnoses included intertrochanteric fracture of left hip, post placement of intra medullary nail, and dementia;
-Signed by the physician on [DATE].
Record review of the resident's acknowledgement of receipt, advance directives/medical treatment decisions, showed the following information:
-Do not resuscitate (withhold CPR);
-Signed by the resident and a witness on [DATE];
-The physician signed it on [DATE].
Record review of the resident's social service progress note, dated [DATE], showed the Outside the Hospital Do Not Resuscitate (OHDNR) form (withold CPR) signed and put on the physician's list.
Record review of the OHDNR form, showed the resident signed the form on [DATE] and the physician signed it on [DATE].
Record review of the resident's current physician orders on [DATE], showed staff did not change the resident's code status to DNR. The physician order sheet continued to show the resident's code status as full code.
3. During an interview on [DATE], at 4:42 P.M., the Social Service Designee (SSD) said if a resident is DNR, an outside the hospital DNR form is completed on admission, and put in the front of the chart. If a resident chooses not to formulate a DNR, there is another form called receipt of acknowledgement, that can either show DNR or CPR, depending on the resident's wishes. Those forms are completed on admission and should be filed under the advance directives tab in the resident's medical record. The POS should show the resident's code status, as CPR or DNR. SSD updates the advance directive form if there is a change, then documents the date and their initials. SSD would tell the nurse the POS needs updated to show the change. SSD does not touch the POS. Staff, including SSD, reviews the resident's code status quarterly during the care plan meetings with the residents. She thinks the DON updates the care plan with code status. SSD does not do it. If SSD knows or is the one asking questions about the resident's code status, SSD documents that information in the social services notes. Otherwise, SSD may or may not document about it, if she doesn't know. No one directly communicates to SSD about the resident's code status on admission. Usually, if there is a change, SSD is the one involved with it. Then, SSD would document a note about it. She did not know for sure what Resident #4's end of life wishes were without looking. Resident #246 is DNR.
4. During an interview on [DATE], at 5:21 P.M., Certified Nursing Assistant (CNA) L said he/she tells the charge nurse, seek assistance, and look for a resident's code status in the front of the resident's medical record, the nurses' notes or on the POS in the case of an emergency. Rarely, staff find the resident's code status in the POS. Usually, it is in the nurses' notes or at the front of the resident's medical record.
5. During an interview on [DATE], at 5:49 P.M., Licensed Practical Nurse (LPN) A said the nurses ask the resident and family about code status. The nurse fills out an outside the hospital DNR form. The nurse has the physician sign it. admission charting includes the acknowledgement form and the full assessment in the nurses' notes. It includes the interim care plan. Nurses document the resident's code status on the POS. If a resident changes their wishes, SSD documents the change in their progress notes and the nurses would document the change in code status on the POS. When they change the code status, the nurse documents on the right side to show the pharmacy to change it. The nurse reviewed Resident #4's and Resident #246's medical record information regarding code status. The nurse said it was kind of confusing and conflicting.
6. During an interview on [DATE], at 6:29 P.M., the Director of Nursing (DON) said the SSD starts the process for code status. The DON and Assistant Director of Nursing (ADON) think she talks to the resident and family. They would expect her to document in her notes. The SSD fills out the outside the hospital DNR order form. The ADON said it gets put in the front of the chart, in a protective sheet if possible. The DON said the nurse usually adds it to the POS. The ADON said she did not know for sure it is on the admission care plan. If a resident is full code status on admission, the SSD completes a form that says the resident chooses not to make an advance directive at this time. That form is put in the front of the chart. If a resident changes their code status, the SSD updates the paper and notifies the nursing staff. SSD updates the acknowledgement sheet and lets the nursing staff know. The nurses update the POS. The ADON said she thought the resident's code status was on the resident's full care plan, but did not know for sure though. She thought it should be.
7. During an interview on [DATE], at 7:31 P.M., the administrator said she noticed discrepancies in code status when making copies of the medical records. They were working to make sure DNR was the first thing staff see in the medical record. They were working to make sure the information is on the face sheet and on the POS.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop a comprehensive care plan that included interventions to address facility identified resident care needs for three residents (Resident #2, #25, and #146) in a sample of 18 residents in a facility with a census of 49.
1. Record review of Resident #25's nurses' notes, dated 8/13/19, showed the resident admitted to the facility. The resident reported blindness in the right eye and vision clear in the left eye. The resident did not wear glasses.
Record review of the resident's physician progress notes, dated 8/14/19, showed the resident had head trauma injury several years prior and became combative and verbally abusive. Since that time, his/her organic brain trauma has been complicated by dementia.
Record review of the resident's nurses' notes, dated 8/15/19, showed the resident's right pupil larger than the left. The resident said, in case you didn't notice, I'm blind in that eye.
Record review of the resident's nurses' notes, dated 8/19/19, showed the resident as incontinent of bladder at night.
Record review of the resident's admission Minimum Data Set (MDS), a federally mandated comprehensive assessment instrument completed by facility staff, dated 8/26/19, showed the following information:
-admission date of 8/13/19;
-Severely cognitively impaired;
-Impaired vision, sees large print, but not regular print;
-The resident did not have corrective lenses;
-Usually understands others;
-Required limited assistance of one staff for bed mobility, transfers, dressing, toilet use, and personal hygiene;
-Required supervision with set up only for eating;
-Diagnoses included dementia;
-Occasional incontinence of bladder;
-Received as needed pain medications in the last 5 days of the assessment lookback period.
Record review of the nurses' notes, dated 9/1/19, showed the resident up to toilet at times, but also incontinent. Staff needed to check the resident for incontinence.
Record review of the resident's care plan, initiated on 9/18/19, showed the following information:
-The resident had impaired visual function. Staff did not document any interventions or resident specific information for staff related to the focus area;
-The resident had nutritional problem or potential nutritional problem. Staff did not document any interventions for staff related to the focus area;
-The resident had a communication problem. Staff did not document any additional information regarding the communication problem or any interventions to address the problem;
-The resident had bladder incontinence. Staff did not document any interventions to address the bladder incontinence;
-The resident had a focus area pain medication therapy related to. Staff did not complete the sentence. Staff did not document any interventions to address the pain medication therapy focus area.
Record review of the resident's physician progress notes, dated 9/25/19, showed the resident as oriented to self. Resident's weight down four pounds in one month.
Record review of the resident's nurses' notes, dated 10/1/19, showed staff reviewed the weight report. The nurse documented to continue regular diet with double entree at lunch. The nurse notified the dietary department.
Record review of the resident's physician's orders showed the following information:
-Order dated 10/3/19, staff to obtain a urinalysis;
-Order dated 10/4/19, Bactrim DS, (antibiotic) one tablet twice a day for 10 days;
-Order dated 104/19, Florastor (probiotic supplement) 250 mg, one capsule three times a day for 14 days.
Record review of the resident's nurses' notes, dated 10/4/19, showed the nurse documented staff found the resident in a puddle of urine again. The resident hung on the transfer pole, sitting on the floor with his/her back against the bed frame.
Record review of the nurses' notes, dated 10/9/19, showed the resident continued on antibiotic for urinary tract infection. The resident was incontinent of urine often.
Observation on 10/23/19 showed the following:
-At 11:53 A.M., the resident sat in the wheelchair by the nurses' station;
-At 12:06 P.M., the resident wheeled his/her wheelchair around the nurses' station and down the hall. The resident used his/her feet to proper him/her self down the hall. The resident wheeled his/her self into the dining room;
-At 12:52 P.M., the resident wheeled around in the dining room, waiting for lunch. Staff followed the resident with his/her plate of food, trying to get the resident to come back to the table and eat.
Observation on 10/24/19, at 12:20 P.M., showed the resident wheeled his/her wheelchair down 600 hall, using his/her feet to propel the chair.
Record review of the resident's care plan on 10/24/19, did not show any additions or clarifications of the focus areas.
3. Record review of Resident #146's quarterly MDS, dated [DATE], showed the following information:
-re-admitted to the facility on [DATE];
-Diagnoses included acute and chronic respiratory failure, pneumonia, morbid obesity, acute and chronic congestive heart failure, diabetes, hypertensive chronic kidney disease Stage 4 (severe), and acute kidney failure;
-Cognitively intact;
-Required extensive assist of 1-3 staff for bed mobility, toileting and dressing;
-Indwelling catheter (tubing placed to drain the bladder to an external collection system) in place; therefore, urinary continence not rated;
-Occasionally incontinent of bowel;
-Received antibiotics on five of five look-back days.
Record review of the resident's POS showed an intravenous (IV) order, dated 9/26/19, for Zosyn (antibiotic) 2.25 grams (gm) four times daily for 10 days.
Record review of the resident's medication administration record (MAR) for September and October 2019, showed staff documented IV administration of Zosyn from 9/26/19 through 10/6/19 per physician orders.
Record review of nurses' notes showed staff documented the following information:
-On 9/27/19, at 3:40 A.M., new IV pump delivered to resident at 1:30 A.M.
-Ran IV ABT (antibiotic therapy) as ordered; flushed well.
-Foley (urinary catheter) intact with clear yellow urine noted.
Record review of the resident's POS showed an order, dated 9/29/19, to begin bladder training and discontinue the Foley catheter.
Record review of nurses' notes showed the following information:
-On 9/29/19, at 3:20 A.M., ABT via port without ADRs (adverse reactions) noted.
-Foley catheter intact with minimal drainage noted; changed bag due to crystallization of tubing noted.
-Resident complaint of bladder cramps as yellow urine started to drain;
-On 9/29/19, at 3:15 P.M., staff removed the resident's catheter. Resident tolerated well;
-On 9/30/19, continued with IV [NAME] without ADRs; IV to right hand with good blood return;
-On 10/1/19, at 4:05 A.M., ABT continued with no ADRs noted. IV to right hand not accessed yet this shift;
-On 10/1/19, at 2:20 P.M., IV ABT ran without difficulty to right hand; no sign of infection to right hand;
-On 10/2/19, at 12:00 P.M., placed on acute list for physician due to poor blood return on port;
-On 10/3/19, on 3:00 P.M. to 11:00 P.M. shift, IV ABT continued without difficulty;
-On 10/3/19, on 11:00 P.M. to 7:00 A.M. shift, continued on IV ABT. Used bedpan frequently, incontinent at times;
-On 10/3/19, at 11:00 A.M., resident is incontinent. IV ABT given as ordered via peripheral line. IV nurse called to report they would not be able to unclog a Port-A-Cath (implanted portal directly to the vein); resident would have to return to the physician who put it in;
-On 10/4/19, at 6:25 A.M., IV ABT continued. Flushed well, no blood return. Had used bedpan once this shift; all other times incontinent;
-On 10/4/19, at 2:30 P.M., ABT given without difficulty; good blood return, flushed without difficulty to IV site to right hand. Used bed pan.
Record review of the resident's POS showed the following orders:
-On 10/4/19: Use the peripheral IV site to finish the ABT;
-On 10/7/19: Discontinue the IV line to the right hand.
Record review of the resident's nurses' notes for the resident showed staff documented the following information:
-On 10/7/19, at 9:45 A.M., IV line to right anterior hand discontinued;
-On 10/10/19, at 9:45 A.M., resident is very incontinent of urine. Groin and buttocks extremely red;
-On 10/11/19, at 4:05 A.M., fracture bed pan missing at the start of shift. Resident refused to use regular bed pan and had several incontinent episodes before staff found another fracture pan;
-On 10/12/19, at 4:43 A.M., resident with increased episodes of incontinence this shift. Manipulative behaviors noted; not calling for bedpan due to not liking the assigned aide, wanted a specific aide to assist;
-On 10/12/19, at 11:20 A.M., used bed pan.
