What is Holly Hill House's CMS rating?

Holly Hill House has a one-star overall rating from CMS (Centers for Medicare & Medicaid Services), based on health inspections, staffing levels, and quality measures.

How many inspection deficiencies does Holly Hill House have?

Holly Hill House has 59 deficiencies from recent inspections. None are at the Immediate Jeopardy level.

What are the staffing levels at Holly Hill House?

Holly Hill House has a one-star staffing rating from CMS with 0.22 RN hours per resident per day. This rating is based on registered nurse (RN), licensed practical nurse (LPN), and nurse aide staffing hours.

Where is Holly Hill House located?

Holly Hill House is located in Sulphur, LA. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does Holly Hill House have?

Holly Hill House has 200 certified beds.

Who owns Holly Hill House?

Holly Hill House is a for profit - corporation facility and operates independently (not part of a chain).

Is Holly Hill House safe?

Holly Hill House has documented safety concerns including a substantiated abuse finding on record. Families should ask about corrective actions taken.

Was Holly Hill House ever fined?

Yes, Holly Hill House has been fined $62,018 by federal regulators. Fines are issued for serious violations of Medicare and Medicaid requirements.

Is Holly Hill House on any federal watch list?

No, Holly Hill House is not on any federal watch list. It is not designated as a Special Focus Facility or SFF Candidate by CMS.

What have inspectors found at Holly Hill House?

Medicare inspectors have found 59 deficiencies at Holly Hill House: 1 serious, 58 moderate. Each deficiency represents a violation of federal nursing home requirements.

What questions should families ask when visiting Holly Hill House?

Families visiting Holly Hill House should ask about what corrective actions were taken after fines. Also ask to speak with current residents or families, tour during mealtime, and request a copy of the most recent inspection report.

How does Holly Hill House compare to other nursing homes?

Holly Hill House has a 1-star overall rating, which is below average compared to other nursing homes in LA. Families should carefully review inspection findings and consider alternatives.

Holly Hill House | 10/100 (Grade F)

Aug 2025 5 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to protect the resident's right to be free from physical abuse by oth...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to protect the resident's right to be free from physical abuse by other residents for 1 (#2) out of 4 (#1, #2, #3 and #4) sampled residents. The facility failed to protect Resident #2 from physical abuse when Resident #3 slapped Resident #2 in the face on 08/09/2025. The deficient practice had the potential to effect a census of 79.Findings: Review of the facility's abuse, prevention and prohibition policy revealed in part .Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers staff of other agencies serving the resident, family members or legal guardians, friends or other individuals.Review of the facility's Incident Report for the past 90 days revealed one incident of resident to resident physical aggression for Resident #2 dated 08/09/2025 at 3:20 p.m. Resident #2Review of Resident #2's record revealed she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, unspecified dementia, unspecified severity, with psychotic disturbance, anxiety disorder, and conductive hearing loss, bilateral.Review of Resident #2's most recent Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score that was unscored, indicating the resident could not participate in the interview. Resident #3 Review of Resident #3's record revealed she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, bipolar disorder, current episode depressed, moderate; vascular dementia, severe, with psychotic disturbance, vascular dementia, severe, with agitation; major depressive disorder, recurrent, mild and anxiety disorder, unspecified.Review of Resident #3's most recent Quarterly MDS assessment dated [DATE] revealed the resident had a BIMS score of 99, indicating her cognitive status could not be assessed.Review of the facility's Incident Report dated 08/09/2025 at 3:20 p.m., revealed the following in part: Incident Location: Common area/day roomPerson Preparing report: S4LPN (Licensed Practical Nurse)Incident Description: Today (08/09/2025) at 3:20 p.m., Resident #2 was involved in an incident where he was the victim of resident-to-resident physical aggression. Resident #2 was sitting at the dining room table and because he was blind, he feels his surroundings and was rubbing the table. S6CNA (Certified Nursing Assistant) stated Resident #2 touched a package of gram crackers that were on the table. S6CNA stated due to Resident #3 getting upset, S6CNA stated she removed the Resident #2 from the table. As she was pushing Resident #2 while in his wheelchair, Resident #3 went around S6CNA, stood in front of the Resident #2, and began to yell at the resident. Resident #3 slapped Resident #2 with her right hand on the left side of Resident #2's face. S4LPN (Licensed Practical Nurse) immediately went in front of the Resident #3 to allow S6CNA to take Resident #2 out of the sight of Resident #3.S4LPN noted a red area to the residents left upper cheek area. Level of Pain: 4.On 08/25/2025 at 11:30 a.m., an interview was conducted with S6CNA, she reported she was present when the resident to resident altercation occurred with Resident #2 (victim) and Resident #3 (accused). She stated she was standing in the hallway, at the dining room door, as she was conducting one on one care with another resident when she observed Resident #2 feeling on the table to put his cup of coffee down. S6CNA stated as Resident #2 passed his hand over a pack of graham crackers, Resident #3 was walking from the table to the door. S6CNA stated Resident #3 turned around and saw Resident #2 touch the crackers then Resident #3 began yelling at Resident #2. Resident #3 turned around moving toward Resident #2. S6CNA stated she went to Resident #2 and got between him and Resident #3 to stop Resident #3 from hitting on Resident #2. She stated she turned him away from Resident #3 and Resident #3 came around her and began slapping Resident #2 on the side of the face, yelling at the resident. She stated the nurse then came in and got between Resident #2 and #3 to stop resident #3 from hitting on Resident #2. On 08/25/2025 at 12:35 p.m., an interview was conducted with S3ADON (Assistant Director of Nursing). She confirmed she was aware of the incident of the resident to resident altercation with Resident #2 and Resident #3. S3ADON confirmed Resident #2 was not protected from abuse. On 08/27/2025 at 10:00 a.m., an interview was conducted with S4LPN. She confirmed she was working when Resident #3 slapped Resident #2. She confirmed Resident #3 willfully intended to hit Resident #2 because the resident yelled and went toward Resident #2 to hit him, yelling as she hit him.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

Based on record reviews and interviews, the facility failed to ensure allegations of injury of known origin were reported immediately to the Administrator or his/her designated representation, and rep...

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Based on record reviews and interviews, the facility failed to ensure allegations of injury of known origin were reported immediately to the Administrator or his/her designated representation, and reported to the state agency not later than 2 hours after the allegation was identified for 1 (#4) out of 4 (#1, #2, #3 and #4) residents reviewed for timely reporting of critical incidents.Findings:Review of the facility's abuse, prevention and prohibition policy revealed in part .Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers staff of other agencies serving the resident, family members or legal guardians, friends or other individuals.Reporting/Response: 1. The facility employee or agent, who becomes aware of abuse or neglect, including injuries of unknown origin or alleged misappropriation of resident property, shall immediately report the matter to the facility Administrator or his/her designated representative in the Administrator's absence.Resident #4Review of Resident #4's critical incident report related to injury of unknown origin with bruising to the right side of head revealed the event occurred on 08/03/2025 at 6:00 p.m. The date the incident was discovered was documented as 08/03/2025 at 6:00 p.m. The date the report was entered was documented as 08/03/2025 at 7:53 p.m., with a report due date of 08/08/2025. Review of Resident #4's progress notes revealed in part, on 08/03/2025 at 10:16 a.m., the resident experienced a change in condition noted as a Hematoma to right side head above temple. S7CNA (Certified Nursing Assistant) reported to S5LPN that Resident #4 had hematoma on the right upper temporal area. Upon assessment, purplish raised bruising noted. Light blue bruising noted below area. Resident #4 unable to let S5LPN know how/when accident occurred.On 08/26/25 at 9:00 a.m., an interview was conducted with S5LPN. She stated she was notified by S7CNA of a bruise to the right side of the face on Resident #4, on the morning of 08/03/2025, before breakfast. She stated the bruise was found the morning of 08/03/2025, and she did not report it to the administrative staff until later in the day, sometime after lunch. She stated she did not know how the bruise occurred. S5LPN confirmed she did not immediately report the injury of unknown origin and should have.On 08/26/2025 at 10:40 a.m., an interview was conducted with S3ADON (Assistant Director of Nursing) who stated the facility Administrator was responsible for reporting alleged violations to the state agency. She confirmed the facility's administrative staff were made aware of Resident #4's injury: S11RN (Registered Nurse) notified S3ADON on 08/03/2025 at 6:43 p.m. S3ADON notified S2DON (Director of Nursing) on 08/03/2025 at 6:47 p.m. and S2DON notified S1ADM on 08/03/2025 at 6:51 p.m. She confirmed Resident #4 had an injury of unknown origin that S5LPN failed to report immediately and that the incident was not reported to the state agency within 2 hours as required.On 08/27/2025 at 10: 15 a.m., an interview was conducted with S1ADM (Administrator). He reported he was responsible for submitting the critical incidents. He stated when a reportable occurs the administrative team discuss the incident, if it is reportable within 2 hours the clinical team will gather with S1ADM to discuss and review the policy for steps to take. He stated S2DON and S3ADON were responsible for gathering the information and investigate and interview the staff and obtain written statements. He stated when he was ready to submit the completed investigation he asked if there was any other witness statements or investigations before submitting.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Investigate Abuse (Tag F0610)

Could have caused harm · This affected 1 resident

Based on interview and record review, the facility failed to ensure an investigation of an allegation of abuse was thoroughly investigated for 1 (#4) of 3 (#2, #3, #4) sampled residents reviewed for a...