Record review of the resident's care plan, last updated in handwriting on 10/10/19, showed the following undated focus areas/interventions:
-Had an indwelling Foley catheter (size 16-French) due to urinary retention; history of urinary tract infections (UTIs);
-Appropriate catheter care to be given at least every shift;
-Used a bed pan with staff assist; was not able to clean him/herself well or do his/her own catheter care.
-Laid on an incontinent pad in bed, but mainly continent of bowel. Provide good pericare and catheter care;
-Had a Port-A-Cath (implanted portal directly to the vein) to the right chest;
-Administer medication as ordered;
-Any IV medications will be given through this port;
-Port-A-Cath access by an RN (Registered Nurse); LPNs (Licensed Practical Nurse) may administer
medications via IV;
-Flush per protocol with IV medication administration;
-Staff did not update the care plan to show the catheter discontinued, the resident incontinent of urine, and the resident would not use a regular bed pan, but required a specialized fracture type bed pan;
-Staff did not update the care plan to reflect the clogged port and that it was no longer being used for IV medication administration.
During an interview on 10/21/19, at 12:13 P.M., the resident said he/she did not have an indwelling catheter; it was removed. Now, he/she uses a fracture-style bed pan, which is smaller and more comfortable than a regular shaped pan.
During an interview on 10/24/19, at 9:45 A.M., the DON said the resident's Port-A-Cath was no longer in good usable condition due to being clogged. The resident requested that the physician replace the port due to medical staff always having difficulty accessing his/her veins for IV medications. The SSD said the resident was scheduled for a port replacement in early November.
4. During an interview on 10/24/19, at 10:57 A.M., the MDS Coordinator said:
-He/she is working on getting through all of the care plans, but there is a lot to catch up on;
-There are several residents that have triggered for care areas with no interventions in place to address those areas;
-Anything that is individual to that resident should be addressed in the care plan, behaviors, depression, antipsychotic medications, restraints, etc.
5. During an interview on 10/24/19, at 4:42 P.M., the SSD said:
-If a resident has a behavior, he/she will try to sit and talk to them or speak with the family about options;
-The options may be a room move, resident is over stimulated, and discuss this with the family;
-She documents the conversations under the social services progress notes.
6. During an interview on 10/24/19, at 7:30 P.M., the administrator said:
-Behaviors, chair alarms, restraints, antipsychotic medications, and toileting needs should all be listed on the care plan with interventions.
-Care plans should be updated to correctly show the resident's status.
-Nurses should either tell the MDS Coordinator about changes or simply write the changes directly onto the care plan.
2. Record review of Resident #2's admission MDS, dated [DATE], showed the following information:
-admitted to the facility on [DATE];
-Diagnoses included Alzheimer's disease, thyroid disorder, delirium due to known psychological condition, disorientation, and history of falling;
-Severely cognitively impaired;
-Required extensive assist of one staff for bed mobility, transfers, and toileting;
-Required limited assist of one staff for personal hygiene and dressing;
-Required supervision for eating;
-Resident has had two falls since admission without injury;
-Resident received an antipsychotic medication on seven of seven lookback days;
-Resident received antianxiety medication on seven of seven lookback days;
-Resident received a diuretic medication on seven of seven lookback days;
-Staff did not mark physical restraints;
-Resident used a chair alarm and bed alarm.
Record review of the resident's physician order sheet (POS), dated 10/1/19 through 10/31/19, showed the following information:
-Quetiapine (antipsychotic medication) 100 milligrams (mg), 2 tablets every evening up to 200 mg;
-Quetiapine 50 mg every morning and after lunch;
-Venlafaxine (antidepressant medication) 37.5 mg two times per day.
Record review of the resident's nurses' notes dated 8/1/19, at 6:00 A.M., showed the resident in his/her wheelchair frequently taking off the seatbelt alarm.
Record review of the resident's nurses' notes dated 8/19/19, at 7:30 A.M., showed the resident propelled his/her self in the wheelchair around the nurses' station. Resident was fidgety and kept undoing the boot and seatbelt, trying to get up out of the wheelchair. Staff assisted the resident to the toilet two times, and assisted the resident to the dining room for breakfast. Resident had not been sleeping well at night and was up and down several times. Resident constantly fidgeted with papers, cups, or anything he/she could get a hold of.
Record review of the resident's nurses' notes dated 8/20/19, at 2:15 A.M., showed the resident had been up most of this shift. The resident took a power nap of plus or minus 20 minutes in the wheelchair in the fireplace room. Resident climbed out of the bed or recliner within a few minutes. The resident would not lay down and rest but repetitively said, I'm so very tired. The resident continued to fidget with the quilt on the table in the fireplace room.
Record review of the resident's nurses' notes, dated 8/24/19 (3-11 shift), showed the resident up in the wheelchair at the nurses' station. New orders received per physician, Haldol (antipsychotic medication) .25 mg in the morning and .75 mg at night.
Record review of the resident's nurses' notes dated 8/29/19 (3-11 shift), showed the resident up in wheelchair with seatbelt alarm in place. Resident had drooled on his/her clothing this shift.
Record review of the resident's nurses' notes dated 8/30/19, at 5:00 A.M., showed the resident kept eyes closed most of the time. When the resident opened his/her eyes, the resident reached for things on the floor that weren't there and picks at things in the air. Resident leaned to the right side in the wheelchair.
Record review of the resident's nurses' notes dated 9/1/19, at 12:00 P.M., showed the resident as awake and alert. The resident sat in the wheelchair with seatbelt alarm in place and active.
Record review of the resident's nurses' notes,dated 9/2/19, at 2:55 A.M., showed the resident up in recliner or wheelchair and awake all shift. Resident has had mean behavior and has been rude to staff.
Record review of the resident's nurses' notes dated 9/2/19, at 3:55 A.M., showed the resident had a witnessed fall. The certified nursing assistant (CNA) toileted and changed the resident, seated the resident back in his/her wheelchair, but did not fasten the seatbelt. The CNA turned his/her back on the resident to pick up the dirty clothing. The resident stood up and began to walk quickly towards the door. The resident fell onto his/her left side and hit his/her head on the wall next to the door. The resident did not have any bruising to head, left side, or back and no bumps on his/her head. Resident complained of pain in left hip. When staff asked the resident if he/she wanted Tylenol, the resident said, let's go for it now before it gets bad. Tylenol administered.
Record review of the resident's nurses' notes dated 9/5/19, at 9:00 A.M., showed the resident as awake and alert to name, confused to time and place. The resident complained of back pain earlier this shift and staff administered Tylenol to the resident. Staff noted a large purple bruise to the resident's lateral thigh. The resident denied pain with palpitation and stood up with difficulty. Resident constantly releasing alarmed self-release seatbelt, nervous, and jittery as per usual behavior.
Record review of the resident's nurses' notes dated 9/15/19, at 11:30 P.M., showed the resident as very agitated and refused to stay in wheelchair. He/she became aggressive, elbowed one of the CNAs, and slapped a nurses' arm. The nurse told staff to step away and told the resident he/she was risking a fall. The resident replied, I don't care.
Record review of the resident's nurses' notes dated 9/16/19, at 9:15 A.M., showed the physician sent new orders for a urinalysis (test used to determine presence of urinary tract infection), Haldol 0.5 mg in the morning, and Haldol 1.0 mg at 6:00 P.M.
Record review of the resident's care plan, last revised on 9/18/19, showed the following information:
-The resident had a nutritional problem or potential nutritional problem;
-Staff did not document any interventions for the focus area;
-The resident had pain;
-Staff did not document any interventions for the focus area;
-The resident is on pain medication therapy related to. Staff did not document the rest of the sentence;
-Staff did not document why the resident was on pain medication therapy and did not document any interventions for the focus area;
-The resident had a behavior problem;
-Staff did not document any interventions for the focus area;
-The resident had a mood problem;
-Staff did not document any interventions for the focus area;
-The resident had limited physical mobility;
-Staff did not document any interventions for the focus area;
-Staff did not include any antipsychotic medications, antidepressant medication, diuretic medication, restraints, falls, or personal safety alarms (chair or bed) on the care plan;
-Staff did not include any interventions for these items on the care plan.
Record review of the resident's nurses' notes dated 9/25/19, at 2:30 P.M., showed the resident as awake, alert, and able to voice needs. Resident up and agitated most of the shift.
Record review of the resident's nurses' notes dated 9/27/19 (3-11 shift), showed the physician had ordered to discontinue the Haldol, to add Seroquel (antipsychotic medication) 50 mg two times daily, and to send the resident out to the hospital for psychological treatment if family was agreeable.
Record review of the resident's nurses' notes, dated 9/29/19, showed the family was notified and agreed. Family took the resident to the hospital and the resident admitted to the hospital.
Record review of the resident's nurses' notes dated 10/7/19, at 12:54 P.M., showed the resident readmitted from the hospital. The resident had diagnoses including anxiety, major depressive disorder, dementia with behavioral disturbances, and delirium. Resident spoke in short answers. The resident could not get words out in a sentence.
Record review of the resident's nurses' notes dated 10/8/19, at 1:50 A.M., showed the resident got up to go to the recliner, set off the bed alarm, and ambulated quickly as staff responded. Staff found the resident in the recliner trying to put on shoes at 1:30 A.M. Staff easily redirected the resident to bed.
Record review of the resident's nurses' notes, dated 10/9/19 (11-7 shift), showed the resident was up in his/her wheelchair for about 1-2 hours at start of shift. Resident fidgeted with the seatbelt several times. Resident was anxious and tried to get up out of the wheelchair. Staff took the resident to his/her room for activity of daily living (ADLs) and toileting, and placed the resident in bed. The resident slept for about 4 hours. Resident had a history of ambulating by self and falling. The resident's bed had a functioning alarm.
Record review of the resident's nurses' notes dated 10/11/19, at 1:30 P.M., showed the resident up in the wheelchair, did not propel self. Appetite had been poor. Resident will start to feed him/herself then stop. When attempts to assist with meal are offered, the resident refused to eat. Resident pleasant and confused.
Record review of the resident's nurses' notes, dated 10/20/19, showed the resident as awake and alert, cooperative and quiet. The resident sat in the wheelchair. The resident did not propel his/her wheelchair. The resident remained in the television room in the wheelchair with the self-release seatbelt intact. Resident made no attempts to release it.
Observation on 10/21/19, beginning at 9:52 A.M., showed the resident sat in his/her wheelchair in the television room visiting with family member. Resident quiet and smiled.
Observation on 10/21/19, at 12:05 P.M., showed the resident sat in his/her wheelchair in the 200 hall. Resident had eyes closed, holding a cup of water that was tipping. Resident had a seatbelt fastened loosely over his/her lap with a chair alarm.
During an interview on 10/24/19, at 10:57 A.M., the MDS Coordinator said:
-The resident has areas that triggered from the last MDS on his/her care plan;
-Those areas have not been addressed at this time and he/she is uncertain why the previous MDS Coordinator did not address them.
During an interview on 10/24/19, at 4:42 P.M., the Social Services Designee (SSD) said:
-The resident didn't sleep at all prior to being hospitalized ;
-He/she would get up and walk;
The resident has a seat belt and chair alarm, which are used as interventions to deter the resident from standing up;
-The resident is able to undo the seatbelt and does it quite a bit;
-The SSD would expect the chair alarm and seatbelt to be addressed in the resident's care plan.
During an interview on 10/24/19, at 6:29 P.M., the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) said:
-The resident was one-on-one prior to the hospitalization;
-The resident was very anxious;
-The resident has a seatbelt and chair alarm to prevent the resident from trying to stand and to alert staff when he/she does get up;
-They would expect the chair alarm, seatbelt, and behaviors to be addressed in the resident's care plan.