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Based on interview and record review, the facility failed to ensure an investigation of an allegation of abuse was thoroughly investigated for 1 (#4) of 3 (#2, #3, #4) sampled residents reviewed for abuse. Findings:Review of the facility's abuse, prevention and prohibition policy, with an approved date of 12/2024, revealed in part .Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers staff of other agencies serving the resident, family members or legal guardians, friends or other individuals . 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. 2. Initiate investigation including initial reporting to all required agencies.5. Complete a thorough investigation. Two management level staff will conduct interviews with witnesses or other staff, resident or visitors who could have knowledge of the allegation. Witnesses will be asked to assist with completing statements if indicated. 6. Every employee will be interviewed who was working on the specific hall/wing that the affected resident resides on.Review of Resident #4's medical record revealed a re-entry admission date of 04/02/2025, with diagnoses that included in part Parkinson's disease without dyskinesia, without mention of fluctuations; unspecified dementia, unspecified severity, with other behavioral disturbance and delusional disorders.Review of Resident #4's Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 07/08/2025 revealed a BIMS score of 00, which indicated severely cognitively impaired. Review of a facility's critical incident report revealed events occurred on 08/03/2025 at 6:00 p.m. and discovered on 08/03/2025 at 6:00 p.m. and was entered on 08/03/2025 at 7:43 p.m. Incident Investigation: completed by S1ADM (Administrator) on 08/07/2025 at 5:53 p.m. revealed the following in part, S1ADM wrote investigation findings: Resident #4 with a BIMS 99, did sustain a hematoma to the right side of head above the temple. The resident is unable to state or recall the origin of injury. The resident did not complain of pain. Resident was assessed with no further injuries noted. Resident was treated for injury. The injury was first noticed by hall CNA (Certified Nursing Assistant) and was reported to the nurse who examined and treated. Recognition of the injury was early afternoon. Nurse initiated all required protocol for the injury, including contacting physician and family. Charge nurse became aware of the injury approximately 6:00 p.m., and informed the regional nurse and Administrator of the injury. Administrator initiated the investigation and critical incident report.There is no video surveillance to view. There is no roommate to interview.There is no evidence to the origin of injury. Abuse cannot be substantiated. Included in the attachment is face sheet, statement, diagnosis of resident, summary of event, police case, nurses' notes, progress notes, skin assessment, SBAR (Situation, Background, Assessment and Recommendation), and in-service. Review of the SBAR communication form and progress note dated 08/03/2025 revealed in part, hematoma to right side of head above temple. Before getting resident up, CNA reported to this nurse that resident had a hematoma on right upper temporal area. Upon assessment, purplish raised bruising noted. Light blue bruising noted below area. Resident unable to let this nurse know how/when accident occurred.Resident family notified on 08/03/2025 at 10:55 a.m. and NP (Nurse Practitioner) notified on 08/03/2025 at 11:00 a.m.On 08/25/25 at 4:15 p.m., an interview was conducted with S8CNA, she reported she worked 11:00 p.m. - 7:00 a.m. on 08/02/2025. S8CNA stated she made her 1st round on Resident #4 with S9CNA. She stated when they entered the room she noticed a bruise to Resident #4's face and asked S9CNA what happened. S9CNA stated she did not know. S8CNA stated the resident did not complain of pain and could not tell them what had happened to her. S8CNA stated S9CNA reported it to nurse. She stated she did not know how Resident #4 had gotten the bruise. On 08/25/2025 at 4:30 p.m., during an interview with S9CNA, she stated she worked with S8CNA, on the night of 08/02/2025. S9CNA stated when they walked into Resident #4's room, S8CNA asked her what had happened to Resident #4's face. S9CNA, told her she did not know saying that was the first time she had seen it. S9CNA stated she reported to the nurse, S12LPN Licensed Practical Nurse), who was covering the unit at the time. S9CNA stated S12LPN's response was yeah ok. And nothing more was asked of her after that time from anyone at the facility.On 08/25/2025 at 6:33 p.m., 08/26/2025 at 9:14 a.m. and 11:44 a.m., attempts were made to contact S12LPN for phone interview, no answer, and unable to leave a message.On 08/26/2025 at 9:00 a.m., an interview was conducted with S5LPN who stated she was notified by S7CNA, of a bruise to the right side of Resident #4's face on the morning of 08/03/2025, before breakfast. She stated she did not report it to the administrative staff until later in the day. She stated she notified the NP and family mid/late morning of the bruise. She stated she did not know how the bruise occurred. She confirmed that no one had ever asked her to write a statement as to what had happened, nor had any administrative staff spoke to her about the incident. She confirmed she did not report the injury of unknown origin immediately.On 08/26/2025 at 10:12 a.m. and 08/27/2025 at 11:38 a.m., attempts were made to contact S11RN, but she did not answer. A message was left for a call back, but she had not returned the call prior to survey exit.On 08/26/2025 at 10:40 a.m., an interview was conducted with S3ADON (Assistant Director of Nursing), she confirmed the times of administration notifications for the incident for Resident #4 were: S11RN (Registered Nurse) notified S3ADON on 08/03/2025 at 6:43 p.m. S3ADON notified S2DON (Director of Nursing) on 08/03/2025 at 6:47 p.m. and S2DON notified S1ADM on 08/03/2025 at 6:51 p.m. On 08/27/2025 at 10: 15 a.m., an interview was conducted with S1ADM (Administrator). He reported he was responsible for submitting the critical incidents. He stated when a reportable occurs the administrative team discuss the incident, if it is reportable within 2 hours the clinical team will gather with S1ADM to discuss and review the policy for steps to take. He stated S2DON and S3ADON were responsible for gathering the information and investigate and interview the staff and obtain written statements. He stated when he was ready to submit the completed investigation he asked if there was any other witness statements or investigations before submitting. On 08/27/2025 at 10:55 a.m., an interview was conducted with S1ADM. S1ADM and surveyor reviewed the incident investigation and abuse policy for the facility, specific to the investigation procedure. S1ADM confirmed the time on the critical incident report occurred was 6:00 p.m. A review of the facility's abuse policy was reviewed specific to investigation with surveyor and S1ADM. S1ADM confirmed the policy stated the investigation process would include: #5. Complete a thorough investigation.#6. Every employee will be interviewed who was working on the specific hall/wing that the affected resident resided on. If the allegation occurred on a specific shift, all staff for the identified shift only will give a statement if indicated. He confirmed only one employee statement was included with the investigation, from S7CNA who reported the finding to S5LPN. S1ADM confirmed he did not speak to any other shift staff that had worked on 8/02/2025.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0628 (Tag F0628)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to notify the State Long Term care Ombudsman of a facility-initiated t...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to notify the State Long Term care Ombudsman of a facility-initiated transfer for 1 (#1) out of 4 (#1, #2, #3 and #4) residents sampled. Findings: A review of Resident #1's admission record revealed an initial admission date of 07/17/2025 and a discharged with return anticipated date of 07/27/2025 with diagnoses that included but were not limited to, depression, Dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. A review of Resident #1's nurse's notes revealed on 07/27/2025 at 9:30 a.m., Resident #1 transferred out of the facility to the hospital with transportation service via stretcher. A review of the emergency transfer log noting the Ombudsman notifications from July 2025 revealed Resident #1's transfer to the hospital on [DATE] was not identified on the list. On 08/25/2025 at 12:35 p.m., an interview and record review was conducted with S3ADON (Assistant Director of Nursing). S3ADON confirmed Resident #1 was transferred out of facility via a stretcher to the hospital on [DATE]. A review of the Emergency Transfer Log noting Ombudsman notification for July 2025 was conducted. S1ADON confirmed that the State Long-Term Care Ombudsman was not notified of Resident #1's facility-initiated transfer, and should have been.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to implement a comprehensive person-centered plan of care that identi...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to implement a comprehensive person-centered plan of care that identified the resident's need for 1:1 (one on one) supervision to manage behaviors for 2 (#1, #3) out of 4 (#1, #2, #3 and #4) sampled residents.Findings:Resident #1Review of Resident #1's EMR (electronic medical record) revealed the resident was readmitted to the facility on [DATE] with a diagnoses not limited to depression, unspecified Dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety.Review of Resident #1's EMR, progress notes revealed a progress note dated 07/26/2025 at 4:28 p.m.,. Resident #1 stated I'm going to go in my room and hang myself. At 4:30 p.m., S13LPN (Licensed Practical Nurse) notified S10NP (Nurse Practitioner) who gave an n/o (new order) for 1:1 r/t (related to) suicidal ideation. Resident #1 was placed immediately on 1:1 with S13LPN at nurses' station.Further review of the EMR progress notes revealed no evidence of 1:1 supervision of the resident from 07/26/2025 at 9:56 p.m. through 07/27/2025 at 9:30 a.m. Resident #1 was transferred out facility with transportation service to the behavioral hospital on [DATE] at 9:30 a.m. for behaviors.Resident #3Review of Resident #3's EMR revealed she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, bipolar disorder, current episode depressed, moderate; vascular dementia, severe, with psychotic disturbance, vascular dementia, severe, with agitation; major depressive disorder, recurrent, mild and anxiety disorder, unspecified.Review of Resident #3's EMR progress note's revealed on 08/09/2025 at 3:43 p.m., S10NP documented: Spoke with S4LPN on memory care unit. S10NP was advised that Resident #3 had become aggressive with Resident #2 and began striking Resident #2 in the face multiple times. Residents #1 and #3 were separated for safety. S10NP advised S4LPN to place Resident #3 on 1:1 and consult inpatient psych.Further review of Resident #3 EMR progress notes revealed no evidence of 1:1 supervision of the resident from 08/09/2025 at 3:20 p.m. until Resident #3 transferred out facility with transportation service to the behavioral hospital on [DATE] at 11:15 p.m.On 08/25/2025 at 12:35 p.m., an interview was conducted with S3ADON (Assistant Director of Nursing). She confirmed she was aware of the incident of suicidal ideation of Resident #1 and the resident to resident altercation with Resident #2 and Resident #3. S3ADON reviewed Resident #1's EMR and confirmed the nursing documentation for Resident #1's 1:1 supervision was not documented in the EMR from 07/26/2025 at 9:56 p.m. through 07/27/2025 at 9:30 a.m., before Resident #1 was transferred out of the facility to the behavioral hospital. S3ADON also reviewed Resident #3's EMR and confirmed there was documentation in the progress note from S10NP for 1:1 supervision, but there was no documentation one to one supervision had been implemented for Resident #3 after the incident on 08/09/2025 at 3:20 p.m. until Resident #3 was transferred out of facility.On 08/26/2025 at 9:42 a.m., an interview was conducted with S10NP, she confirmed she was notified by the facility of the suicidal ideation for Resident #1 on 07/26/25 and gave a telephone order to initiate 1:1 supervision and consult inpatient psych. She also confirmed she had given a telephone order on 08/09/2025 to S7LPN for 1:1supervision after the resident to resident altercation for Resident #3 with a consult for inpatient psych care.

Apr 2025 12 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Resident Rights (Tag F0550)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews, the facility failed to maintain dignity for 2 (Resident #27 and #61) out o...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews, the facility failed to maintain dignity for 2 (Resident #27 and #61) out of 29 sampled residents by failing to provide residents with metal utensils and non-disposable drinking cups during dining. Findings: A review of the facility's policy titled, Resident Rights Policy with a last review date of 12/2024, read in part, Each resident in this community has the right and will be afforded he right to a dignified existence, self-determination, and communication with an access to persons and services inside and outside the community without interference, coercion, discrimination or reprisal. Resident #27 A review of Resident #27's Quarterly MDS (Minimum Data Set) dated 11/13/2024 revealed he had a BIMS (Brief Interview for Mental Status) of 12, indicating his cognition was moderately impaired. On 04/13/2025 at 12:09 p.m., an observation was conducted of dining. Resident #27 was observed consuming lunch using plastic utensils and drinking out of a disposable cup. On 04/13/2025 at 12:25 p.m., an interview was conducted with Resident #27. He stated some of the residents have been receiving plastic utensils and disposable drinking cups for approximately two months now for all meals. He stated he does not like using plastic utensils and would rather use metal utensils and he would like to drink out of a non-disposable cup. Resident #61 A review of Resident #61's Quarterly MDS dated [DATE] revealed she had a BIMS of 15, indicating her cognition was intact. On 04/13/2025 at 1:17 p.m., an interview was conducted with Resident #61. She stated that she is the Resident Council President and all concerns are discussed during monthly meetings. She stated some residents have been receiving plastic utensils and disposable drinking cups for about two months now due to the kitchen not having enough metal utensils and non-disposable drinking cups. She stated she received plastic utensils and a disposable drinking cup for lunch today. She stated she would like to use metal utensils and a non-disposable cup for all meals. On 04/13/2025 at 1:24 p.m., an interview was conducted with S8DA (Dietary Aide). She confirmed that some residents received plastic utensils and disposable drinking cups for all meals due to the kitchen not having enough for all residents. On 04/13/2025 at 2:30 p.m., an interview was conducted with S7DM (Dietary Manager). He stated that plastic utensils and disposable drinking cups were used during meals for some residents. He stated the facility recently purchased and received non-disposable cups, metal silverware, and plates for the facility and that they do have enough metal utensils and non-disposable drinking cups for all residents. He confirmed that metal utensils and non-disposable cups should be used for all meals. On 04/13/2025 at 3:20 p.m., an interview with S1ADM (Administrator). He confirmed during all meal services for residents only metal utensils and non-disposable drinking cups should be provided to residents and not plastic utensils or disposable drinking cups.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Safe Environment (Tag F0584)

Could have caused harm · This affected 1 resident

Based on observations and interviews the facility failed to maintain 3 (#23, #41, and #75) of 3 (#23, #41, and #75) clients rooms and property observed for cleanliness. This had the potential to affec...

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Based on observations and interviews the facility failed to maintain 3 (#23, #41, and #75) of 3 (#23, #41, and #75) clients rooms and property observed for cleanliness. This had the potential to affect the census of 88 residents that reside in the facility. Findings: On 04/13/25 at 10:32 a.m., an observation in Resident #23 room revealed behind the head of her bed was covered with dust, Her Fan grill was covered with lint and her wheel chair spokes and frame was were covered with dust. At 10:40 a.m., an observation in Resident #41's room revealed the floor under her bed was covered with dust and dirt particles and her wheel chair spokes and frame were covered with dust. At 11:00 a.m., an observation in Resident #75's room revealed the floor under his bed was covered with dust and dirt particles and his wheel chair spokes and frame were covered with dust. On 04/14/25 at 3:00 p.m., an interview and observation of Resident #23, Resident #41 and Resident #75's rooms was conducted with S12 HKM (House Keeping Manager). S12HKM confirmed the floors under the resident's beds were dirty and their wheel chairs were dirty. She stated the House Keepers on the floor were required to clean the rooms daily and had not cleaned under the beds appropriately. She stated it was the C.N.A.'s (Certified Nursing Assistant's) responsibility to clean the resident's fan grill and wheel chairs. On 04/14/25 3:20 p.m., S13 HKD (House Keeping Director) observed and confirmed the house keeper had not effectively cleaned the floors under Resident #23, Resident #41, and Resident #75's beds. She also confirmed the fan and wheel chairs were dirty and needed to be cleaned by the C.N.A.'s.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

PASARR Coordination (Tag F0644)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to refer a resident with a diagnosed mental disorder to the appropriat...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to refer a resident with a diagnosed mental disorder to the appropriate state-designated authority for Level II PASARR (Preadmission Screening and Resident Review) evaluation and determination for 1 (Resident #16) of 1 (Resident #16) residents investigated for PASARR in a final sample of 29 residents. Findings: Review of Resident #16's electronic medical record (EMR) revealed she was admitted to the facility on [DATE] with diagnoses that included in part, alcohol induced dementia with an onset date of 01/02/2025, schizoaffective disorder, anxiety, restlessness and agitation with an onset date of 12/27/2025. Review of Resident #16's Level I PASARR dated 05/25/2012 revealed part A - Mental illness, Question #1 Does the individual have indications of or a diagnosis of a major mental illness as defined in the D8M-IVR (Advance Directive for Mental Health Treatment), limited to schizophrenia, mood disorder, severe anxiety disorder, personality disorder, other psychotic disorder or another mental disorder that may lead to a chronic disability? Answer checked was No. Further review of Resident #16's records revealed no evidence that Level II PASARR had been submitted to the appropriate state-designated authority after Resident #16 had newly identified mental disorder of alcohol induced dementia, with an onset date of 01/02/2025 and schizoaffective disorder with an onset date of 12/27/2025. On 04/14/2025 at 2:54 p.m., an interview was conducted with S5SSD (Social Services Director), she confirmed Resident #16's PASARR was dated 05/25/2012. On 04/14/2025 at 4:56 p.m., an interview was conducted with S4ADON (Assistant Director of Nursing), she confirmed Resident #16 had a new diagnoses of schizoaffective disorder and alcohol induced dementia since admission to the facility on [DATE]. S4ADON further confirmed a request for Level II PASARR was not resubmitted since the new diagnoses and should have been resubmitted.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to follow physician's orders for 1 (#46) resident in a sample of 29 r...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to follow physician's orders for 1 (#46) resident in a sample of 29 residents. The deficient practice had a potential to affect a total census of 88 residents. Findings: Resident #46 admitted to the facility on [DATE] with diagnoses that included in part, but were not limited to metabolic encephalopathy, major depressive disorder, bipolar disorder, and anxiety disorder. A review of Resident #46's Care Plan which included a focus that read, the resident has mood problem disease process dementia, bipolar, depression, anxiety. The focus interventions included in part, give anti-anxiety medications ordered by M.D. (Doctor of Medicine). A review of Resident #46's medical record revealed an active physician's order dated 1/06/2025 that read Buspirone oral tablet 10mg give one tablet in the evening for anxiety disorder. A review of Resident #46's EMAR (Electronic Medication Administration Record) for February 2025 through April 14, 2025 revealed the resident was administered Buspirone 10 mg every evening. A review of Resident #46's medical record revealed a physician progress note dated 02/26/2025 which read in part, Treatment plan: will d/c (discontinue) Buspar (Buspirone). Further review of Resident #46's scanned documents revealed a handwritten physician order dated 02/26/2025 which read, d/c Buspar. On 04/15/2025 at 8:47 a.m., a review of Resident #46's medical record and interview was conducted with S3ADON. She confirmed the resident had an active order dated 01/06/2025 that read Buspirone 10 mg give 1 tablet by mouth in the evening for anxiety. S3ADON confirmed the physician's progress note dated 02/26/2025 read d/c Buspar. She also confirmed a handwritten order dated 02/26/2025 that read d/c Buspar. S3ADON reviewed the MARs for February, March, and April 2025 and confirmed the Resident #46 had received Buspirone 10mg every evening and the physician order was not discontinued and it should have been.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility failed to ensure routine drugs and biologicals were available f...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility failed to ensure routine drugs and biologicals were available for administration for 1 (#46) resident in a sample of 29 residents. The deficient practice had a potential to affect a total census of 88 residents. Findings: Resident #46 was admitted to the facility on [DATE] with diagnoses that included in part, but were not limited to metabolic encephalopathy, major depressive disorder, bipolar disorder, and anxiety disorder. A review of Resident #46's Care Plan which included a focus that read, the resident has mood problem disease process dementia, bipolar, depression, anxiety. The focus interventions included in part, give anti-anxiety medications ordered by M.D. (Doctor of Medicine). A review of Resident #46's medical record revealed a physician's order dated 12/12/2024 that read, Lorazepam oral tablet 0.5 mg (milligram) give 0.5 mg by mouth three times a day related to anxiety disorder. A review of Resident #46's EMAR (Electronic Medication Administration Record) revealed Lorazepam oral tablet 0.5 mg give 0.5 mg by mouth three times a day was scheduled for 9:00 a.m., 1:00 p.m., and 5:00 p.m. Further review revealed from 04/13/2025 at 9:00 a.m. through 04/14/2025 at 1:00 p.m. (a total of 5 doses) was coded a 6 which indicated Other - See Progress Notes. A review of Resident #45's medical record revealed the following nursing progress notes titled Orders - Administration Notes read the following: On 04/13/2025 at 9:14 a.m., Lorazepam Oral Tablet 0.5 mg Give 0.5 mg by mouth three times a day related to anxiety disorder. None available. On 04/13/2025 at 1:06 p.m., Lorazepam Oral Tablet 0.5 mg Give 0.5 mg by mouth three times a day related to anxiety disorder. None available. On 04/13/2025 at 6:33 p.m., Lorazepam Oral Tablet 0.5 mg Give 0.5 mg by mouth three times a day related to anxiety disorder. None on hand, waiting on pharmacy delivery. On 04/14/2025 at 1:36 p.m., Lorazepam Oral Tablet 0.5 mg Give 0.5 mg by mouth three times a day related to anxiety disorder. Non available. On 04/14/2025 at 1:27 p.m., an interview was conducted with S11LPN (Licensed Practical Nurse) who confirmed Resident #46 did not have Lorazepam 0.5 mg available for administration. On 04/14/2025 at 3:20 p.m., a review of Resident #46's medical record and interview was conducted with S3ADON (Assistant Director of Nursing) who confirmed the resident had a physician's order for Lorazepam 0.5 mg give three times a day. S3ADON confirmed Resident #46's EMAR and nursing progress notes indicated the resident did not receive Lorazepam 0.5mg from 04/13/2025 at 9:00 a.m. through 04/14/2025 at 1:00 p.m. She confirmed the medication was not available for administration and it should have been.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

Based on observation and interview, the facility failed to ensure all drugs and biologicals were stored in accordance with currently accepted professional practice by failing to ensure the medication ...