Based on observation, interview, and record review, the facility failed to ensure staff treated each resident with respect and dignity when staff failed to interact with one resident (Resident #196) in a respectful manner while assisting the resident to eat. The facility census was 49.
1. Record review of Resident #196's 5 day Minimum Data Set (MDS), a federally mandated comprehensive assessment instrument completed by facility staff, dated 9/30/19, showed the following information:
-Original admission date of 5/1/19;
-Diagnoses included Alzheimer's disease, dementia, diabetes, anxiety disorder, seizure disorder, and psychosis;
-Severely cognitively impaired;
-Required extensive assistance with bed mobility, transfers, toilet use, personal hygiene, and eating.
Observation on 10/22/19, beginning at 12:55 P.M., showed the following:
-The resident sat in the television room alone and reached for a cup of water;
-The resident knocked over the cup. The resident continued to try to reach it;
-Certified Nursing Assistant (CNA) H entered the television room, shoved the resident's tray out of reach, pushed the resident's arm down and away from the cup, and proceeded to wipe up the water;
-CNA H moved the tray closer and picked up the spoon with mashed potatoes and gravy on it and moved it up to the resident's mouth;
-The resident pursed his/her lips, moved his/her head back, and shook his/her head no;
-CNA H pressed the spoon against the resident's lips, while the resident continued shaking his/her head no;
-CNA H kept it pressed there and said bite until the resident finally took a bite;
-CNA H pulled a chair up and sat down beside the resident;
-The resident reached out for a cup of liquid and the CNA pushed the resident's hand down towards the resident's lap;
-CNA H used the spoon to pick up another bite of mashed potatoes and gravy for the resident;
-CNA H moved the spoon to the resident's mouth and pressed it there, while the resident moved his/her head back and shook his/her head no;
-CNA H placed his/her hand against the back of the resident's head, pressed the spoon against the resident's lips, and said bite again until the resident took the bite of food;
-After the resident took the bite of food, CNA H watched the television over his/her shoulder;
-CNA H picked up the resident's cup of milk and pressed it against his/her lips and said drink and held the cup against the resident's lips until he/she took a drink;
-CNA H picked up the spoon and put corn on it and pushed it towards the resident's mouth as the resident continued to lean his/her head back and shake his/her head no;
-CNA H kept the spoon pressed to the resident's lips and said bite, then turned over his/her shoulder and watched television until the resident took the bite of food;
-This continued throughout the entire meal until the resident had eaten his/her food;
-CNA H did not interact with the resident other than to say bite or drink throughout the entire process.
During an interview on 10/24/19, at 5:23 P.M., CNA I said the following:
-When assisting residents to eat, staff look at the resident, interact with them, and talk to them;
-Staff cue residents and let them know that you are giving them a bite of food and what it is;
-Staff never carry on side conversations and ignore the resident;
-Staff never watch television while assisting a resident to eat;
-Staff do not press utensils or cups against the resident's mouth while they are pulling away and saying no and never hold the back of the resident's head still to try to get them to eat;
-He/she has had to assist the resident before and the resident will tell staff yes or no if he/she wants something to eat or drink;
-The resident is usually very cooperative when staff assist him/her to eat.
During an interview on 10/24/19, at 6:29 P.M., the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) said the following:
-Staff should pay attention to the resident and talk to the resident while they assist them with eating;
-Staff should not watch television while assisting a resident with eating;
-Staff should not hold the back of the resident's head, push the utensil or cup against their mouth while they are pulling back, and say bite or drink.
During an interview on 10/24/19, at 7:30 P.M., the administrator said the following:
-Staff should communicate with the resident while they are assisting them with eating;
-Staff should look at and talk to the resident and include them in the conversation if they are able to participate;
-Staff should not watch television while assisting a resident to eat;
-Staff should encourage and cue residents to eat, telling them what they are giving them and allowing them to choose if they want to it eat or not;
-Staff should never place a hand on the back of a resident's head, press a utensil or cup against their lips while they are pulling away, and saying bite or drink to them.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to check one resident's (Resident #1) blood glucose level (blood test to determine glucose level) before meals as ordered by the physician and according to the standard of practice. Facility staff failed to administer two residents' (Resident #1 and #146) insulin injections timely and as ordered by the physician. Staff failed to ensure the resident's physician orders included the sliding scale for insulin administration ordered by the physician. A sample of 18 residents was reviewed in a facility with a census of 49.
Record review of a facility policy and procedure entitled, Insulin Administration (Revised April 2007), showed the following information:
-The three key characteristics of insulin are onset of action (how quickly the insulin reaches the bloodstream and begins to lower blood glucose); peak effects (the time when the insulin is at its maximum effectiveness); and duration of effects (the length of time during which the insulin is effective).
-The four types of insulin and their characteristics are rapid-acting, regular/short acting, intermediate-acting, and long-acting.
Record review of the (undated) facility policy titled, Taking Off Orders, showed the following information:
-Written orders-when the physician or nurse practitioner (NP) write an order on the physician order (PO) sheet, staff need to initial it to indicate staff are aware of the order and staff have followed through with it. Staff need to take the order and place it in a box on the PO sheet. That way, next time, orders are pulled, the new order will be on the new medication administration record (MAR), PO sheets, and/or treatment administration records (TAR). Staff then need to write the order on the order sheets for pharmacy and fax it over to the pharmacist. Staff should also write the order on the supervisor's sheet and give it to the medication nurse so that she can place the order on the MAR.
-Telephone and verbal orders- staff should write out a telephone order. Staff will then write the order on the PO sheet and also write it in the box. Then, follow all the same process as for written orders.
1. Record review of Resident #1's face sheet (brief resident information sheet) showed the following information:
-The resident admitted to the facility on [DATE];
-Diagnoses included type 2 diabetes mellitus (insulin-dependent) with diabetic neuropathy (weakness, numbness, or pain from nerve damage), anxiety disorder, and major depressive disorder.
Record review of the resident's admission physician order sheet (POS), dated 10/14/19 through 10/31/19, showed the following information:
-Admit to skilled nursing;
-Novolog Flex Pen (fast-acting insulin) 100 units/milliliter (ml), inject 7 units every morning, (scheduled at 7:00 A.M.) subcutaneously (SQ) plus sliding scale;
-Novolog Flex Pen 100 units/ml, inject 4 units at noon (scheduled at 12:00 P.M.) SQ plus sliding scale;
-Novolog Flex Pen 100 units/ml, inject 7 units before supper SQ (scheduled at 5:00 P.M.) plus sliding scale;
-Levemir Flex Pen (long-acting insulin) 100 units/ml inject 10 units SQ twice daily (scheduled at 7:00 A.M. and 5:00 P.M.);
-Accuchecks before meals (scheduled at 7:00 A.M., 12:00 P.M., and 5:00 P.M.), order dated 10/14/19;
-On 10/15/19, the physician ordered staff may use Novolin insulin regular (rapid-acting insulin) until Novolog is available;
-On 10/15/19, the physician ordered staff may use bottle of Novolin regular until empty then start Novolog.
-The physician order sheet did not include the sliding scale parameters for how much insulin to administer based on the resident's blood glucose levels.
Record review of the resident's admission evaluation and interim care plan, dated 10/14/19, showed the resident had a diagnosis of diabetes mellitus type II.
Record review of a fax from the hospital, dated 10/14/19, showed discharge instructions and medication list. It included the following information:
-Discharge from hospital on [DATE];
-Medication of Novolog FlexPen 100 units/ml, inject 7 units in the morning, 4 units at noon, and 7 units at supper plus sliding scale. Staff handwrote in to change the insulin administration to before meals.
-Levemir Flextouch 100 units/ml, inject 10 units SQ twice daily;
-Staff handwrote a telephone order in the open space to the right of the medication list the sliding scale information.
-Blood sugar level of 151-200 milligram (mg)/deciliter (dL), administer one unit of insulin;
-Blood sugar level of 201-250 mg/dL, administer 2 units of insulin;
-Blood sugar level of 251-300 mg/dL, administer 3 units of insulin;
-Blood sugar level of 301-400 mg/dL, administer 4 units of insulin;
-Blood sugar above 400 mg/dL, call the provider.
-Change to no sliding scale at bedtime, just morning, noon, and supper;
-Staff signed the order on 10/14/19.
During an interview on 10/21/19, at 2:57 P.M., the resident said he/she is supposed to have an insulin injection before he/she eats. Staff are slow to check his/her blood glucose level. The resident has already ate or is in the process of eating when staff check his/her blood glucose. Staff do not explain why they are late. It happened today at lunch. Staff checked his/her blood glucose after he/she ate lunch and then administered the insulin injection.
Observation and interview on 10/23/19 showed the following information:
-At 11:55 A.M., the resident walked up the hall with his/her walker. The resident said no one had checked his/her blood glucose yet and no one had administered his/her insulin yet. The resident said it makes him/her nervous, can't keep it controlled if not done right.
-At 12:03 P.M., the resident sat in the dining room chair in the dining room, drinking diet coke at the table. The resident poured diet coke out of the can into a silver cup.
-At 12:11 P.M., the resident continued to sit in the dining room;
-At 12:21 P.M., the resident sat waiting for lunch. Staff did not check the resident's blood glucose at this time;
-At 12:24 P.M., Licensed Practical Nurse (LPN) K walked to the resident in the dining room, wiped the resident's finger with an alcohol wipe, checked the resident's blood glucose, and obtained the accucheck reading of 198 mg/dL. The nurse said he/she would wait until the resident got his/her lunch before he/she administered the resident's insulin;
-At 12:45 P.M., the resident stood up and walked out of the dining room with his/her walker. The resident had not received food or insulin at this time;
-At 12:49 P.M., the resident walked back into the dining room with his/her walker;
-At 12:56 P.M., the resident sat in a dining room chair, waiting for lunch;
-At 12:56 P.M., staff served the resident his/her lunch;
-At 12:59 P.M., the resident began eating lunch;
-At 1:21 P.M., the resident finished eating lunch. He/she ate 100% of the meal. Staff had not administered the resident's insulin at this time. The resident said he/she had not received his/her insulin yet.
-At 1:25 P.M., the nurse applied gloves, said the resident would receive 4 units of novolin R, plus one unit of sliding scale insulin. The nurse drew up 5 units in the syringe and administered it into the resident's left upper arm.
Observation and interview on 10/24/19 showed the following information:
-At 12:06 P.M., the resident sat in the dining room. He/she said staff had not checked his/her blood glucose yet or administered his/her insulin yet.
-At 12:33 P.M., the resident said staff still had not checked his/her blood glucose yet. The resident said he/she had soup coming from therapy;
-At 12:37 P.M., therapy brought the resident's soup to the resident. The resident sat, waiting, not eating it yet. Staff brought the resident a glass of milk;
-At 12:40 P.M., the resident started eating the soup;
-At 12:44 P.M., staff entered the dining room and checked the resident's blood glucose. The resident's blood glucose level registered at 120 mg/dL. Staff said he/she would be right back.
-At 12:49 P.M., the resident left the dining room;
-At 12:57 P.M., the resident returned to the dining room. Staff administered the resident's insulin injection in the left upper arm. When asked if it bothered him/her to get insulin and accuchecks in the dining room, the resident said he/she had got used to it. When asked about his/her preference, he/she said it was ok.
2. Record review of Resident #146's face sheet showed the following information:
-The resident readmitted to the facility from the hospital on 9/26/19;
-Diagnoses included Type 2 diabetes mellitus with diabetic nephropathy, chronic kidney disease (Stage 4), acute kidney failure, long term (current) use of insulin, and morbid obesity.