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Based on observation and interview, the facility failed to ensure all drugs and biologicals were stored in accordance with currently accepted professional practice by failing to ensure the medication cart was locked when unattended for 1 Medication Cart (Med Cart A) out of 3 (Med Cart A, Med Cart B, Med Cart C) medication carts observed. The deficient practice had the potential to affect a total of 88 residents in the facility. Findings: On 04/15/2025 at 8:27 a.m., an observation was made of Med Cart A that was unattended and unlocked. Further observation revealed there was no nurse located on the hall. On 04/15/2025 at 8:29 a.m., an interview was conducted with S9LPN (Licensed Practical Nurse) upon her return to Med Cart A. She confirmed she had left the medication cart unlocked while unattended. S9LPN confirmed she should have locked the med cart prior to leaving the cart.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Menu Adequacy (Tag F0803)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews the facility failed to serve 1 (Resident #23) of 1 (Resident #23) resident ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews the facility failed to serve 1 (Resident #23) of 1 (Resident #23) resident investigated for food, her recommended diet as required by her diagnosis of gastroenteritis and her assessed dislikes. This had the potential to affect the 88 residents that consumed food out of the kitchen. Findings: Record review revealed Resident #23 was admitted to the facility on [DATE] with diagnosis in part, Gastroparesis, Diarrhea, Severe Morbid obesity, Chronic Obstructive Pulmonary Disease, Anxiety Disorder, Bipolar Disorder, Obstructive Sleep Apnea, Gastro Esophageal Reflux Disease. She had a BIMS (Brief Interview for Mental Status) of 15, meaning she was cognitively intact. Record review of Resident #23 care plan dated 06/13/2024 read in part, Goal: my dietary preferences will be honored . Foods I dislike are: .Hamburger Patties. Record review of Resident #23 gastroenterologist progress notes dated 09/06/2024 read in part, She needs to be on a gastroparesis diet . Record review of Resident #23's current diet order dated 09/25/2024 read in part, Heart Healthy low fiber diet .NO Fruit Punch Record review of the diet recommendations posted in the kitchen for the staff to follow for Resident #23 gastroparesis diet read in part, Cooks: Resident #23 has a special diet, we have to follow it. What not to eat, Fried or greasy foods, Sausage, any raw vegetables, cooked vegetables with skin, Nuts and seeds, Potato Skins, Vegetables, peppers, potatoes should be well cooked and peeled. Record review of Resident #23 Registered Dietician (RD) notes dated 04/02/2025 read in part, RD was requested to come to resident's room by resident. She became very agitated as she showed her meal tickets and receipts. Stated she was not getting what she should get and stated that it is laws to have food listed on meal ticket that was to be served . Record review of Resident #23's Meal Ticket that is put on her tray, dated 04/14/2025 dinner, and 04/15/2025 Breakfast .read, No raw vegetables with seeds or skin . On 04/14/2025 at 9:35 a.m., Resident #23 stated she was served dinner last night at 6:30 p.m., a hamburger, with a sesame seeds bun, lettuce, tomatoes that had the skin and seeds, and a pickle that had seeds. She stated also on the plate was French fries with the skin, She stated she was not supposed to get hamburgers and any vegetables that had the skin still on or seeds. She stated she saved her plate and put it in her refrigerator. An observation of a plate in the resident's refrigerator revealed, a hamburger patty on a sesame seed bun, tomatoes with skin and seeds, lettuce, and French fries with the skin. On 04/14/2025 at 10:33 a.m., an interview with S7DM (Dietary Manager). S7DM confirmed that Resident #23 had a diagnosis of gastroparesis and was on a special diet. He stated the resident could not have raw vegetables and the staff should remove the skin and seeds from the tomatoes, peppers, potatoes, and zucchini. He stated he had the resident's diet with the things she can and cannot have posted in the kitchen for the cooks to refer to. He stated the resident's likes and dislikes have been assessed and are printed on her meal ticket and some are on her physician orders. On 04/14/2025 at12:50 p.m., an observation was made of Resident #23 eating her lunch. On the tray was chopped chicken with a gold grease-like substance around the edges of the chicken, mash potatoes covered with a cream gravy, fruit punch, cooked carrots, sugar cookie, and prune juice. Resident #23 stated she did not want fruit punch on her tray and said the chicken was greasy. On 04/14/2025 at 2:00 p.m., an interview with S7DM revealed the red drink on the Resident #23's lunch tray was punch. On 04/15/2025 at 8:27 a.m., an observation was made of Resident #23 eating her breakfast. On her tray was scrambled eggs with sausage and a red bell pepper with the skin. Resident #23 stated she did not like the sausage because it was spicy and greasy. She further revealed she could not eat the red bell peppers because it still had the skin. On 04/15/2025 at 2:13 p.m., S7DM was informed of the meals Resident#23 was served on 04/13/2025 for dinner, on 04/14/2025 for lunch, and on 04/15/2025 for breakfast. He confirmed the kitchen staff were not following the resident's recommended diet and dislikes.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Respiratory Care (Tag F0695)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #30 Review of Resident #30's electronic medical record revealed she was admitted to the facility on [DATE] with diagnos...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #30 Review of Resident #30's electronic medical record revealed she was admitted to the facility on [DATE] with diagnoses including chronic respiratory failure with hypoxia, pulmonary edema, shortness of breath, pleural effusion, and malignant neoplasm of unspecified part of unspecified bronchus or lung. Review of Resident #30's current physician's orders read in part: Oxygen at 3L (liters) per Nasal Cannula continuously, and Ipratropium-Albuterol Inhalation Solution 0.5-2.5 mg (milligrams)/ml (milliliters) 1vial inhaled orally three times a day. On 04/13/2025 at 10:30 a.m., an observation of Resident #30's oxygen concentrator revealed a humidifier with no date. There was no date on the nasal cannula oxygen tubing. Resident #30's nebulizer mask was laying on the table next to the bed. It was dated 03/24/2025 and was not stored in a bag. On 04/13/2025 at 11:45 a.m., an observation of Residents #30's oxygen concentrator and nebulizer mask was conducted with S6LPN (Licensed Practical Nurse). She confirmed the nasal cannula oxygen tubing was not dated, and the humidifier was not dated. S6LPN confirmed they should have been dated and changed every week. S6LPN confirmed Resident #30's nebulizer mask was labeled 03/24/2025 and was not stored in a bag. She stated the nebulizer mask should be changed weekly and stored in a bag when not in use. Based on observation, interview, and record review the facility failed to ensure the resident's respiratory equipment was labeled, dated ,and stored properly for 4 (Resident #20, #30, #63 and #237) out of 4 (Resident #20, #30, #63 and #237) sampled residents reviewed for respiratory care. Findings: Resident #20 Review of Resident #20's electronic medical record revealed she was admitted to the facility on [DATE] with diagnoses including acute and chronic respiratory failure, chronic obstructive pulmonary disease and SOB (shortness of breath). Review of Resident #20's current physician's orders that read in part, 03/31/2025 - Oxygen Tubing - Change weekly every night shift every Thursday; 03/31/2025 - Oxygen (O2) - clean O2 concentrator filter with water and allow to air dry weekly every night shift every Thursday; 03/31/2025 - Oxygen - Change nebulizer and nebulizer tubing weekly every night shift every Thursday; 03/31/2025 - OXYGEN 2L (liters) via N/C (nasal cannula) - every shift; 03/31/2025 - Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG (milligrams)/3ML (milliliters) give 3 ml inhale orally every 6 hours for SOB/Wheezing. On 04/13/2025 at 9:58 a.m., an observation of Resident #20's oxygen concentrator revealed a humidifier dated 04/04/2025 and there was no date or label on the O2 tubing. On 04/13/2025 at 12:00 p.m., an observation of Residents #20's oxygen was conducted with S6LPN. She confirmed the tubing for Resident #20's oxygen was not dated. S6LPN confirmed the tubing should have been dated and changed every week. Resident #63 Review of Resident #63's electronic medical record revealed she was admitted to the facility on [DATE] with diagnosis including chronic kidney disease. Review of Resident #63's current physician's orders that read in part, 03/31/2025 - Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML 3 ml inhale orally every 6 hours as needed for SOB and 04/14/2025 - Oxygen - Change nebulizer and nebulizer tubing weekly every night shift every Thursday. On 04/13/2025 at 10:20 a.m., an observation of Resident #63's nebulizer tubing/mask in a storage bag with no label or date in the nebulizer supplies or storage bag. On 04/13/2025 at 12:05 p.m., an observation of Resident #62's nebulizer tubing and mask was conducted with S6LPN. S6LPN confirmed Resident #63's nebulizer tubing, and mask, and the storage bag was not dated. She confirmed the tubing should have been dated when it is changed. Resident #237 Review of Resident #237's electronic medical record revealed she was admitted to the facility on [DATE] with diagnoses including Heart failure, shortness of breath, obstructive sleep apnea. Review of Resident #63's current physician's orders that read in part,0 4/07/2025 - Oxygen Tubing - change weekly every night shift every Thursday; 04/07/2025 - Oxygen - clean O2 concentrator filter with water and allow to air dry weekly every night shift every Thursday; 04/07/2025 - Oxygen - Change nebulizer and nebulizer tubing weekly every night shift every Thursday; 04/07/2025 - OXYGEN 2L via Nasal cannula every shift. On 04/13/2025 at 10:09 a.m., an observation of Resident #237's oxygen tubing revealed there was no label or date on oxygen tubing and O2 was patent at 2L/NC without a humidifier. On 04/13/2025 at 12:05 p.m., an observation and immediate interview of Resident #237's oxygen was conducted with S6LPN. S6LPN confirmed the tubing for his oxygen was not dated and that there was no humidifier in use with the concentrator to administer oxygen to resident. She confirmed the tubing should have been dated when changed and changed every week. On 04/14/2025 at 2:30 p.m., an interview was conducted with S3ADON, she confirmed oxygen should be administered using humidified oxygen and the tubing for the oxygen and nebulizer should be changed every week on Thursday's and documented on the MAR (Medication administration record). She confirmed the oxygen tubing change for Resident's #20, #63 and #237 was not documented on their MAR.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Drug Regimen Review (Tag F0756)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #58 Review of resident #58's medical record revealed resident was admitted to the facility on [DATE] with diagnoses inc...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #58 Review of resident #58's medical record revealed resident was admitted to the facility on [DATE] with diagnoses including morbid obesity, mild cognitive impairment, insomnia, anxiety disorder, major depressive disorder, apraxia, unspecified anemia, and frontal lobe and executive function deficit. Review of resident #58's June 2024 physician's orders revealed: Sertraline HCl oral tablet 100 mg (milligrams), give 1 tablet by mouth one time a day for depression related to major depressive disorder; give with 50 mg daily to equal 150 mg; (start date 06/19/2024) Sertraline HCl oral tablet 50 mg, give 1 tablet by mouth one time a day for depression related to major depressive disorder; give with 100 mg to equal 150 mg daily; (start date 06/19/2024) Trazadone HCl oral tablet 50 mg, give 1 tablet by mouth at bedtime for sleep related to major depressive disorder; insomnia; (start date 06/18/2024) Wellbutrin SR oral tablet extended release 12 hour, give 100 mg by mouth at bedtime for depression related to major depressive disorder; (start date 06/18/2024) Buspirone HCl oral tablet 5 mg, give 1 tablet by mouth two times a day for anxiety related to anxiety disorder (start date 06/18/2024) Review of resident #58's April 2025 physician's orders revealed: Sertraline HCl oral tablet 100 mg (milligrams), give 1 tablet by mouth at bedtime for depression related to major depressive disorder; (start date 07/01/2024) Wellbutrin SR oral tablet extended release 12 hour, give 100 mg by mouth at bedtime for depression related to major depressive disorder; (start date 06/18/2024) Buspirone HCl oral tablet 5 mg, give 2 tablets by mouth two times a day for anxiety related to anxiety disorder; (start date 11/29/2024) Review of the facility's Monthly Medication Reviews (MMR) from 03/15/2024 through 03/27/2025 for resident #58 revealed the consulting pharmacist had sent lsf (letter sent to facility) with recommendations to the physician to evaluate the routine use and consider gradual dose reduction for resident #58's psychoactive medications on 06/21/2024 and 10/28/2024. Review of resident #58's Monthly Medication Review (MMR), conducted by the consulting pharmacist on 06/21/2024, read: Please evaluate the routine use of the following psychoactive medications and consider a dose reduction. If a dose reduction is not desired, please indicate below a rational for the continued use. This resident is prescribed the following psychoactive medication (with corresponding start dates). Buspirone 5 mg bid (twice daily) (06/24/2024) Sertraline 150 mg qd (every day) (06/24/2024) Trazadone 50 mg hs (at hour of sleep/bedtime) (06/24/2024) Wellbutrin SR 100 mg hs (06/24/2024) Please also evaluate the concurrent use of two or more antidepressants Review of resident #58's Monthly Medication Review (MMR), conducted by the consulting pharmacist on 10/28/2024, read: Please evaluate the routine use of the following psychoactive medications and consider a dose reduction. If a dose reduction is not desired, please indicate below a rational for the continued use. This resident is prescribed the following psychoactive medication (with corresponding start dates). Sertraline 100 mg hs (07/24/2024) Wellbutrin SR 100 mg hs (08/24/2024) Please also evaluate the concurrent use of two or more antidepressants Review of the Pharmaceutical Consultant Reports, dated 06/21/2024 and 10/28/2024, revealed neither had a signature or any comments from the Director of Nursing (DON) or physician, to indicate the pharmacist's suggestions had been reviewed and considered. On 04/15/2025 at 9:48 a.m., S3ADON (Assistant Director of Nursing) confirmed that Pharmaceutical Consultant Reports, dated 06/21/2024 and 10/28/2024, had no comments or physician signature. S3ADON verified that the reports had not been submitted to resident #58's physician for review. Based on record review and interview, the facility failed to have a resident's physician respond timely to a consulting pharmacist's recommendations for 4(#11, #27, #46, #58) of 5 (#11, #23, #27, #46, #58) residents reviewed for unnecessary medications. The facility had a total census of 88. Findings: Resident #11 Review of Resident #11's medical record revealed the resident was admitted to facility on 09/17/2021 with diagnoses including diabetes mellitus, bipolar, anxiety, schizoaffective disorder, major depressive disorder and dementia. Review of physicians' orders for April 2025 included the following order: 06/06/2024 - Seroquel 400mg orally every night. Review of the facility's Monthly Medication Review (MMR) forms from 05/2024 to 03/27/2025 for Resident #11 revealed the consulting Pharmacist wrote: 10/28/2024- lsf (letter sent to Facility). Review of a GDR (Gradual Dose Reduction) form dated 10/28/2024 revealed a recommendation for dose reduction for Seroquel 400mg hs (hour of sleep) (ordered 06/2024). The form had no documented signatures by the DON (Director of Nursing) or physician that the recommendation was reviewed. On 04/15/2025 at 8:47 a.m., an interview was conducted with S4ADON (Assistant Director of Nursing). She confirmed the GDR form had not been reviewed by the facility's DON or physician after receiving the recommendation from the pharmacist. Resident #27 A review of Resident #27's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included in part, dementia, anxiety disorder, bipolar disorder, and major depressive disorder. A review of Resident #27's medical record revealed the following physician's orders in part, 08/06/2024 Divalproex sodium 500 mg give 1 tablet by mouth at bedtime for mood and 02/26/2025 Seroquel XR Extended Release 24 Hour give 250 mg by mouth at bedtime related to dementia. A review of the facility's Monthly Medication Review (MMR) form from 10/27/2024 and 12/20/2024 for Resident #27 revealed the consulting Pharmacist wrote: 10/27/2024 lsf psych and 12/20/2024 lsf Seroquel dx. A review of GDR dated 10/28/2024 revealed a recommendation for a dose reduction for Divalproex DR 500mg hs (8/24) and Seroquel XR 150mg hs (8/24). The form had no documented signatures by the DON (Director of Nursing) or physician, that the recommendations was reviewed. A review of GDR dated 12/20/2024 revealed a request for an appropriate diagnosis for the use of Seroquel XR 200mg hs. The following diagnoses are considered appropriate indicated a check mark for mood disorder (bipolar disorder). The form had no documented signatures by the DON (Director of Nursing) or physician, that the recommendations was reviewed. Resident #46 Review of Resident #46's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included in part, but were not limited to metabolic encephalopathy, major depressive disorder, bipolar disorder, and anxiety disorder. A review of Resident #46's medical record revealed the following physician's orders in part, 12/12/2024 that read, Lorazepam oral tablet 0.5 mg give 0.5 mg by mouth three times a day related to anxiety disorder. 12/06/2024 Venlafaxine ER (Effexor XR) 75mg give 1 tablet by mouth in the evening for major depressive disorder. A review of the facility's Monthly Medication Review (MMR) form from 10/27/2024 and 02/24/2025 for Resident #46 revealed the consulting Pharmacist wrote: 10/27/24 - lsf psych and 2/24/25 lsf 2aa. A review of GDR (gradual dose reduction) for 10/28/2024 revealed a recommendation for a dose reduction for Effexor XR 75mg hs (hour of sleep) (6/24) and Lorazepam 0.5mg q (every) 8hrs (hours) prn (as needed) anxiety (6/24). The form had no documented signatures by the DON (Director of Nursing) or physician, that the recommendations was reviewed. A review of GDR for 02/24/2025 revealed a recommendation to evaluate and verify the desire to utilize the following psychotropic medications: Lorazepam 0.5mg tid (three times a day) and Buspirone 10mg qpm (every evening). The form had no documented signatures by the DON (Director of Nursing) or physician, that the recommendations was reviewed. On 04/14/2025 at 3:20 p.m., an interview was conducted with S3ADON who confirmed the GDRs for Resident #27 and #46 had not been reviewed by the facility DON or physician after receiving the recommendation from the pharmacy.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

Based on observation, and interview, the facility failed to store food in accordance with professional standards for food service, and ensure sanitary conditions were maintained in the kitchen as evid...