Record review of the resident's POS for October 2019, showed an order for AccuChecks AC (before meals) & H.S. (bedtime) with Humalog (rapid-acting insulin) per following sliding scale:
-Blood sugar level of 150 mg/dL to 200 mg/dL, administer three units of insulin;
-Blood sugar level of 201 mg/dL to 250 mg/dL, administer five units of insulin;
-Blood sugar level of 251 mg/dL to 300 mg/dL, administer seven units of insulin;
-Blood sugar level of 301 mg/dL to 350 mg/dL, administer nine units of insulin.
During an observation and interview on 10/24/19, at 1:19 P.M., the resident ate lunch. He/she had finished the vegetables and had taken bites from a sandwich. The resident said the nurse had not administered his/her insulin yet, but would do so because, they always do.
Observation on 10/24/19, at 1:34 P.M. showed LPN K drew up insulin at the medication cart located next to the nurse's desk and took the syringe into the resident's room for administration.
3. During an interview on 10/24/19, at 5:35 P.M. Certified Medication Technician (CMT) B said AccuChecks should be done per physician orders, usually four times daily; before meals and at bedtime. They can be done up to one hour prior to meals. Insulin should be given no more than 10-15 minutes prior to the meal and should not be given after a meal unless the physician ordered it that way. They did not currently have any resident with an order for post-meal AccuChecks or insulin.
4. During an interview on 10/24/19, at 5:42 P.M., LPN A said AccuChecks should be done and insulin given prior to meals; the reading would not be accurate if done after eating. Residents should be given privacy for both AccuChecks and insulin administration. LPN A said insulin can be given up to one hour before a meal. All insulin orders should be confirmed by the nurse and put on the current POS; if necessary, call for clarification orders to include sliding scale amounts.
5. During an interview on 10/24/19, at 6:29 P.M., the Director of Nursing (DON) and Assistant Director of Nursing (ADON) said accuchecks should be completed as per the order of the physician. Usually, that is before meals and at bedtime. Short acting insulin should be administered right before meals, no more than 10-15 minutes, before the meal. Staff should check the resident's blood glucose. If the blood glucose is okay, above 80-110, staff can go ahead and administer the short acting insulin before they eat, but no more than 10-15 minutes before the meal. The sliding scale should be on the actual POS.
6. During an interview on 10/24/19, at 7:31 P.M., the administrator said accuchecks and insulin needs to be administered consistently and prior to the meal. Staff should follow the POS and the recommendations of the manufacturer.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to care plan and implement effective interventions to prevent one residents (Resident #25) from exiting the facility and/or wandering into another resident's room. The facility census was 49.
1. Record review of Resident #25's face sheet (brief resident information sheet), showed the following information:
-admitted to the facility on [DATE];
-Diagnoses included unspecified dementia with behavioral disturbance.
Record review of the resident's physician order sheet (POS) showed order, dated 8/13/19, for Perphenazine, 4 milligram (antipsychotic medication) three times a day.
Record review of the resident's nurses' notes, dated 8/13/19, showed the resident as alert and oriented to self, forgetful. The resident had poor short term memory. Staff to monitor safety awareness. The resident forgot to lock his/her wheelchair before standing.
Record review of the resident's social services progress note, dated 8/13/19, showed the resident admitted from home. The resident's family member had been taking care of him/her, but had increased difficulty. The resident had a history of aggression. The resident had an unsteady gait, but did ambulate. The resident's family member said the resident wandered at home.
Record review of the resident's safety assessment, dated 8/13/19, showed staff determined the resident to not have safety to be outside.
Record review of the resident's nurses' notes, dated 8/14/19 (11-7 shift), showed the resident up and exited 200 hall door to the outside. Staff able to bring resident in without issues. Resident very confused, ambulatory with walker.
Record review of the resident's admission evaluation and interim care plan, admission date 8/13/19, showed the following information:
-Dementia diagnosis;
-Family stated resident could be aggressive.
Record review of the resident's nurses' notes, dated 8/14/19 (3-11 shift), showed staff saw the resident rushing out the 200 hall end door. He/she fell on his/her right side on the door frame at the bottom of the door. Staff notified the resident's spouse. Alarm initiated.
Record review of the resident's nurses' notes dated 8/16/19, at 2:00 P.M., showed the physician came in and ordered Phenergan 50 milligram (mg) (can be used as sedative) intramuscular (IM) every evening for increased aggressive behaviors or increased agitation. Staff notified the resident's spouse. He/she agreed and said.
Record review of the resident's POS showed order, dated 8/16/19, for Promethazine (Phenergan) injection 50 mg IM every day in the evening as needed for aggressive behaviors and agitation.
Record review of the residents' nurses' notes, dated 8/18/19, showed the resident as very confused. Resident took the alarm off, got up and walked all evening. The resident tried going outside 500 wing.
Record review of the resident's admission Minimum Data Set (MDS), a federally mandated comprehensive assessment instrument completed by facility staff, dated 8/26/19, showed the following information:
-admit date of 8/13/19;
-Hospice resident;
-Severely impaired cognition:
-Required limited assist of one staff for bed mobility, transfers, dressing, toilet use, and personal hygiene;
-Mood score showed mild depression;
-Diagnoses included dementia;
-Staff administered an antipsychotic medication 7 days out of the 7 day assessment lookback period;
-Staff administered an antidepressant 7 days out of the 7 day assessment lookback period;
-Staff documented the resident had physical behavior, verbal behavior, and other behavior 1-3 days out of the 7 day lookback period;
-The resident put others at risk for physical injury;
-The resident rejected care 1-3 days during the lookback period;
-The resident wandered 1-3 days of the assessment lookback period.
Record review of the resident's behavior/intervention monthly flow record, from 8/14/19 through 8/31/19, showed the following information:
-Staff listed two behaviors to monitor for the resident, exit seeking and agitation.
-Staff documented the resident had one episode of exit seeking on 8/14/19 night shift. Staff did not document any intervention provided in response to the behavior.
-Staff documented the resident had exit seeking behavior one time on 8/15/19 on day shift. Staff documented an intervention of redirected resident;
-Staff did not document if the resident had exit seeking behaviors on evening shift. Staff left the form blank.
Record review of the resident's nurses' notes, dated 9/25/19, showed the resident as very agitated and yelling at staff. The resident tried getting out of the facility two times. The resident went out 200 hall twice, stating, I'm going home where is my truck. Staff administered as needed Phenergan IM with assist of three staff. The resident continued to be agitated, yelling, and cussing.
Record review of the resident's nurses' notes, dated 9/26/19 (11-7 shift), showed the resident up once to try and go outside. Resident redirected back to room.
Record review of the resident's nurses' notes, dated 9/26/19 (3-11) shift, showed the resident up in the wheelchair, went out 300 door. The nurse and certified nursing assistant (CNA) brought the resident back in. The resident had on the alarm.
Record review of the resident's September 2019 behavior intervention/monthly flow record showed the following information:
-Staff listed two behaviors to monitor for the resident, exit seeking, agitation, getting up by self and self transferring;
-The resident had exit seeking behavior on evening shift of 9/1, 9/2, 9/3, 9/7, 9/8, 9/9, 9/10, 9/15, 9/16, 9/17, 9/18, 9/22, 9/23, 9/24, 9/29, 9/30, ranging from 1 to 10+ times during the shift.
-Staff documented intervention of redirect two times, 9/10 and 9/24.
-The resident had exit seeking behavior on night shift on 9/15 and 9/25. Staff did not document any intervention provided in response to the behavior.
Record review of the resident's care plan, dated 9/18/19, showed the following information:
-The resident had impaired cognition function/dementia or impaired thought processes.
-Staff did not document any interventions for the focus area.
-The resident had a communication problem;
-Staff did not document any interventions for the focus area.
-Staff did not document any focus area or interventions regarding behaviors, exit seeking, or the use of the antipsychotic medication.
Record review of the resident's nurses' notes dated 10/9/19, at 3:45 A.M., showed the resident got up and went into Resident #32's room across from his/her room. The resident scared the other resident. The resident was agitated, but did get up and leave with staff.
Record review of the resident's nurses' notes, dated 10/10/19, (11-7 shift), showed the resident up three times transferring self. The resident went out the 200 hall end door. Staff able to redirect the resident back to his/her room. The resident became very agitated very easy and became angry with staff. The resident threatened to leave the facility or hit staff.
Record review of the POS, showed an order, dated 10/11/19, to increase Perphenazine to 8 mg three times a day.
Record review of the nurses' notes, dated 10/15/19, (3-11 shift), showed the resident exit seeking one time. CNAs' reported the resident tried to feel of their personal area while obtaining his/her vital signs. The resident also made a sexual remark. Resident was calm at the moment, will monitor. Snacks offered.
Record review of the nurses' notes, dated 10/16/19, (11-7 shift), showed the resident wandered into Resident #32's room again, upsetting him/her. Resident hard to redirect, but did go back to his/her own bed.
Record review of the nurses' notes, dated 10/20/19, at 10:55 P.M., showed the resident tried escaping, made it out 300. Resident redirected after several attempts.
Record review of the nurses' notes, dated 10/21/19, at 5:10 A.M., showed staff found the resident in Resident #32's room and would not leave. Staff talked to the resident for 10-15 minutes and he/she still refused to leave.
Record review of the resident's October 2019 behavior/intervention monthly flow record, showed the following information:
-Staff listed three behaviors to monitor: exit seeking, increased agitation, getting up by self, self transferring, and inappropriate touching;
-On evening shift of 10/6, 10/7, 10/10, 10/13, 10/14, 10/17, 10/18, 10/19, 10/20 the resident showed exit seeking behavior. Staff did not document any interventions provided in response to the behavior.
-On night shift, the resident had exit seeking behavior on 10/10/19. Staff did not document any intervention provided in response to the behavior.
Observation on 10/23/19, at 12:06 P.M., showed the resident wheeled self around the nurses' station and down the hall in his/her wheelchair. The resident sat in the short hall with his/her personal alarm attached. The aide asked the resident to move to one side of the hall. The resident wheeled into the doorway of the whirlpool room and then wheeled back by the nurses' station. The resident used his/her feet to propel the wheelchair. The resident wheeled down 300 hall and started to stand. Staff intervened and the resident wheeled him/her self into the dining room.
Observation on 10/24/19, at 12:20 P.M., showed the resident sat in his/her wheelchair in the hall, wheeling down 600 hall using his/her feet to propel the wheelchair. The resident came back up the hall toward the nurses' station. The resident stopped and sat about halfway down the hall.
During an interview on 10/24/19, at 4:42 P.M., the Social Services Designee (SSD) said regarding Resident #25, she has never witnessed him/her having any behaviors. The resident is always pleasant with her. She has never seen him/her wander into another resident's room. She was told he/she has gone across the hall into that room. She was told twice about it happening. She thinks he/she is confused about which room belongs to him/her. She tried putting up a stop sign. They are going to make more signs now. When he/she first admitted , she thought Resident #25 tried to go out the end door on his/her hall. As far as she knows, he/she hasn't done that again. She did not know of the other attempts to go out the door. She did not know of any interventions attempted to stop him/her from exit seeking. The outside doors are alarmed if someone tries to open them. Resident #25 has a personal alarm attached to his/her wheelchair. She would expect his/her exit seeking and wandering to be addressed in his/her care plan.
During an interview on 10/24/19, at 5:21 P.M., CNA L said the resident wants to go home and also doesn't understand. The resident has got out the door, more than once. When they get going, they get going. The resident depends on his/her mood. Sometimes, it takes more than one staff. Sometimes, staff cannot redirect him/her and they just have to get him/her back inside. One staff distracts while the other staff pushes him/her back into the facility. If the resident is heading that way, staff are told to cut the resident off before he/she gets there. If they see a resident wandering, staff try to distract them, give them something to do. For the resident, sometimes that works, sometimes not, about 50/50. It is hit and miss with the resident.
During an interview on 10/24/19, at 5:23 P.M., CNA I said the resident gets angry a lot. He/she doesn't understand why he/she is here and often tries to exit seek. He/she wanders, but mainly around the nurses station. The resident has gotten outside a couple of times and had to be redirected once back in the facility. The aide has not talked to others about it or tried other interventions to see if it has worked. The aide has never seen him/her go into other residents rooms recently. When he/she first admitted to the facility, then he/she wandered into random rooms. The aide would redirect the resident and they did put up stop signs which seemed to help.
During an interview on 10/24/19, at 5:49 P.M., Licensed Practical Nurse (LPN) A said the facility has two residents currently that wander. They wander occasionally, not every day. Resident #25 tries to get out the door. He/she doesn't want to be here. They try to offer snacks, sit with him/her, or redirect him/her. The resident has got right out the door. He/she is just at the door. Staff redirect him/her back into the door. He/she has not tried lately and it wasn't daily. They changed his/her medications and it seems to have helped. The physician determines the interventions. Staff document daily any behaviors and document the interventions attempted in the nurses' notes. The resident's careplan should include focus areas and interventions for wandering and exit seeking. Generally, the MDS/care plan coordinator updates the careplans, not the floor nurses.
During an interview on 10/24/19, at 6:29 P.M., the Director of Nursing (DON) and Assistant Director of Nursing (ADON) said the facility has two residents who wander or exit seek currently, including Resident #25. The DON said Resident #25 doesn't exit seek, he/she just wanders. The ADON said yes, Resident #25 does try to get out the door. He/she fell in the doorway right after admission into the facility. The aides said he/she tried to get out the door one other time. The ADON heard them talking one day. Interventions should distract the resident. Staff should offer snacks, listen to music, toilet the resident, sit and talk to him/her. The care plan should include the behavior of exit seeking/wandering and interventions for staff to attempt. Resident #25 does go into another resident's room, one night that she heard. The DON said that was left for social services to try and find a different room, or area, or move one of them. The ADON thought Resident #25's family would be in agreement with moving him/her. There is a new psychiatrist in town and they are checking to see if he/she would be interested in coming to the nursing home. They have not tried new interventions with Resident #25.
During an interview on 10/24/19, at 7:31 P.M., the administrator said Resident #25 sometimes will hit the door. The administrator did not know he/she got out the door. She did not know any of resident actually getting out the door. All doors have alarm and the facility does not utilize wander guards and the door alarm will usually stop the resident from exiting. She is not aware of any resident physically getting outside of the door or facility. Wandering and exit seeking behaviors should be listed on the care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed attempt effective interventions, including non-pharmacological interventions and failed to develop an individualized, person-centered care plan to meet the needs of one resident (Resident #32) with dementia and exhibiting continued behaviors. The facility census was 49.
Record review of the facility's (undated) behavior policy showed the following information:
-Goal was to encourage individual resident independence and autonomy by structuring a least restrictive environment which allows each resident to be restraint free for optimal periods of time and enhances the goal of quality therapeutic, preventative, restorative, and rehabilitative care;
-Objective was to provide health care services which allow the resident to attain the highest practicable physical, mental and psychosocial well-being using the least restrictive method practicable for the shortest period of time necessary;
-Appropriate support services are available to implement alternative and least restrictive measures, including the following: walk and exercise residents, be creative in your activities and recreation; remember antipsychotic medications are not introduced simply to keep the resident looking normal;
-Possible alternatives included:
-Meaningful activities, judicious use of psychotropic medications to treat psychosis or panic disorders, scheduled toileting, offer snacks and fluids to wanders;
-Regular exercise program, indoor and outdoor, for agitated residents;
-Door monitoring systems, qualified sitters;
-Attempt to identify various factors involved in the manifestation of problems and eliminate them if possible;
-Educate staff to recognize stressors for the resident early and possibly correct problem behavior;
-Have resident reviewed by a psychiatrist to possible regain control over his/her life with medication or behavior management;
-Environmental manipulation such as increased lighting, placing resident near quiet room, adaptable call light system, or other means of communication;
-Psychosocial intervention such as reality orientation, remotivation therapy, therapeutic touch, active listening, attention to feelings and concerns;
-Physical and diversionary activities such as television, radio, music, recreation, exercise, ADL training;
-Use distraction;
-Personal body alarms.
Record review of the Behavior/Intervention monthly flow record showed the following directions:
-Enter target behavior in one of the behavior sections;
-Record the number of episodes by shift with initials;
-Enter the intervention code, outcome code, and side effects codes with initials for each shift;
-See side two for list of behaviors and potential side effects;
-Specific behaviors listed on form included: agitated, angry, anxiety, continuous crying, continuous screaming/yelling, continuous pacing;
-Behaviors by themselves such as agitated, anxiety, and wandering, do not justify antipsychotic drugs.
1. Record review of Resident #32's face sheet, showed the following information:
-admitted to the facility on [DATE];
-Diagnoses included Alzheimer's disease, unspecified dementia with behavioral disturbance, anxiety disorder, insomnia, and major depressive disorder.
Record review of the resident's physicians' order sheet (POS) showed an order, dated 9/3/19, for Trazadone (antidepressant medication) 50 milligrams (mg) at bedtime as needed.
Record review of the resident's admission evaluation and interim care plan, admission date 9/3/19, showed the resident had diagnoses including Alzheimer's disease, anxiety, depression, and dementia.
Record review of the resident's social services progress notes, dated 9/4/19, showed the following information:
-Resident admitted on [DATE];
-Resident arrived from home;
-Resident was alert and oriented to self and able to voice some needs;
-Ambulated independently;
-Diagnoses of unspecified dementia with behavioral disturbance and insomnia;
-Social services to visit three times per week to monitor for needs and issues.
Record review of the resident's nurses' notes dated 9/13/19, at 2:30 P.M., showed the resident as alert to self only, pleasantly confused. Resident couldn't remember how to get from his/her bedroom to the sitting area in the hallway. Resident wandered into the hall asking for direction. Staff redirected the resident.
Record review of the resident's nurses' notes, dated 9/15/19 (7 AM - 3 PM shift), showed the resident had increased confusion this shift in the morning.
Record review of the resident's nurse's note dated 9/15/19, at 9:00 P.M., showed the resident had increased confusion, was packing his/her bags, and could not remember where his/her spouse or the bathroom were at.
Record review of the resident's nurses' notes, dated 9/16/19 (7 AM - 3 PM shift), showed the resident did get confused and often needed redirected.
Record review of the resident's admission MDS, dated [DATE], showed the following information:
-admitted to the facility on [DATE];
-Severely cognitively impaired;
-Independent with bed mobility, transfers, walk in corridor, dressing, eating, toilet use, and personal hygiene;
-Required supervision with locomotion off the unit (areas set aside for dining, activities, or treatments);
-Mood score showed no depression;
-Diagnoses included Alzheimer's disease, anxiety, depression and dementia;
-Staff administered antidepressant medication 7 days out of the 7 day assessment lookback period;
-Staff documented no behaviors in the 7 day lookback period.
Record review of the resident's care plan, dated 9/18/19, showed the following information:
-The resident had impaired cognition function/dementia or impaired thought processes;
-Staff did not document any interventions for the focus area;
-The resident had a mood problem;
-Staff did not document any interventions for the focus area;
-Resident had depression;
-Staff did not document any interventions for the focus area;
-Staff did not document any focus area or interventions to address behaviors.
Record review of the resident's nurses' notes, dated 9/23/19, showed the resident had increased anxiety and confusion related to his/her spouse's condition. Family requested something for the anxiety. Physician gave a new order.
Record review of the resident's POS, showed an order, dated 9/24/19, for Xanax 0.25 mg (antianxiety medication) two times per day as needed for 14 days.
Record review of the resident's social services progress notes, dated 9/26/19, showed the following information:
-The resident's spouse passed away today;
-The resident will go home with family for grievance time.
Record review of the resident's medical record showed the resident did not have a behavior/intervention monthly flow record completed for September 2019.
Record review of the resident's nurses' notes, dated 10/1/19, showed the resident back in the facility. Family had the resident at home during grievance time. The resident only knows his/her name. The resident was not oriented to date, time, or place. The resident's family member at bedside. Family member left for a short period of time and the resident became very anxious during that time. Staff administered as needed (PRN) Xanax. The resident needed redirection by staff.
Record review of the resident's nurses' notes, dated 10/2/19, showed the resident as anxious and staff administered PRN Xanax.
Record review of the resident's nurses' notes dated 10/3/19, at 1:50 P.M., showed the resident as pleasantly confused. Staff administered PRN Xanax at 8:00 A.M., per the family's request for increased agitation in the room.
Record review of the resident's social services progress notes, dated 10/3/19, showed the resident's family member requested someone to check on the resident because he/she was packing up his/her things.
Record review of the resident's nurses' notes, dated 10/3/19 (3-11 shift), showed the resident had been seeking a way out of the facility. Staff redirected the resident many times. Staff administered PRN Xanax for increased agitation. Family called and requested more medications for the behavior issues, will monitor.
Record review of the resident's nurses' notes dated 10/4/19, at 2:00 P.M., showed the resident cried a lot and packed clothing. The family member called and said, resident called me demanding to leave. Staff notified the physician and obtained a new order for Xanax three times per day.
Record review of the resident's POS showed an order, dated 10/4/19, for Xanax 0.25 mg three times per day routinely.
Record review of the resident's nurses' notes, dated 10/5/19 (3-11 shift), showed the resident was upset about another resident standing at the end of the hallway near his/her room. Resident had put a chair behind his/her door.
Record review of the resident's nurses' notes dated 10/5/19, at 4:52 A.M., showed the resident ambulated in the hall looking for his/her spouse. Resident was not easily redirected back to his/her room, kept trying to go to other rooms looking for spouse.
Record review of the resident's nurses' notes dated 10/6/19, at 1:35 A.M., showed the resident became easily confused. Staff redirected the resident.
Record review of the resident's nurses' notes, dated 10/6/19, showed the resident up in room packing stuff, confused this evening, won't stay in bed. Resident easily redirected by staff.
Record review of the resident's nurses' notes dated 10/7/19, at 4:30 A.M., showed the resident walked up to the nurses' station and asked where he/she was. Resident easily redirected to room.
Record review of the resident's nurses' notes, dated 10/7/19, showed the resident as alert and forgetful. Oriented to self only and wanders.
Record review of the resident's nurses' notes dated 10/7/19, at 3:45 P.M., showed the resident wandered and wanted to go home. Resident did not think this is where he/she should be and angrily said this is not my home. Staff notified the physician.
Record review of the resident's nurse's notes dated 10/7/19, at 3:55 P.M., showed the resident as exit seeking, tearful, and wanted to go home. Staff received new orders to increase Xanax medication to 0.50 mg, three times daily routinely.
Record review of the resident's nurse's notes dated 10/7/19, at 10:00 P.M., showed the resident as very anxious and escaped outside. Staff brought the resident back into the facility. The resident wandered into everyone's rooms asking where spouse is at repeatedly. Staff and several residents reoriented the resident to his/her spouse's death. Physician ordered an increase in Xanax. Staff administered the increased dose of Xanax around 5:00 P.M. along with Trazodone (antidepressant). The increase did settle the resident down.
Record review of the resident's POS showed an order, dated 10/8/19, to discontinue Xanax 0.25 mg three times per day and a new order to increase Xanax to 0.50 mg three times per day routinely.
Record review of the resident's nurses' notes, dated 10/9/19, at 3:00 P.M., showed the resident as alert and oriented to person, confused, and wandered.