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Based on observation, and interview, the facility failed to store food in accordance with professional standards for food service, and ensure sanitary conditions were maintained in the kitchen as evidenced by: 1. Food storage: A. Refrigerated items: 1. One container of peaches not labeled with the date it had been prepared. 2. Two containers of brown gravy with meat not labeled with the date it had been prepared. 3. One container of white gravy not labeled with the date it had been prepared. 4. One bag of pepper jack cheese not labeled with the date it had been opened. 5. One bag of sausage not labeled with the date it has been opened. B. Freezer items: 1. One bag of fries opened and not labeled with the date it had been opened or placed in a closed bag. 2. One bag of mushrooms opened and not labeled with the date it had been opened or placed in a closed bag. C. Walk-in refrigerator items: 1. Two red bell peppers with texture changes in the refrigerator indicated the items were spoiled. This deficient practice had the potential to affect the 88 residents who consumed food from the kitchen. Findings: A review of the facility's policy titled, Labeling and Dating Foods (Date Marking) undated, read in part, All foods stored will be properly labeled according to the following guidelines. The policy also indicated general guidelines, once opened all ready to eat, potentially hazardous food will be re-dated . On 04/13/2025 at 10:00 a.m., an observation and interview was conducted with S7DM (Dietary Manager). S7DM stated any food items prepared in a container or bag should have been labeled with the preparation date. He stated the items in the freezer should have been in a sealed bag and labeled with the open date. He stated any vegetables with texture changes should have been discarded.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0727 (Tag F0727)

Could have caused harm · This affected most or all residents

Based on record review and interviews, the facility failed to ensure an RN (Registered Nurse) provided services for at least 8 consecutive hours a day. Findings: Review of the facility's PBJ (Payroll...

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Based on record review and interviews, the facility failed to ensure an RN (Registered Nurse) provided services for at least 8 consecutive hours a day. Findings: Review of the facility's PBJ (Payroll Based Journal) RN Coverage Report for 01/01/2025 to 03/28/2025 revealed no RN hours for 01/01/2025, 01/04/2025, and 01/05/2025. Review of RN clock in hours for 01/01/2025 to 03/28/2025 revealed there were no RN hours for 01/01/2025, 01/04/2025, and 01/05/2025. On 04/14/2025 at 12:30 p.m., an interview was conducted with S1ADM (Administrator). S1ADM acknowledged the PBJ RN Coverage report for 01/01/2025 to 03/28/2025 revealed on 01/01/2025, 01/04/2025, and 01/05/2025 there was not 8 hours of RN coverage on those dates. He stated the RN scheduled to work did not show up for her scheduled shifts. He stated he was unaware at the time it occurred and did not find out about it until after the fact. S1ADM stated they must have 8 hours of RN coverage daily. On 04/15/2025 at 10:00 a.m., an interview and review of RN timesheets was conducted with S10HR (Human Resources). She stated 01/01/2025 was a holiday, and confirmed there was no indication that an RN was on staff for 8 hours that day. She stated a salaried RN may have worked, but would be unable to provide any documentation that showed they were clocked in for 8 hours. She reviewed the RN timesheets and confirmed that on 01/04/2025 and 01/05/2025 there was no RN hours for those dates. She reviewed the schedule and confirmed the scheduled RN had called in on both of those dates. On 04/15/2025 at 11:40 a.m., an interview was conducted with S2DON (Director of Nursing). He confirmed there was not 8 hours of RN coverage provided on 01/01/2025, 01/04/2025, and 01/05/2025. He stated the scheduled RN did not work her scheduled shift on those days. He further stated he was not aware at the time this occurred and didn't find out about it until he returned to work and reviewed the schedule.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0865 (Tag F0865)

Could have caused harm · This affected most or all residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure an effective Quality Assurance and Performance Improvement (...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure an effective Quality Assurance and Performance Improvement (QAPI) program was developed, implemented, and/or maintained in an effective and comprehensive manner. The facility failed to maintain documentation of evidence of its ongoing facility QAPI program. This deficient practice has the potential to affect 88 residents residing in the facility. Findings: Review of a facility policy on 04/15/2025 at 3:00 PM titled, QAPI Policy with a revised date of 01/2024, revealed the following in part, the QAPI program takes a systematic, comprehensive and data-driven approach to maintaining and improve safety and quality while involving all caregivers in practical and creative problem solving. The community QAPI program achieves the following: monitor quality/performance, find opportunities for improvement, improve performance, achieve resident/family desired outcomes, meet regulatory requirements, understand the CMS (Center for Medicare and Medicaid services) survey process and regulations, provide a QAPI path to correcting issues. The QAPI program consist of monthly/quarterly meetings, daily quality activities, QAPI tasks and performance improvement plans. On 04/15/2025 at 1:30 p.m., a review of the facility's QAPI binder was conducted. There was no evidence of any monitoring for quality performance On 04/15/2025 at 1:40 p.m., a [NAME] interview was conducted with S1ADM (Administrator) and S2DON (Director of Nursing) to determine the QAPI monitoring process for the facility. S1ADM reported a QAPI meeting was held every morning, and that was how the facility monitored for quality assurance. S2DON confirmed he did not have any documentation to show monitoring of facility QAPI concerns.

Feb 2025 1 deficiency

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Grievances (Tag F0585)

Could have caused harm · This affected multiple residents

Based on record reviews and interviews, the facility failed to resolve a grievance within 5 working days per facility grievance policy for 1 (#3) out of 1 (#3) resident reviewed for personal property....

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Based on record reviews and interviews, the facility failed to resolve a grievance within 5 working days per facility grievance policy for 1 (#3) out of 1 (#3) resident reviewed for personal property. Findings: Review of the facility's policy titled Resident Grievance Policy and Procedure with no revision date revealed in part; The response will be given to the person initiating the grievance within 5 working days of the findings and along with any corrective action accomplished. Review of Resident #3's electronic medical record revealed an admission date of 01/03/2022 with diagnoses that included acquired absence of left leg above the knee, dementia, and morbid obesity. Review of facility grievances revealed a grievance filed regarding Resident #3 concerning odor and a soiled brief. The grievance was dated 01/07/2025. The resolved date was 01/28/2025. On 02/26/2025 at 4:00 PM, concurrent records review and interview was conducted with SDON (Director of Nursing). S2DON reviewed the grievance dated 01/07/2025 and acknowledged the grievance had not been resolved until 21 days later on 01/28/2025. He reviewed the facility policy for resident grievances and agreed the grievance had not been resolved in a timely manner or within 5 working days as stated and should have been. On 02/26/2025 at 4:30 PM, concurrent records review and interview was conducted with S1Adm (Administrator). S1Adm reviewed the grievance dated 01/07/2025 and acknowledged the grievance had not been resolved until 21 days later on 01/28/2025. He reviewed the facility policy for resident grievances and agreed the grievance had not been resolved in a timely manner or within 5 working days as stated and should have been.

Feb 2025 3 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected 1 resident

Based on record review and interview, the facility failed to ensure the resident's Minimum Data Set (MDS) was completed accurately for 1 (#1) out of 9 (#1, #2, #3, #4, #5, #6, #7, #8, #9) sampled resi...

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Based on record review and interview, the facility failed to ensure the resident's Minimum Data Set (MDS) was completed accurately for 1 (#1) out of 9 (#1, #2, #3, #4, #5, #6, #7, #8, #9) sampled residents. The deficient practice had the potential to effect a total census of 82. Findings: Review of Resident #1's electronic clinical record revealed and admission date of 06/03/2024 with diagnoses that included in part atrial fibrillation, vascular dementia, and anxiety disorder. Review of Resident #1's December 2024 MAR (Medication Administration Record) revealed the resident received Eliquis (an anticoagulant) and Trazodone (an antidepressant). Further review of the December 2024 MAR failed to reveal Resident #1 received any antibiotics. Review of the Resident #1's quarterly MDS (Minimum Data Set) dated 12/17/2024 revealed under Section N-Medications, the resident was not indicated for the use of an anticoagulant or for the use of an antidepressant. Further review of Section N-medications revealed the resident was indicated for antibiotic use. On 02/12/2025 at 9:00 AM, a concurrent records review and interview was conducted with S4MDS (Minimal Data Set). S4MDS viewed Resident #1's December 2024 MAR and confirmed the resident had received an anticoagulant, an antidepressant, and did not receive any antibiotics. S4MDS then reviewed Resident #1's 12/17/2024 quarterly MDS, Section N. S4MDS confirmed she failed to indicate the resident had received the anticoagulant and antidepressant and incorrectly indicated the resident received an antibiotic.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure the residents received all care and treatment in accordance ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure the residents received all care and treatment in accordance with professional standards of practice as evidenced by nurses failing to complete neurological checks on a resident with an unwitnessed fall for 2 (Resident #1 and Resident #3) out of 3 (Resident #1, Resident #2, Resident #3) residents reviewed for accident/hazards. Findings: Review of the facility policy titled, Neurologic Assessment, with an approved date of 12/2024 read in part: 1. Neurological assessments will be completed b. following an unwitnessed fall . 3. Neurological assessments (neuro checks) will be done every 15 minutes for the first hour, then every 30 minutes times 2, every hour times 6, every 4 hours times 4, every 8 hours times 6 for a total of 72 hours. a. if the schedule should be interrupted due to transfer to hospital, the schedule will be resumed upon return from the hospital. Resident #1 Review of the Resident #1's incident report dated 01/14/2025 at 9:50 PM, revealed the resident was found on the floor in his room, with visible blood. Resident had a laceration to the face, mental status was alert, oriented to person. Predisposing physiological factors revealed behaviors. Immediate action taken: Resident taken to hospital? No. Review of Resident #1's electronic clinical record (ECR) revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included vascular dementia. Review of Resident #1's quarterly MDS (Minimum Data Set) dated 12/17/2024 revealed the resident's BIMS (Brief interview for mental status) score was 06 for being severely impaired for cognition. Review of Resident #1's neurologic checks for 72 hours post fall revealed resident refused on 01/14/2025 at 9:50 PM and 10:05 PM. From 01/14/2025 at 10:20 PM to 01/15/2025 at 5:35 AM resident was at hospital. 01/16/2025 there were no documented neuro checks at 1:35 PM and 9:35 PM. On 01/17/2025 there were no documented neurologic checks document at 1:35 PM and 9:35 PM. Review of Resident #1's progress notes revealed there was no documentation of incident or the resident's mental status from 01/16/2025 at 3:59 AM until 01/16/2025 at 2:35 PM when the resident refused a shower. Further review revealed a note revealed on 01/18/2025 at 12:02 PM, patient continued to complain of pain, x-ray done awaiting results. On 02/11/2025 at 1:30 PM, a record review and interview with S3ADON was conducted. She confirmed Resident #1's neurologic checks for a fall on 01/14/2025 were incomplete. She stated the neuro checks should have completed for 72 hours after the resident had an unwitnessed fall. Resident #3 Review of Resident #3's incident report dated 02/02/2025 at 8:20 PM, revealed the resident was found on the floor in her room, with visible blood. Resident was going to the dining room and slipped. Denied hitting her head, noted right side weakness, unable to lift right arm or right leg. Mental status was not answered post incident injury report with no injuries observed. Predisposing situation factors revealed ambulating without assist. Immediate action taken: Resident taken to hospital? No Review of Resident #3's ECR revealed the resident was admitted to the facility on [DATE] with a diagnosis including Alzheimer's disease. Review of Resident #3's quarterly MDS dated [DATE] revealed the resident's BIMS score was 09 for being moderately impaired for cognition. Review of Resident #3's neurologic checks for 72 hours post fall revealed the resident was in the hospital from [DATE] at 12:05 AM to 02/0/2025 at 12:05 PM. On 02/05/2025 there were no documented neuro checks at 8:05 PM and on 02/06/205 at 4:05 AM. On 02/12/2025 at 9:30 AM, an interview was conducted with S2ADON. S2ADON reviewed the resident neuro checks from the resident's fall on 02/02/2025 and confirmed they were incomplete.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected multiple residents

Based on record reviews and interview the facility failed to ensure the allegation of abuse/neglect or injury of known origin were reported immediately, but not later than 2 hours after the allegation...

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Based on record reviews and interview the facility failed to ensure the allegation of abuse/neglect or injury of known origin were reported immediately, but not later than 2 hours after the allegation is made, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury and reported the results of all investigations, and; report the results of all investigations to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken for 9 (Resident #1 - Resident #9) out of 9 (Resident #1 - Resident #9) residents reviews for timely reporting of critical incidents. Findings: Resident #1 Review of Resident #1's critical incident report related to neglect with head injury revealed the event occurred on 01/14/2025 at 9:50 PM. The discovered date was 01/15/2025 at 8:00 AM. The entered date was 02/11/2025 at 3:59 PM, with a report due date of 01/22/2025. Further review of Resident #1's critical incident revealed the incident investigation was dated 02/11/2025 at 5:44 PM. Review of Resident #1's critical incident report related to physical abuse revealed the event occurred on 12/18/2024 at 2:45 PM. The discovered date was 12/18/2024 at 2:45 PM. The entered date was 12/18/2024 at 2:45 PM, with a report due date of 12/27/2024. Further review of Resident #1's critical incident revealed the incident investigation was dated with dates, 01/09/2025 and 01/30/2025. Resident #2 Review of Resident #2's critical incident report related to a fall with a fracture revealed the event occurred on 01/07/2025 at 3:38 PM. The discovered date was 01/08/2025 at 3:15 PM. The entered date was 01/08/2025 at 3:19 PM, with a report due date of 01/15/2025. Further review of Resident #2's critical incident revealed the completed dated was 02/04/2025. Resident #3 Review of Resident #3's critical incident report related to injury of unknown origin revealed the event occurred on 02/02/2025 at 8:20 PM. The discovered date was 02/03/2025 at 10:00 AM. The entered date was 02/03/2025 at 10:15 AM, with a report due date of 02/10/2025. Further review of Resident #3's critical incident revealed the incident investigation was dated 02/11/2025 at 10:15 AM. Resident #4 Review of Resident #4's critical incident report related to verbal abuse revealed the event occurred on 11/01/2024 at 9:00 PM. The discovered date was 11/04/2024 at 1:45 PM. The entered date was 02/02/2025 at 8:24 PM, with a report due date of 11/12/2024. Further review of Resident #4's critical incident revealed the incident investigation was dated 02/11/2025 at 10:50 AM. Resident #5 Review of Resident #5's critical incident report related to physical abuse revealed the event occurred on 10/23/2024 at 1:45 PM. The discovered date was 10/23/2024 at 1:45 PM. The entered date was 12/17/2024 at 1:52 PM, with a report due date of 10/30/2024. Further review of Resident #5's critical incident revealed the incident investigation was dated 01/30/2025 at 12:13 PM. Resident #6 Review of Resident #6's critical incident report related to mental abuse revealed the event occurred on 11/30/2024 at 2:00 AM. The discovered date was 11/30/202 at 2:00 AM. The entered date was 02/02/2025 at 9:29 PM, with a report due date of 12/06/2024. Further review of Resident #6's critical incident revealed the incident investigation was dated 02/02/2025 at 10:02 PM. Resident #7 Review of Resident #7's critical incident report related to injury of unknown origin revealed the event occurred on 11/20/2024 at 12:30 PM. The discovered date was 11/20/2024 at 12:30 PM. The entered date was 02/02/2025 at 11:03 PM, with a report due date of 11/27/2024. Further review of Resident #7's critical incident revealed the incident investigation had no documentation. Resident #8 Review of Resident #8's critical incident report related to physical abuse revealed the event occurred on 12/18/2024 at 2:45 PM. The discovered date was 12/18/2024 at 2:45 PM. The entered date was 12/18/2024 at 2:45 PM, with a report due date of 12/27/2024. Further review of Resident #8's critical incident revealed the incident investigation was dated with dates, 01/09/2025 and 01/30/2025. Resident #9 Review of Resident #9's critical incident report related to injury of unknown origin revealed the event occurred on 11/25/2024 with no identified time. The discovered date was 11/25/2024 at 2:10 PM. The entered date was 02/02/2025 at 9:07 PM, with a report due date of 12/04/2024. Further review of Resident 9#'s critical incident revealed the incident investigation was dated 02/02/2025 at 9:28 PM. On 02/11/2025 at 9:15 AM, an interview was conducted with S1ADM who confirmed he was responsible for reporting critical incident for the facility. S1ADM reported that he did not have access to state critical reporting system until about 3 weeks ago. S1ADM stated he had sent the critical incident information for Resident's #1 - #9 via fax to state reporting agency. S1ADM reported he did not know that the information that was faxed had to be entered into the system after he received access. S1ADM reviewed the facility's critical incident report log and stated he was unaware that there were still critical incidents pending. He confirmed the facility had 4 critical incidents pending.

Dec 2024 1 deficiency

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0849 (Tag F0849)

Could have caused harm · This affected multiple residents

Based on interview and record review, the facility failed to ensure the Hospice agency provided services based on the agreement and facility policy to meet professional standards for 1(Resident #1) of...

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Based on interview and record review, the facility failed to ensure the Hospice agency provided services based on the agreement and facility policy to meet professional standards for 1(Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents by failing to collaborate with the hospice agency to ensure the hospice nurse's visit notes were up-to-date in the resident's hospice binder. Findings: A review of Resident #1's Hospice binder revealed the last hospice nurse visit notes were on 09/27/2024. On 12/11/2024, a review of Hospice services agreement made and entered into on 07/27/2023 by Hospice agency and the facility indicated . 5.1 Compilation of records. 5.1.1 Preparation. Facility and hospice each shall prepare and maintain complete and detailed clinical records concerning each Residential Hospice Patient receiving facility services and hospice services under the agreement in accordance with prudent record-keeping procedures .Each clinical record shall completely, promptly and accurately document all services provided. On 12/11/2024, a review of the facility's policy titled Third Party Provider Collaborative Documentation Standards dated 04/2023, indicated .3. Third party providers will complete the Third-Party Provider collaborative documentation form for each resident seen. 4.Third-party providers will provide printed copies of the Plan of care and visit notes for each visit . A. Documents will remain in the binder until the episode of care is complete A review of Resident #1's electronic health record (EHR) revealed an admission date of 10/09/2023, with diagnoses which included, but were not limited to Congestive Heart Failure, Alzheimer's disease, Muscle Wasting and Atrophy, and Unsteadiness on Feet. During an interview with S1ADM (Administrator) on 12/10/2024 at 3:40 p.m., he stated that he is the designated Hospice contact for the facility. S1ADM was asked about the missing hospice visit notes, and he stated that he had called the hospice agency in October regarding the notes, but did not follow up, and should have.