Record review of the resident's nurses' notes, dated 10/9/19 (11-7 shift), showed at 3:45 A.M., Resident #25 entered the resident's room and scared the resident so badly he/she was upset and crying. Staff took Resident #25 back to his/her room. Resident #32 said This is not my spouse, get him/her out of here. Resident also said he/she would not go back to the room and to bed because he/she was afraid the other resident would come back in.
Record review of the resident's nurses' notes dated 10/10/19, at 1:50 P.M., showed the resident awake and alert to name only. The resident needed assistance with activities of daily living (ADLs - dressing, grooming, bathing, eating, and toileting) or will wear the same clothes over and over.
Record review of the resident's nurse's notes dated 10/11/19, at 3:00 P.M., showed the resident's family member called and spoke with the facility. The resident's former physician recommended to discontinue the Trazodone and replace it with Seroquel (antipsychotic medication). The facility physician approved the orders. New orders noted on POS.
Record review of the resident's POS showed an order, dated 10/11/19, to discontinue Trazodone 50 mg at bedtime and a new order for Quetiapine (Seroquel) 25 mg two times per day.
Record review of the resident's nurse's note dated 10/13/19, at 4:00 P.M., showed the resident tried to crawl into bed with another resident last night. The resident said it was his/her spouse and he/she wanted make out time. Resident was not easily redirected but did finally leave the other resident's room. Continue to monitor.
Record review of the resident's nurse's notes dated 10/14/19, at 3:35 A.M., showed the resident was at the nurses' station earlier looking for spouse. Staff redirected the resident back to his/her room and reminded the resident that the spouse had passed away. Resident stayed in room for 5 minutes or so and came back to nurses' station agitated and demanding to speak with family. Family called and was very upset because the resident was so upset. Resident taken back to bed, visibly upset and tearful.
Record review of the resident's nurse's note dated 10/14/19, at 9:48 A.M., showed the resident as alert with confusion. Needed direction related to forgetfulness. Resident was confused of where room is located.
Record review of the resident's nurse's note dated 10/14/19, at 9:40 P.M., showed after supper, the resident packed up his/her stuff and tried to escape out 200 hall door. Staff redirected the resident back inside. Staff redirected the resident to a different subject other than he/she wanted to go home.
Record review of the resident's nurse's notes, dated 10/19/19 (3-11 shift), showed the resident had high anxiety this shift over spouse's death. Staff called physician and family. Family requested something for high anxiety. Resident was put on acute list and will continue to monitor.
Record review of the resident's nurses' notes, dated 10/20/19, showed the resident did get up several times, running around asking about his/her spouse. Staff reminded the resident his/her spouse had passed away. The resident was very anxious. At 11:00 P.M., the resident up running around again.
Record review of the resident's nurse's note dated 10/21/19, at 4:15 A.M., showed the resident at the nurses' station and said, there is a person in my room. The resident from across the hall had sat in Resident #32's recliner. Staff attempted to redirect the resident for 10 minutes. Resident #32 was very upset and doesn't want to be here anymore if people are going to be showing up in his/her room at all hours. Resident wanted a lock on his/her door.
Record review of the resident's nurses' notes dated 10/21/19, at 2:00 P.M., showed the facility called the physician and requested an increase in Xanax to 1 mg three times per day. Resident was confused, alert and oriented to name only. Resident packed up belongings several times and wandered aimlessly. Staff administered the increased dose at lunch and resident was a little unsteady upon rising. The resident was now up pacing the floor.
Record review of the POS showed an order, dated 10/21/19, to discontinue Xanax 0.50 mg three times per day and a new order to increase Xanax to 1.0 mg three times per day.
Record review of the resident's nurse's note dated 10/21/19, at 2:40 P.M., showed the resident went out 600 hall door and staff easily redirected the resident back into the facility. Staff directed the resident into an activity.
Record review of the resident's nurses' notes, dated 10/21/19, showed after supper, staff found the resident on his/her knees picking up pieces of tissues. Resident said he/she was looking for a ring. Staff redirected the resident to his/her room.
Record review of the resident's nurse's note dated 10/22/19, at 12:00 P.M., showed the resident walked in the 200 hall with a staff member. The resident fell after walking over the threshold of carpet to wood flooring. Family member requested the resident to not have the noon dose of Xanax 1 mg. Staff notified the physician.
Record review of the resident's nurse's note dated 10/22/19, at 3:08 P.M., showed the physician called back, was notified of the fall, and did not want to reduce the dosage of medication at this time. Resident went out the door in the dining room during lunch and staff redirected the resident back into facility. The resident had been pacing the floor and looking for his/her spouse and bags.
Record review of the resident's nurses' notes, dated 10/23/19 (11-7 shift), showed the resident had been up pacing since 4:30 A.M. and asking where is my spouse and where do I live. Resident was a bit nervous. The resident saw his/her spouse's obituary on the bulletin board and started to cry.
Record review of the resident's nurses' notes dated 10/24/19, at 5:10 A.M., showed the resident ambulated in the hall, confused.
Observation on 10/21/19, at 2:42 P.M., showed the following:
-The resident sat in the lounge area on 200 hall;
-Resident was extremely upset, crying, and asking for his/her spouse;
-Staff walked by the area and did not stop to address the resident;
-An alert and oriented resident attempted to speak with the resident and calm him/her down;
-The resident repetitively kept asking about his/her spouse and the other alert and oriented resident left the area;
-The resident continued to wring his/her hands crying, and voiced concern about his/her spouse.
During an observation and interview on 10/22/19, at 9:22 A.M., showed the following:
-The resident sat in the lounge area on 200 hall;
-Resident was visibly upset and crying;
-Resident kept repeating that he/she could not find his/her spouse;
-Resident said, I am looking for my spouse because I am bored. I want something to do. Can you give me something to do?;
-When asked, resident said I would like to fold things or do anything to keep busy;
-Resident said he/she is unhappy and wants to go home because I had things to do there.
Observation on 10/22/19, at 5:04 P.M., showed the resident wrung his/her hands and paced the halls and around the nurses' station. Staff attempted to redirect the resident and the resident asked where is my spouse and where am I at. Resident concerned his/her spouse had not shown up yet. Staff offered resident food and resident refused, I am not hungry. Resident said I need something to do. Staff offered a movie or reading and the resident refused and said again, I need something to do. Staff did not attempt any other interventions. Resident continued to pace and wring hands.
Observation on 10/23/19, at 9:14 A.M., showed the resident as extremely upset, sobbing loudly, and asking for his/her spouse.
Observation on 10/23/19, at 10:30 A.M., showed the resident stood at the nurses' desk leaning his/her arms on the counter. The resident asked staff several times why he/she was still here and what to do now. The resident asked twice (pointing toward the front entrance) if that was the main door out of this church or this place.
Observation on 10/23/19, at 3:08 P.M., showed the resident was exit seeking at the 200 hall door. An alert and oriented resident stood between the resident and the door blocking his/her way. The resident kept reaching around the alert and oriented resident and pushed on the door handle. The resident kept insisting he/she was going to visit family and wait for his/her spouse. The alert and oriented resident kept waving his/her hand to get the staff's attention. This continued for approximately 10 minutes. There were two CNAs on the 200 hall at the time of the incident. Staff did not attempt to intervene or redirect the resident. The alert and oriented resident was able to redirect Resident #32 who then began to pace down the hall carrying a bag. The resident repeatedly said he/she was going to visit family and wait for his/her spouse. The resident entered two other resident rooms and looked through things before saying this isn't my stuff. Resident #32 went into Resident #4's room. Resident #4 attempted to calm the resident down. Staff entered the room and redirected the resident into the television room to watch the birds. The resident stayed seated for approximately 15 minutes, then exited the television room, and began to pace the hallway again. The resident was tearful during this entire time and kept wiping tears from his/her face.
During an interview on 10/24/19, at 4:42 P.M., the Social Service Director (SSD) said:
-The resident exit seeks, is very repetitive, and asks other residents and staff where his/her spouse is;
-The resident packs up his/her belongings;
-The resident's behaviors have increased since his/her spouse passed away;
-The resident is more depressed and anxious since his/her spouse passed away;
-Would expect the behaviors to be care planned;
-Would expect other interventions to be attempted;
-If he/she hears about behaviors, he/she goes and talks to the resident and the family about options, which may include a room change or if there is too much stimulation;
-He/she documents in the social services progress notes about the conversation;
-There is a behavior log, but he/she is not involved with determining specific behaviors to monitor and he/she does not document any interventions attempted and does not know who does that;
-Sometimes other staff will ask him/her for options and interventions.
During an interview on 10/24/19, at 5:21 P.M., Certified Nurse Aide (CNA) L said the aides document behaviors. They write down the details on a piece of paper. It includes what, when, where, how, who was involved with the incident/behavior. The aides give that to the nurse. The aides do not document directly in the resident's medical record. The facility always have some resident trying to get out. He/she thought the residents just don't understand or thinks they are at the facility on vacation. They try to get out for a variety of reasons. They have a handful of residents currently that try to get out. To know how to take care of a resident, the aides can look at the careplan or talk to the nurse, family, or sometimes the resident can tell them. Sometimes, there is a paper in the front of the resident's full careplan that will guide the aides on care of a resident. The aides also have a CNA ADL sheet that the aides document on that gives some guidance on care.
During an interview on 10/24/19, at 5:23 P.M., CNA I said:
-The resident very confused and has been worse since his/her spouse passed away;
-The resident is always looking for his/her spouse and has had increased depression and anxiety;
-The resident packs up his/her room frequently and they have to have him/her unpack it;
-These are the types of behaviors that are reported to the nurses' and should be charted on;
-They have attempted interventions, but have never tried to give the resident something to do.
-If a resident presents with behaviors, the staff have been told to try to redirect the resident;
-If the resident is entering other resident rooms, then try to redirect and offer other things to do;
-If the resident is being aggressive with staff, walk away and approach at a later time or find another staff member to assist the resident;
-If the resident is exit seeking, bring the resident back into the facility and redirect them to another area or offer an activity;
-The CNAs do not document behaviors;
-The CNAs report which resident, when the resident exhibits behaviors, what the behaviors are, how often the behaviors are occurring, and what interventions they attempted and the nurse is supposed to document all of this on the behavior flow sheet;
-The CNAs learn about new residents needs and behaviors or changes in current residents needs and behaviors during report;
-There is also a CNA book for each hall which gives information for activities of daily living (ADLs), but not behaviors;
-He/she does not speak with the nurses about interventions to attempt.
During an interview on 10/24/19, at 5:49 P.M., LPN A said they monitor behavior and make sure a resident doesn't hurt him/her self or others. They notify the physician of behaviors. They have a log sheet that the nurses document on. They document the number of times a resident has a behavior. If it is a major behavior, then the nurses document in the nurses' notes also. Nurses determine the behaviors that need monitored for a resident.
During an interview on 10/24/19, at 6:29 P.M., the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) said:
-The resident wanders and exit seeks, even into other resident rooms;
-The resident has changed since his/her spouse died and is more confused;
-The resident now wanders more looking for his/her spouse;
-The DON said the resident has gone out the door two times that he/she knows of;
-The ADON said two times in one day, the resident left an activity and almost got out the fence outside the door of 600 hall and the other day at lunch was the second time;
-The resident has only gotten outside twice;
-They have not tried new interventions with the resident;
-Exit seeking and wandering behaviors along with interventions should be included in the care plan;
-There is a behavior sheet in the medication administration record (MAR) book;
-The behavior sheet includes target behaviors, how often the behavior has occurred, and the interventions tried;
-The nurse who does the medication pass will add the target behavior;
-The nurses' will sometime document in the nurses' notes;
-Exit seeking behavior and antipsychotic medications should be included on the care plan;
-When a resident is wandering or exit seeking, staff should offer interventions which include: snacks, listening to music, toileting, distraction, and sit and talk to the resident.