Oct 2024 3 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Notification of Changes (Tag F0580)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and facility's policy and procedure review, the facility failed to ensure S4LPN (Licensed Pr...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and facility's policy and procedure review, the facility failed to ensure S4LPN (Licensed Practical Nurse) notified the physician and/or charge nurse when a resident had a significant change in condition for 1 (#3) resident out of 7 (#1, #2, #3, #4, #5, #6, and #7) sampled residents. Findings: On 10/15/2024, a review of the facility's policy titled, Catheter Care, Urinary with a last reviewed date of 07/2024, read in part, . Input/Output: 1. Observe the resident's urine output for noticeable increased or decreases. If the output decreases significantly . report it to the medical practitioner or charge nurse . Review of Resident #3's record revealed he was admitted to the facility on [DATE] with diagnoses that included in part, Retention of Urine, Benign Prostatic Hyperplasia, and Parkinsonism. Review of Resident #3's most recent Quarterly Minimum Data Set (MDS) dated [DATE], revealed the resident's Brief Interview for Mental Status (BIMS) score was 7, indicating his cognition was severely impaired. Further review of Resident #3's Significant Change MDS dated [DATE], read in part, Section H: Bladder and Bowel selected yes for indwelling catheter. Review of Resident #3's May 2024 electronic MAR/TAR (Medication Administration Record/Treatment Administration Record), read in part, foley catheter output every shift . 05/12/2024: day output = 800 cc (cubic centimeters), evening output = 1200 cc, night output = 500 cc; 05/13/2024: day output = 700 cc, evening output 800 cc, night output = 500 cc; 05/14/2024: day output = 350 cc, evening output 425 cc, night output = 600 cc; 05/15/2024: day output = 350 cc, evening output 800 cc, night output = 100 cc . Review of Resident #3's progress notes revealed a note dated 05/16/2024 by S4LPN that read in part, foley catheter output every shift less than 100 cc . On 10/14/2024 at 11:52 a.m., an interview was conducted with S4LPN. S4LPN stated she did work the night shift on 05/15/2024 from 11:00 p.m. - 7:00 a.m. a total of 8 hours. She stated she noticed the urinary output was very low at 6:00 a.m. She confirmed that she did not notify Resident #3's physician and/or the on call charge nurse of this significant change related to the resident's decreased urinary output. On 10/15/2024 at 9:12 a.m., a joint interview was conducted with S1DON (Director of Nursing) and S2ADON (Assistant Director of Nursing). A review of Resident #3's foley catheter urinary output on May 2024 MAR was conducted with S1DON and S2ADON. On 05/15/2024, the night shift revealed Resident #3 had a urinary output of 100 cc in 8 hours. S1DON stated per documentation Resident #3 usually has a urinary output of 350 cc - 800 cc or more per shift. S1DON confirmed that Resident #3's urinary output of 100 cc in 8 hours was a significant change in the resident's condition, and the nurse should have notified the on call charge nurse and Resident #3's physician.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to protect the resident's right to be free from physical abuse for 1 (...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to protect the resident's right to be free from physical abuse for 1 (#2) out of 4 (#2, #4, #6, #7) residents investigated for abuse. The facility failed to protect Resident #2 from physical abuse by Resident #7. The deficient practice had to potential to affect a total census of 78. Findings: On 10/15/2024, a review of the facility's policy titled Abuse and Neglect-Clinical Protocol, with a review date of 01/2024, defined abuse as; resident to resident abuse includes the term 'willful'. The word willful means that the individual's action was deliberate (not inadvertent or accidental). Resident #2 Review of the Clinical Record revealed Resident #2 was admitted to the facility on [DATE] with diagnoses, which included Alzheimer's disease, Major Depressive Disorder, and Mood Affective Disorder. Review of the Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 08/22/2024 revealed Resident #2 had a BIMS (Brief Interview of Mental Status) score of 9, which indicated she was mildly cognitively impaired. Review of the facility's Progress Notes revealed the following, in part: On 09/21/2024 at 10:36 a.m., S6LPN (Licensed Practical Nurse) documented in part: Resident (Resident #2) was walking from dining room area and other resident (Resident #7) asked her a question. She answered and the other resident (Resident #7) accused her (Resident #2) of being a gossiper and then proceeded to punch her (Resident #2) in her right hip. Resident #7 Review of the Clinical Record revealed Resident #7 was admitted to the facility on [DATE] with diagnoses, which included Bipolar Disorder, Hallucinations, and Dementia. Review of the Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 08/29/2024 revealed Resident #7 had a BIMS (Brief Interview of Mental Status) score of 9, which indicated she was mildly cognitively impaired. Review of the facility's Progress Notes for Resident #7 revealed the following, in part: On 09/21/2024 at 10:14 a.m., S6LPN documented in part: Patient (Resident #7) left out of the dining room and went up to another resident (Resident #2) and stated that she (Resident #2) was a gossiper and then initiated to argue with the other resident (Resident #2) and then punched the resident (Resident #2) on right hip and stated are ya'll going to send me out of this unit now? Resident (Resident #7) was removed away from other resident (Resident #2). On 10/14/2024 at 9:30 a.m., it was confirmed that Resident #7 was hospitalized and was unavailable for interview. On 10/15/2024 at 9:45 a.m., an interview was conducted with Resident #2. She was unable to recall the incident in which she was struck by Resident #7. On 10/14/2024 at 1:15 p.m., an interview was conducted with S6LPN. S6LPN confirmed she witnessed Resident #7 hit Resident #2 with a closed fist. She stated she was standing next to Resident #7 when she starting making accusations against Resident #2 as Resident #2 unknowingly approached Resident #7. She stated, at that time Resident #7 reached out and willfully struck Resident #2 with a closed fist on Resident #2's right hip then stated ya'll going to send me out of this unit now? On 10/15/2024 at 10:00 a.m., an interview was conducted with S1DON (Director of Nursing). S1DON confirmed Resident #7 had struck Resident #2 on the hip with a closed fist, and he believed the intention of Resident #7 was a willful and intentional act of physical abuse.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure that services were provided as outlined in the comprehensi...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure that services were provided as outlined in the comprehensive plan of care for 1 (#3) out of 7 (#1, #2, #3, #4, #5, #6, and #7) sampled resident as evidence by failing to: 1. foley catheter urinary output was monitored and recorded every shift, and 2. side effects of anticoagulants were monitored and recorded. Findings: On 10/15/2024, a review of the facility's policy titled, Catheter Care, Urinary with a last reviewed date of 07/2024, read in part, . Input/Output: . 2. Maintain an accurate record of the resident's daily output every shift . Review of Resident #3's record revealed he was admitted to the facility on [DATE] with diagnoses that included in part, Retention of Urine, Benign Prostatic Hyperplasia, and Heart Failure. Review of Resident #3's most recent Quarterly Minimum Data Set (MDS) dated [DATE], revealed the resident's Brief Interview for Mental Status (BIMS) score was 7, indicating his cognition was severely impaired. Section N: Medications selected yes for receiving anticoagulants. Further review of Resident #3's Significant Change MDS dated [DATE], read in part, Section H: Bladder and Bowel selected yes for indwelling catheter. Review of Resident #3's comprehensive plan of care, read in part, The resident is on Anticoagulant therapy (Apixaban) with interventions . Dated 09/29/2022: Monitor/document/report to Nurse/Dr. anticoagulant complications: blood tinged or frank blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising , blurred vision, SOB (Shortness of Breath), Loss of appetite, sudden changes in mental status, significant or sudden changes in v/s (vital signs). Further review of the care plan revealed, The resident has Catheter with interventions . Dated: 04/16/2024: Monitor and document . output as per facility policy. Review of Resident #3's April 2024 electronic MAR/TAR (Medication Administration Record/Treatment Administration Record) revealed that Resident #2 received Eliquis (Apixaban) Tablet 5 mg (milligram) 1 tablet by mouth two times a day for anticoagulant. Further review of the MAR failed to reveal foley catheter urinary output monitoring and side effects of anticoagulant monitoring from 04/25/2024 - 04/30/2024. Review of Resident #3's May 2024 MAR/TAR revealed that Resident #2 received Eliquis (Apixaban) Tablet 5 mg (milligram) 1 tablet by mouth two times a day for anticoagulant. Further review of the MAR failed to reveal foley catheter urinary output monitoring on 05/01/2024, 05/02/2024, and day and evening shift on 05/03/2024, and failed to reveal side effects of anticoagulant monitoring from 05/01/2024 - 05/15/2024. On 10/14/2024 at 1:09 p.m., and interview was conducted with S5LPN (Licensed Practical Nurse). She stated that Resident #3 was on an anticoagulant, there was no side effects of anticoagulant monitoring that was documented anywhere. On 10/15/2024 8:30 a.m. a policy and procedure regarding anticoagulant monitoring was requested from S2ADON (Assistant Director of Nursing). On 10/15/2024 at 8:45 a.m. S2ADON stated the facility does not have any policies regarding anticoagulant monitoring. On 10/15/2024 at 9:12 a.m. a joint interview was conducted with S1DON (Director of Nursing) and S2ADON (Assistant Director of Nursing). S2ADON stated residents that have a foley catheter staff should be documenting their output on resident's MAR every shift. Review of Resident #3's comprehensive care plan with S2ADON and confirmed that Resident #3 had an order to monitor and document the foley catheter urinary output and monitor and document side effects of anticoagulant. Review of Resident #3's April and May 2024 MAR with S2ADON confirmed that there was no documentation of Resident #3's foley catheter urinary output from 04/25/2025 - 04/30/2024, 05/01/2024 - 05/02/2024, and day and evening shift on 05/03/2024. S2ADON confirmed side effects of anticoagulant monitoring was supposed to be done every shift, after review of April 2024 and May 2024 MAR with S2ADON. She confirmed the Resident #3 was on Eliquis (Apixaban) and there was no side effects of anticoagulant monitoring that was documented from 04/25/2024 - 05/15/2024.

Sept 2024 4 deficiencies

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #R13 was admitted to the facility on [DATE]. Further review of his admission orders, revealed an order for Weight every...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #R13 was admitted to the facility on [DATE]. Further review of his admission orders, revealed an order for Weight every day shift every Tue (Tuesday) for monitoring for 4 weeks. There was no evidence any weights were obtained until 09/05/2024. Resident #R14 admitted to the facility on [DATE]. Further review of his admission orders, revealed an order for Weight every day shift every Tue for monitoring for 4 weeks. There was no evidence that ordered weekly weight obtained for week 3. Resident #R15 admitted to the facility on [DATE]. Further review of his admission orders, revealed an order for Weight every day shift every Fri (Friday) for monitoring for 4 weeks. There was no evidence that ordered weekly weights were obtained for weeks 2 or 4. Resident #R16 admitted to the facility on [DATE]. Further review of his admission orders, revealed an order for Weight every day shift every Tue for monitoring for 4 weeks. There was no evidence that ordered weekly weight were obtained for week 2. Resident #R17 was admitted to the facility on [DATE]. Further review of his admission orders, revealed an order for Weight every day shift every Tue (Tuesday) for monitoring for 4 weeks. There was no documentation any weights were obtained until 09/05/2024. During an interview on 09/05/2025 at 2:15 p.m., S2ADON confirmed the above residents' admission dates, and admission orders to obtain weights every week for 4 weeks. She confirmed the above residents' weights were not obtained as ordered. Based on record reviews and interviews, the facility failed to ensure residents were weighed per physician's orders for 20 (#1, #2, #3, #R1, #R2, #R3, #R5, #R6, #R7, #R8, #R9, #R10, #R11, #R12, #R13, #R14, #R15, #R16, #R17 and #R18) of 20 (#1, #2, #3, #R1, #R2, #R3, #R5, #R6, #R7, #R8, #R9, #R10, #R11, #R12, #R13, #R14, #R15, #R16, #R17 and #R18) residents reviewed for nutrition. Findings: Resident #1: Review of Resident #1's admission orders revealed she was admitted to the facility on [DATE] further review of her admission orders, revealed an order for Weight every day shift every Tue (Tuesday) for monitoring for 4 weeks. There was no evidence that ordered weekly weights were obtained for weeks 3 and 4. Resident #2: Review of Resident #2's admission orders revealed he was admitted to the facility on [DATE]. Further review of his admission orders, revealed an order for Weight every day shift every Tue for monitoring for 4 weeks. There was no evidence that ordered weekly weight were obtained for weeks 2, 3, and 4. Resident #3: Review of Resident #3's admission orders revealed she was admitted on [DATE]. Further review revealed an order for Weight every day shift every Tue for monitoring for 4 weeks. There was no evidence that ordered weekly weight were obtained for weeks 2, 3, and 4. Resident #R6: Review of Resident #R6's admission orders revealed he was admitted to the facility on [DATE]. Further review of his admission orders revealed an order for Weight every day shift every Tue for monitoring for 4 weeks. There was no evidence that ordered weekly weight were obtained for weeks 2, 3, and 4. Resident #R7: Review of Resident #R7's admission orders revealed he was admitted to the facility on [DATE]. Further review of his admission orders revealed an order for Weight every day shift every Tue (Tuesday) for monitoring for 4 weeks. There was no evidence that any weights were obtained until before 09/05/2024. Resident #R8: Review of Resident #R8's admission orders revealed he was admitted to the facility on [DATE]. Further review of his admission orders revealed an order for Weight every day shift every Tue for monitoring for 4 weeks. There was no evidence that ordered weekly weight were obtained for weeks 2, 3, and 4. Resident #R18: Review of Resident #R18's admission orders revealed he was admitted to the facility on [DATE]. Further review of his admission orders revealed an order for Weight every day shift every Tue for monitoring for 4 weeks. There was no evidence that ordered weekly weights were obtained on admit or for weeks 2 and 4.Resident #R6 admitted to the facility on [DATE]. Further review of his admission orders, revealed an order for Weight every day shift every Tue (Tuesday) for monitoring for 4 weeks. There was no documentation any weights were obtained until 09/05/2024. Resident #R7 admitted to the facility on [DATE]. Further review of his admission orders, revealed an order for Weight every day shift every Tue for monitoring for 4 weeks. There was no documentation ordered weekly weight were obtained for weeks 2, 3, 4. Resident #R8 admitted to the facility on [DATE]. Further review of his admission orders, revealed an order for Weight every day shift every Tue for monitoring for 4 weeks. There was no documentation ordered weekly weights were obtained for week 2. Resident #R9 admitted to the facility on [DATE]. Further review of her admission orders, revealed an order for Weight every day shift every Tue for monitoring for 4 weeks. There was no documentation ordered weekly weights were obtained for weeks 3 and 4. Resident #R10 admitted to the facility on [DATE]. Further review of his admission orders, revealed an order for Weight every day shift every Tue for monitoring for 4 weeks. There was no documentation ordered weekly weights were obtained for weeks 2, 3, and 4. Resident #R11 admitted to the facility on [DATE]. Further review of her admission orders, revealed an order for Weight every day shift every Tue for monitoring for 4 weeks. There was no documentation ordered weekly weights were obtained for weeks 2, 3, and 4. Resident #R12 readmitted to the facility on [DATE]. Further review of his re-admission orders, revealed an order for Weight every day shift every Tue for monitoring for 4 weeks. There was no documentation any weights were obtained since his readmission until 09/05/2024.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0692 (Tag F0692)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure residents maintained acceptable parameters of nutrition fo...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure residents maintained acceptable parameters of nutrition for 2 (#3 and #R18) of 20 (#1, #2, #3, #R1, #R2, #R3, #R5, #R6, #R7, #R8, #R9, #R10, #R11, #R12, #R13, #R14, #R15, #R16, #R17 and #R18) residents reviewed for nutrition The facility failed to ensure: 1.Resident's #3 was assessed for weight changes and intervene to prevent severe weight loss; and 2.The registered dietician's recommendations were implemented for Resident #R18. Findings: 1. Review of facility's policy on 09/05/2024 titled, Weight Assessment and Intervention, with a reviewed date of 01/2017, revealed in part: 1. The nursing staff will measure resident weights on admission, and weekly for four weeks thereafter. If no weight concerns are noted at this point, weights will be measured monthly. 2. Weights will be recorded in the individual's medical record. 3. The threshold for significant unplanned and undesired weight loss will be based on the following criteria [where percentage of body weight loss = (usual weight - actual weight)/(usual weight) x 100]: a. 1 month - 5% weight loss is significant; greater than 5 % is severe. b. 3 months - 7.5% weight loss is significant; greater than 7.5% is severe. c. 6 months - 10% weight loss is significant; greater than 10% is severe. 4. If the weight change is desirable, this will be documented and no change in the care plan will be necessary. 5. Should the resident become unweighable due to medical condition, medical practitioner will be contacted to discuss need to weigh the resident. Resident #3: Review of Resident #3's admission orders revealed she was admitted to the facility on [DATE] with diagnoses that included Muscle Wasting and Atrophy; Adult Failure to Thrive and Dementia. Further review of her admission orders, revealed an order for Weight every day shift every Tue for monitoring for 4 weeks. There was no evidence that ordered weekly weight were obtained for weeks 2, 3, and 4. Resident #3's weight was obtained on 09/04/2024 with surveyor observation with a noted weight of 154.4 lbs (pounds). Resident #3's admit weight was 170.4 lbs which indicated that the resident had a 9.39 percent weight loss in over a month that had not been addressed. On 09/03/2024 at 1:15 p.m., an observation of Resident #3 was conducted with resident sitting up in bed eating lunch, picking at food with fork. Daughter-in-law stated the food is usually too hard or dry for resident to eat. She stated she feels like Resident #3 is losing weight, but she does not think she had been weighed. On 09/04/2024 at 10:00 a.m., a review of Resident #3's care plan revealed the resident had a potential nutritional problem, with the only intervention was to provide and serve diet as ordered. The goal was to maintain adequate nutritional status by maintaining weight, no sign or symptoms of malnutrition. The resident also had ADL (Activities of daily living) performance deficit with an intervention of eating: resident requires one staff participation to eat. Review of Nursing admission Data Collection dated 07/25/2024 revealed Resident #3 was on a Cardiac Diet with a Resident Dietary Goal to maintain current weight. On 09/05/2024 at 11:00 a.m., a review of the Nutritional Monitoring flow sheet for August 13, 2024 revealed Resident #3 had not been seen by the Registered Dietitian. 2. Review of Resident #R18's Dietitian admission assessment completed on 08/06/2024 revealed in part: Nutrition Plan: 1. Resident may benefit from (nutritional supplement) BID (twice a day) after meals to help increase nutritional/caloric intake. There was no evidence the supplement was implemented. During an interview on 09/05/2024 at 2:12 p.m., S2ADON (Assistant Director of Nursing) confirmed Resident #3 did have a significant weight loss since admission and weights should have been done as ordered. S2ADON reviewed the EMR (Electronic Medical Record) for Resident #R18 and confirmed the registered dietitian had seen Resident #R18 on 08/06/2024 with Nutrition Plan of nutritional supplements twice a day to help increase nutritional/caloric intake. S2ADON then reviewed the August 2024 Nutritional Monitoring Flow Sheet, Registered Dietitian communication sheet. She confirmed Resident #R18 had not been identified on the list with the recommendation, and had not reviewed the RD (Registered Dietitian) Assessment in the EMR to identify the recommendation. S2ADON confirmed Resident #R18's dietary recommendation should have been addressed.