During an interview on 10/24/19, at 7:30 P.M., the administrator said:
-Not aware of any resident physically getting outside of the door or facility;
-She did not know the resident had gotten outside;
-Any resident with behaviors should have a behavior monitoring sheet and the nurses' should fill them out;
-The nurses' also chart in nurses' notes when an incident occurs because the physician likes to see the narrative for what caused the behavior and what interventions were attempted;
-They utilize the behavior monitoring sheets to see if there is a pattern to the behavior, a time of day or a certain trigger so they can attempt different interventions;
-They look at what might work, look at medications, is the resident involved in activities, if one resident doesn't like another resident that would be a trigger they would look at and attempt to keep the residents apart;
-There are some residents that walk a lot around the building, sometimes they will set off the alarm;
-All doors have alarm and the facility does not utilize wander guards and the door alarm will usually stop the resident from exiting;
-Wandering and exit seeking behaviors should be listed on the care plan;
-Nurses can add things to the care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to prepare food in a form to meet each resident's nutritional needs when staff did not follow portion sizes for mechanical soft diets or prepare and serve pureed foods according to the approved recipe and the correct consistency for three residents (Resident #9, #11, and #16). The facility census was 49.
Record review of facility records showed the facility did not provide a policy for therapeutic diets.
1. Record review of the facility's weekly menu, dated October 20, 2019 through October 26, 2019, showed the following information:
-Wednesday, October 23, 2019: Salisbury steak, au gratin potatoes, and mixed vegetables;
-Thursday, October 24, 2019: Roast turkey with gravy, sweet potatoes, and whole green beans.
Record review of the facility's menu cycle, entitled Week 1 Wednesday, showed the following information:
-Mechanical soft diet: one-half cup Salisbury steak;
-Pureed diet: one-half cup Salsibury steak with pureed bread, one-half cup pureed au gratin potatoes, and one-half cup pureed butter mixed vegetables with pureed bread.
Record review of the facility's menu cycle, entitled Week 1 Thursday, showed the following information:
-Pureed diet: one-half cup pureed turkey with pureed bread and one-quarter cup gravy, one-half cup pureed sweet potatoes, and one-half cup pureed green beans with pureed bread.
Record review of the facility's recipe entitled Pureed Meats for pureed meat, poultry, or fish, showed the following information:
-For 10 servings of pureed meat make as directed:
-Ingredients: 1 pound and 14 ounces of cooked meat, poultry, or fish, 2 ½ cups of broth, and 5 slices of bread;
-Place entrée in blender and grind;
-Add bread and grind;
-Add 4 ounces or ½ cup liquid, blend. Continue alternating adding ½ cup liquid until consistency is smooth and between pudding and mashed potatoes;
-Transfer to serving pan(s) and cover with foil;
-Reheat;
-Hold on steam table above 165 degrees;
-Note: Use only the amount of liquid necessary to puree this product. Do not increase or decrease the amount of meat or bread;
-Serving size: ½ cup;
-Utensil: #8 scoop or 4 ounce spoodle.
Record review of the facility's recipe entitled Pureed Side Dishes, showed the following information:
-For 10 servings of pureed side dish (potatoes, rice, dumplings, noodles, or baked beans) make as directed;
-Ingredients: 1 and ¼ quarts of prepared side dish and 2 cups of broth or milk;
-Place side dish in food processor, blend;
-If necessary, add small amount of broth or milk, and blend. Alternate adding broth or milk and blending until consistency is smooth;
-Transfer to serving pan(s) and cover with foil;
-Reheat;
-Hold on steam table above 160 degrees;
-Note: Use only the amount of liquid necessary to puree the product. Do not increase or decrease the amount of the side dish;
-Serving size: ½ cup;
-Utensil: #8 scoop or ½ cup spoodle.
Record review of the facility's recipe entitled Pureed Vegetables and Salads for pureed vegetables, showed the following information:
-For 10 servings of pureed vegetables cooked and drained, make as directed;
-Ingredients: 1 ¾ quarts plus one-half cup of cooked and drained vegetables, 5 slices of bread, 1 cup vegetable juice, and 1 cup butter or margarine, melted;
-Place vegetables into food processor, blend;
-Add bread, blend;
-Add small amount of juice and blend until consistency is smooth;
-Add butter or margarine, blend;
-Transfer to serving pan(s) and cover with foil;
-Reheat;
-Hold on steam table above 160 degrees;
-Note: Use only the amount of liquid necessary to puree the product. Do not increase or decrease the amount of vegetables or bread;
-Serving size: ½ cup;
-Utensil: #8 scoop or 4 ounce spoodle.
Observation of the kitchen on 10/23/19, beginning at 11:48 A.M., showed the following:
-Cook C began the puree for ten servings;
-Cook C added 8 one-half cup scoops of mixed vegetables and water to puree bowl;
-Cook C began the puree;
-Cook C added 5 slices of white bread to the mixed vegetable puree and continued to puree until it was at a pudding consistency;
-Cook C placed the pureed mixed vegetables into a steam pan and placed it in the steam table;
-Cook C scooped out 8 one-half cup scoops of au gratin potatoes into puree bowl and added some whole milk;
-Cook C did not measure the milk;
-Cook C started the puree machine and pureed until it was a syrup consistency;
-Cook scooped the pureed au gratin potatoes into a steam pan and placed it on the steam table;
-Cook C removed the salisbury steaks from the oven and put five, 3 ounce patties into the puree bowl;
-Cook C began to puree the meat and added an unmeasured amount of beef broth to the meat;
-Cook C continued to puree the meat and added 5 slices of white bread to the puree bowl;
-Cook C continued to puree until the meat reached a mashed potato consistency;
-Cook C scooped the pureed meat into a steam pan and placed it on the steam table;
-Cook C began to prepare the mechanical soft diets for six residents;
-Cook C added 5 salisbury steaks to the puree bowl and grounded them to a ground hamburger consistency;
-Cook C did not utilize a recipe book or measure the liquid during this process.
During an interview on 10/23/19, at 11:48 A.M., [NAME] C said:
-He/she makes enough puree to serve ten residents;
-There are only nine residents who have a pureed diet order, but just in case someone wants more, he/she makes ten servings;
-The pureed meat recipe for ten servings calls for 14 ounces of meat, five slices of bread, and add broth until it is at the desired consistency;
-The pureed vegetable recipe for ten servings is one quart of vegetables and water or juices and five slices of bread to thicken.
Observation of the kitchen on 10/24/19, beginning at 12:01 P.M., showed the following:
-Cook C began the puree diets for ten servings;
-Cook C scooped out one quart and one-half cup of green beans and water into a pitcher and added it to the puree bowl;
-Cook C began to puree the green beans and added 5 slices of white bread to the mixture and pureed until it was a mashed potato consistency;
-Cook C scooped out the pureed green beans into a steam pan and placed the pan onto the steam table;
-Cook C scooped four six ounce scoops (total of 24 ounces) of sweet potatoes into the puree bowl;
-Cook C began to puree the potatoes and added water to the mixture and did not add bread;
-Cook C pureed this until it was a pudding like consistency;
-Cook C scooped the sweet potato puree into a steam pan and placed the pan onto the steam table;
-Cook C brought the scale to the prep table by the pan of turkey breast and thighs;
-Cook C measured 14 ounces of meat for the puree and placed the turkey into the puree bowl;
-Cook C began to puree the turkey and added an unmeasured amount of chicken broth and five slices of white bread to the meat puree;
-Cook C pureed until it reached a mashed potato consistency;
-Cook C scooped the turkey puree into a steam pan and placed the pan onto the steam table;
-Cook C did not measure the liquid or utilize a recipe during this process.
Observation of the kitchen on 10/24/19, beginning at 12:36 P.M., showed the following:
-Cook C served all pureed diets with the prepared turkey puree, sweet potato puree, and green bean puree.
During an interview on 10/24/19, at 2:01 P.M., [NAME] C said:
-He/she knows the recipes by heart and does not need to look at them to make the mechanical soft or pureed diets;
-For meat purees, it is 14 ounces of meat, 5 slices of bread, and 2 ½ cups of broth for ten servings;
-For vegetables, it is one quart plus a ½ cup of vegetables, ½ cup of butter which is cooked into the water in the vegetables, and five slices of bread for ten servings;
-He/she did not know that he/she was using less than one-half of the meat required for meat puree dishes and was using half of the required vegetables for pureed vegetables;
-He/she should have used the recipe book to ensure the residents received all of the required nutritional value for their meals;
-Pureed foods should be at a mashed potato to pudding consistency, they should never be runny;
-He/she used a one-quarter cup scoop of mechanical soft meat for all mechanical diets instead of one-half cup scoop;
-He has been doing this for over a year.
2. Record review of Resident #16's nutritional assessment, dated 2/6/19, showed the following information:
-Regular diet;
-Monitor intake;
-No supplements;
-Weight 163 pounds;
-Adequate intake;
-Continue diet order.
Record review of the resident's quarterly Minimum Data Set (MDS), a federally mandated comprehensive assessment instrument, completed by facility staff, dated 8/11/19, showed the following information:
-admitted on [DATE];
-Diagnoses included dementia without behavioral disturbance, encephalopathy (brain disease or damage), muscle weakness, history of dehydration, and cognitive communication deficit;
-Severely cognitively impaired;
-Required extensive assistance with eating;
-Weight loss of 5% or greater in the last month or 10% or greater in the past 6 months and not on a physician-prescribed diet.
Record review of the resident's care plan, last updated on 8/16/19, showed the following information:
-Resident has had weight loss;
-Resident is on a pureed diet and has supplements;
-Give resident supplements as ordered;
-Invite resident to activities that promote fluid and nutrition intake;
-Resident is able to feed him/herself at times, but mostly is dependent on staff assistance with all intake;
-Physician has refused use of appetite stimulants;
-Medication pass supplement 60 milliliters (mls) three times daily;
-Monitor and evaluate for weight loss, determine percentage lost and follow facility protocol for weight loss;
-Provide and serve supplements as ordered: ice cream with lunch and juice supplement with breakfast;
-Provide and serve diet as ordered, monitor and record intake every meal;
-Registered dietitian (RD) to evaluate and make diet change recommendations as needed;
-Resident requires assistance with all activities of daily living (ADLs - dressing, grooming, bathing, eating, and toileting) due to limited mobility and cognitive issues.
Record review of the resident's weight flow sheet showed the following information:
-8/20/19 - 136 pounds;
-9/5/19 - 144 pounds;
-9/18/19 - 152.6 pounds;
-10/1/19 - 153.4 pounds;
-10/8/19 - 148.6 pounds.
Record review of the resident's physician order sheet (POS) dated October 1, 2019 through October 31, 2019, showed the following information:
-5/17/19: Med pass supplement, give 60 ml by mouth three times daily;
-Pureed diet;
-Juice supplement with breakfast;
-Ice cream with lunch.
Record review of the resident's nutrition progress notes, dated 10/14/19, showed the following information:
-Significant weight loss from 10/1/19 at 153.4 pounds to 10/8/19 at 148.6 pounds;
-Continue weekly weights;
-Continue all supplement orders.
Observation on 10/21/19, beginning at 12:36 P.M., showed the following:
-Resident sat in a geri-chair (reclining wheeled chair) at the table in the dining room on the unit;
-Staff provided the resident a meal tray that included a pureed breaded pork chop, pureed stuffing with gravy, pureed steamed broccoli, applesauce, and a bowl of super cereal;
-Staff mixed the resident's regular pureed diet into the bowl of super cereal;
-The resident fed him/herself and ate 100% of the meal.
Observation of the kitchen on 10/23/19, beginning at 12:35 P.M., showed the following:
-Cook C began to place the food on the plates for the residents;
-For the resident's plate, [NAME] C placed one-half cup of potatoes, one-half cup of mixed vegetables, and one-half cup of pureed meat on to the resident's plate.
3. Record review of Resident #9's annual MDS, dated [DATE], showed the following information:
-admitted to the facility on [DATE];
-Short and long term memory problem;
-Severely impaired decision-making skills;
-Required limited assistance for eating;
-Weight of 114 pounds;
-Diagnoses included cancer, peripheral vascular disease (common circulatory problem in which narrowed arteries reduce blood flow to limbs), renal insufficiency (defective function of the kidneys, with accumulation of waste products (particularly nitrogenous) in the blood), hip fracture, and dementia.
Observation on 10/21/19, beginning at 12:36 P.M., showed the following:
-Resident sat in his/her wheelchair at the table in the dining room on the unit;
-Staff served the resident a lunch tray with a pureed breaded pork chop, pureed dressing with gravy, pureed steam broccoli, and applesauce;
-Staff assisted the resident to eat;
-The resident ate 100% of his/her meal.
Observation of the kitchen on 10/23/19, beginning at 12:35 P.M., showed the following:
-Cook C began to place the food on the plates for the residents;
-For the resident's plate, [NAME] C placed one-half cup of potatoes, one-half cup of mixed vegetables, and one-quarter cup ground Salisbury steak with gravy on to the resident's plate;
-For the resident's plate, [NAME] C placed one-half cup of potatoes, one-half cup of mixed vegetables, and one-half cup of pureed meat on to the resident's plate.
4. Record review of Resident #11's quarterly MDS, dated [DATE], showed the following information:
-Moderately impaired cognition;
-Required supervision and set up only for eating;
-Diagnoses included malnutrition;
-Current weight 85 pounds, 64 inches height;
-Weight loss.
Record review of the resident's care plan, created 2/5/19, revised 10/21/19, showed the following information:
-Adult failure to thrive related to chemotherapy;
-Monitor nutritional status and intervene as indicated;
-Increase calories and protein as needed;
-Provide small meals throughout the day to improve tolerance and increase intake;
-Nutritional problem related to disease process and failure to thrive;
-Up in gerichair for all meals;
-He/she prefers to eat in the main dining room at facility scheduled times;
-Prefers to have hot breakfast.
Record review of the resident's POS, dated 10/1/19 through 10/31/19 showed the following information:
-Hospice;
-Pureed diet with nectar thick liquids;
-Frozen treat with lunch and supper;
-Medication pass supplement 90 ml four times daily;
-Additional diagnosis of basal cell carcinoma (cancer).
Observation on 10/23/19, at 6:19 P.M., showed the resident sat in the gerichair, eating pureed food.
Observation on 10/24/19, at 1:01 P.M., showed the resident sat at the dining room table in his/her gerichair, eating pureed food by him/her self.
5. During an interview on 10/24/19, at 2:18 P.M., the Certified Dietary Manager (CDM) said:
-The staff are expected to use the recipe books for preparing all foods, including mechanical soft and pureed diets;
-The staff should have followed the recipes and ensured the residents received the correct amount of nutritional value for their meals;
-Pureed foods should have a consistency between pudding and mashed potatoes, they should never be runny;
-Mechanical soft diets should receive one-half cup of ground meat for each serving, [NAME] C has only been giving them one-quarter cup for each serving;
-He/she did not know that the staff had not been utilizing the recipe books or had cut the necessary meat and vegetables in half for pureed diets.
8. During an interview on 10/24/19,, at 7:30 P.M., the administrator said:
-She expects dietary staff to prepare food according to the approved recipes, approved menus, and to the approved consistency;
-He/she did not know the dietary staff were not following the recipes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to serve residents, including six sampled residents (Resident #4, #15, #17, #26, #33, and #196) palatable and attractive food to resident. The facility census was 49.
1. Record review of the facility's resident council minutes dated 6/18/19, at 10:30 A.M., showed the meat was too tough to cut.
Record review of the facility's resident council Quality of Life questionnaire, dated 6/18/19, showed the following information:
-Is the flavor and appearance of your food satisfactory? Sometimes;
-Are the meats tender enough? No.
Record review of the facility's grievance log dated 6/18/19, showed Resident #33 filed a grievance and said the meat was still tough.
Record review of the facility's resident council minutes dated 7/16/19, at 10:15 A.M., showed the
the food did not taste good.
Record review of the facility's resident council minutes dated 8/13/19, at 10:15 A.M., showed the following information:
-Food discussed during food forum;
-Meat was not tender.
During an interview with the resident council members, on 10/22/19, beginning at 11:02 A.M., the following was said:
-The residents said the meat, specifically pork and beef, are always too tough to eat;
-The vegetables are always overcooked and mushy or everything is covered in gravy;
-They have asked for the gravy to be left off, but the cooks just keep putting it on there;
-The food has no flavor and is bland tasting;
-They have made this complaint to the dietary staff and the administrator more than once, but nothing changes about it;
-The dietary manager told them at the August 2019 resident council meeting that the reason the meat is so tough is because of how it was raised;
-The residents said almost everything is overcooked either until it is too tough or it is mushy and falling apart and nothing is ever seasoned correctly;
-They would prefer the cooks make chicken every day so they do not have to eat the pork or beef;
-When pork or beef is served, they usually do not eat it.
2. Record review of Resident #15's annual Minimum Data Set (MDS), a federally mandated comprehensive assessment instrument, completed by facility staff, dated 9/9/19, showed the following information:
-Original admission date 4/7/17;
-Cognitively intact;
-Independent with activities of daily living (ADLs - dressing, grooming, bathing, eating, and toileting).
Observation and interview on 10/22/19, at 12:44 P.M., showed the following:
-The resident pulled all the breading off the country fried chicken and ate the meat underneath;
-The resident said the chicken itself was wonderful, but there was too much breading and it was too hard to chew;
-The resident said the corn looked funny and he/she was afraid to eat it due to the discoloration;
-The resident said the mashed potatoes were ruined because they were covered in gravy;
-The resident ate approximately 30% of his/her meal, which included the chicken meat and dessert only.
3. Record review of Resident #26's annual MDS, dated [DATE], showed the following information:
-Original admission date of 8/18/16;
-Severely cognitively impaired;
-Independent with eating.
Observation and interview on 10/21/19, beginning at 12:26 P.M., showed the following information:
-Certified Nursing Assistant (CNA) I and Nursing Assistant (NA) J passed trays on 100 hall to residents;
-Staff served the resident his/her meal tray. The resident pushed on the meat and broccoli and pushed the tray away;
-The resident ate only his/her orange sherbet for lunch and left the remainder of the food on his/her tray.
4. Record review of Resident #33's annual MDS, dated [DATE], showed the following information:
-Original admission date of 9/12/18;
-Severely cognitively impaired;
-Supervision with eating.
Observation on 10/22/19, at 12:35 P.M., showed the following:
-Staff setup the resident lunch tray. Staff cut the meat and opened the drinks;
-The resident put a piece of country fried chicken in his/her mouth and spit it back out;
-The resident pulled all the breading off the country fried chicken and ate the chicken underneath;
-The resident ate less than 50% of his/her meal.
5. Record review of Resident #196's 5-day MDS, dated [DATE], showed the following information:
-Original admission date of 5/1/19;
-Severely cognitively impaired;
-Required extensive assistance with eating.
Observation and interview on 10/21/19, beginning at 12:26 P.M., showed the following information:
-CNA I and NA J passed trays on 100 hall to residents;
-NA J assisted the resident by cutting his/her meat, which required the NA to utilize a sawing motion to cut through the meat;
-NA J said the meat was tough today;
-The resident picked up a piece of meat and chewed it for approximately two minutes before spitting it out and laying it on his/her plate;
-The resident repeated this with five more pieces of meat and spit out three pieces onto his/her plate;
-The resident ate less than 25% of his/her meal.
6. Record review of Resident #4's quarterly MDS, dated [DATE], showed the following information:
-Cognitively intact.
Record review of the resident's care plan, reviewed 10/25/18, showed the resident had a regular diet with thin fluids. The resident's appetite was typically good. The resident could feed his/her self with regular utensils.
Observation on 10/21/19 showed the following:
-At 12:38 P.M., staff had served the resident lunch. The resident said the pork meat was tough. The broccoli was too soft. It was cooked too much;
At 12:58 P.M., the resident said the first pork was too tough to eat. Staff brought a second portion of pork. It is not as tough, but still too tough to eat. The broccoli is too mushy. It has been cooked to death.
-At 2:12 P.M., the resident said the food was not good. He/she cannot eat the meat. It is too tough. He/she couldn't cut or eat the meat at lunch today. He/she told staff before it was tough. The Certified Dietary Manager (CDM) told the resident he knew.
7. Record review of Resident #17's quarterly MDS, dated [DATE], showed the following information:
-Severely cognitively impaired;
-Independent/set up only for eating.
Record review of the weight variance notification, dated 10/9/19, showed the following information:
-Denied chewing difficulties or mouth pain;
-The resident did say food gets stuck in his/her throat;
-He/she doesn't cough, eyes don't water;
-The resident had a poor appetite, he/she just doesn't eat,
Observation on 10/21/19 showed the following:
At 12:37 P.M., staff served the resident's lunch. The resident's family member sat at the tablet with the resident and attempted to cut the pork. The resident's family member sawed back and forth on the pork with a butter knife, trying to cut it. The family member told the resident, not sure if you will be able to eat it, too tough.
-At 12:45 P.M., a staff member tried to cut the pork for the resident;
-At 12:56 P.M., the resident ate a bite of ice cream and picked at the pork.
During an interview on 10/22/19, at 10:07 A.M., the resident's family member said the food is never cooked enough. The beans are still hard. The meat is not done. It should fall apart if done. The meat was tough yesterday because it was not done. It should be tender and falling apart. Food cools quickly. At night, staff serve warm meat and lay a cold bun over it.
8. Observation on 10/21/19, at 1:21 P.M., showed the following:
-The regular lunch meal consisted of breaded pork chops, cornbread dressing with gravy, and steamed broccoli florets;
-The breaded pork chops were cooked unevenly, with half of it being tender and able to cut it with a fork, and the other half was overcooked, dry, and tough and unable to cut with a knife;
-The steamed broccoli was mushy;
-The cornbread stuffing was overcooked, with a glue-like consistency, and was covered in a bland gravy.
Observation on 10/22/19, at 1:16 PM, showed the following:
-The regular lunch meal consisted of country fried chicken, whipped potatoes with gravy, and sweet corn;
-The country fried chicken had a thick breading (approximately 1/4 - 1/3 of an inch thick) on it that was hard and crunchy and had to be peeled off to be able to cut through to the chicken;
-The chicken underneath the breading was dried out in places due to being overcooked;
-The mashed potatoes and gravy were bland and slightly runny;
-The corn was overcooked and had changed colors to light pink and orange instead of yellow.
Observation on 10/23/19, at 12:37 P.M., showed the following information:
-The regular lunch meal consisted of Salisbury steak with gravy, Au Gratin potatoes, and butter mixed vegetables;
-The Salisbury steak and gravy were bland;
-The Au Gratin potatoes were overcooked and unable to be picked up and eaten with a fork;
-The mixed vegetables were bland.
9. During an interview on 10/24/19, at 2:18 P.M., the Certified Dietary Manager (CDM) said food should look appetizing and taste good when served.
10. During an interview on 10/24/19, at 7:30 P.M., the administrator said the food should look appetizing and taste good.