CONCERN (F) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0802 (Tag F0802)

Could have caused harm · This affected most or all residents

Based on interviews, observations and record review, the facility failed to ensure there was enough dietary staff to provide residents' meals within 45 minutes of the facility's scheduled meal times f...

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Based on interviews, observations and record review, the facility failed to ensure there was enough dietary staff to provide residents' meals within 45 minutes of the facility's scheduled meal times for 84 residents who consumed meals from the kitchen. Findings: A review of the facility's policy on 09/05/2024, titled, Dining Service Meal Times, with no reviewed date, read in part, procedure: .3. Dining service times are planned in accordance with resident preferences and staffing available at scheduled meal times. 4. Meals and snacks will be served at the following times: Breakfast 7:30 a.m., Lunch 12:00 p.m., Afternoon snack 2:00 p.m., Supper 5:30 p.m., HS (nightly) snack 6:00 p.m. On 09/03/2024 at 8:35 a.m., an interview was conducted with S9CNA. She reported the meals were not always served at the same time each day and meal service was often late. S9CNA could not say what time the breakfast meal was usually served as the time always varied. On 09/03/2024 at 8:40 a.m., an observation of the facility main dining room was done. There were 3 (#2, #R4, #R5) residents in the dining room. 2 (#2, #R4) of the residents stated they were waiting on a nurse to come to the dining room so they could be served breakfast. Resident #2 stated breakfast was supposed to be served at 7:30 a.m. and she had not been served breakfast yet. On 09/03/2024 at 8:45 a.m., an interview was conducted with S7DM (Dietary Manager). He reported that he normally served breakfast at 7:30 a.m. He stated, today, the residents in the dining room had not been served breakfast yet because they are waiting on a nurse to come to dining room to observe during the meal. On 09/03/2024 at 9:45 a.m., an interview was conducted with Resident #2. She stated they are supposed to be served breakfast at 7:30 a.m. in the dining room. She stated she had to wait until almost 9:00 a.m. to get her breakfast this morning, because she was waiting for a nurse to come to the dining room. She stated that a few weeks ago they were had to wait a long time to get their meals. On 09/03/2024 at 11:07 a.m., an interview was conducted with Resident #R1. She reported they had not been getting their meals trays on time for the last couple of weeks. She stated the meal trays are up to 2 hours late sometimes. On 09/03/2024 at 12:49 p.m., an observation revealed lunch meal trays being delivered to Hall 1 by staff. On 09/03/2024 at 1:02 p.m., an observation revealed lunch meal trays being delivered to Hall 2 by staff. On 09/03/2024 at 1:15 p.m., observation and interview conducted with Resident #3's family member. Family member reported the meals are often late as lunch was supposed to be at noon and it usually didn't get to the room until 1:30 p.m. to 2:00 p.m. She stated this happened often and she felt Resident #3 had lost weight. On 09/03/2024 at 2:10 p.m., an interview was conducted with S7DM. He confirmed the breakfast and lunch meal trays carts were not delivered to all residents in a timely manner today. On 09/03/2024 at 2:25 p.m., an interview was conducted with S3LPN.She reported Hall 3 had not received any snacks for the residents today. She reported she did not recall receiving 2:00 p.m. snacks very often since she had been working at the facility. On 09/03/2024 at 4:47 p.m., an interview was conducted with S7DM. He confirmed snacks were not delivered to all the units for the resident's 2:00 p.m. snacks.

CONCERN (F) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0806 (Tag F0806)

Could have caused harm · This affected most or all residents

Based on observations, record reviews, and interviews, the facility failed to ensure residents received diets and preferences as described on diet cards were followed for 5 (#R1, #R2, #R3, #R4, and #R...

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Based on observations, record reviews, and interviews, the facility failed to ensure residents received diets and preferences as described on diet cards were followed for 5 (#R1, #R2, #R3, #R4, and #R5) of 20 (#1, #2, #3, #R1, #R2, #R3, #R5, #R6, #R7, #R8, #R9, #R10, #R11, #R12, #R13, #R14, #R15, #R16, #R17 and #R18) of 20 (#1, #2, #3, #R1, #R2, #R3, #R5, #R6, #R7, #R8, #R9, #R10, #R11, #R12, #R13, #R14, #R15, #R16, #R17 and #R18) residents reviewed for nutrition. This failure had the potential to contribute to an unpleasant dining experience, decreased intake, altered nutritional needs, and weight loss for the 84 residents who received meals from the kitchen. Findings: On 09/03/2024 at 11:07 a.m., an interview was conducted with Resident #R1. She stated she was supposed to get a banana and yogurt every day and had not been getting them for some time. She stated the 2 weeks ago they were only served a small portion of fish and a few fries with nothing else to go with it. She stated they had only got water on meal trays for a couple of weeks. On 09/03/2024 at 12:09 p.m., an observation of Resident R#5's meal tray and diet slip was made. The resident had a carton of whole milk and the dietary slip stated skimmed milk. The slip had beverage hot tea and decaf coffee which was not on the tray; only a glass of water was observed. On 09/03/2024 at 12:10 p.m., an observation of Resident #R4's meal tray and diet slip was made. The resident was given whole milk and diet card indicated 2% milk. The slip had beverage: hot tea and decaf coffee, which was not on the tray. On 09/03/2024 at 12:15 p.m., an observation of Resident #R3's meal tray and diet slip was made. The resident was served 2 cartons of whole milk and card stated 2% milk. The slip had beverage: hot tea and decaf coffee which was not on the tray; only a glass of water. On 09/03/2024 at 12:30 p.m., an interview was conducted with S4CNA (Certified Nursing Assistant). She confirmed Residents #R3, #R4 and #R5 had the wrong milk served to them. S4CNA confirmed that the diet served was supposed to be confirmed with the slip before serving it to the resident. She confirmed she had not checked the slip before giving the whole milk to the residents. On 09/03/2024 at 12:59 p.m., an observation of Resident #R1's meal slip indicated dessert red velvet cake, dairy beverage 2% milk, beverage hot tea and decaf coffee was not on the tray. Resident stated does that look like red velvet cake to you? It is yellow. The resident stated this happened all the time. Resident #R1 stated the meal on the tray did not always match what was served, and that they only got a glass of water. There was no other drink provided. On 09/03/2024 at 1:05 p.m., am observation of Resident #R2's meal slip indicated dessert red velvet cake, dairy beverage 2% milk, beverage hot and decaf coffee, was not on the tray. Resident stated I don't have red cake either, these meals never match the slip anymore. On 09/03/2024 at 4:47 p.m., an interview was conducted with S7DM (Dietary Manager). He confirmed sometimes the food per the meal slip was not always available and a substitute is made. He stated the residents are not notified when the menu is changed and should be notified.

Jun 2024 2 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interviews, the facility failed to follow the physician's orders for 1 (#3) resident ou...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interviews, the facility failed to follow the physician's orders for 1 (#3) resident out of 5 (#1, #2, #3, #4, #5) residents sampled, as evidence by failing to follow orders for obtaining an x-ray timely causing a delay in care for the resident. Findings: Review of Resident #3's Electronic Medical Record (EMR) revealed she was admitted to the facility on [DATE]. The resident had diagnoses which included, but were not limited to Fracture of Unspecified part of Neck of Right Femur, subsequent encounter for Closed Fracture with routine healing and Encounter for other Orthopedic Aftercare. Review of Resident #3's physician's orders revealed the following orders for x-rays: An order date of 05/24/2024 at 1:44 p.m. that read, X-ray left femur. An order date of 05/28/2024 at 7:55 a.m. that read, X-ray left leg. An order date of 05/28/2024 at 8:15 a.m. that read, X-ray left hip, femur, knee, tib (tibia), fib (fibula), ankle, foot. An order date of 05/31/2024 at 2:02 p.m. that read, X-ray pelvis and lumbar spine. Review of Resident #3's nurse's notes revealed on 05/24/2024 at 12:00 p.m., she had a witnessed fall. Resident #3 had no visible injuries and had no complaints of pain. On 05/24/2024 at 1:51 p.m., Resident #3 complained of pain in her left leg while ambulating per therapy. The nurse practitioner was notified and ordered an x-ray. Further review of Resident #3's nurse's notes revealed on 05/27/2024 at 2:09 p.m., the nurse called contracted radiology service three times to check on the x-ray of the left leg and there was no answer. A note on 05/28/2024 at 7:59 a.m. revealed an order for an x-ray was faxed to the contracted radiology service. A note on 06/01/2024 at 5:20 p.m. revealed new order to send resident to hospital for positive left femur fracture. A further review of Resident #3's EMR revealed no x-ray results for 05/24/2024. The radiology interpretation for x-rays completed on 05/28/2024 revealed the following impressions: the left foot x-ray was an unremarkable foot examination; the left ankle and the left tibia/fibula x-rays had no significant findings; the left knee x-ray revealed severe osteoarthritis; the left femur x-ray revealed no obvious displaced fracture identified with a note the femoral neck region is sub-optimally evaluated; and the left hip x-ray revealed limited exam, no obvious acute osseous abnormality noted. The radiology interpretation for the lumbar spine x-ray completed on 06/01/2024 revealed 1) possible left proximal femur fracture, recommend correlation with left hip radiographs. 2) Demineralization of the spine. The radiology interpretation for the pelvis x-ray completed on 06/01/2024 revealed acute left proximal femur fracture, recommend dedicated left hip views or CT. On 06/10/2024 at 10:48 a.m., an interview was conducted with S4LPN (Licensed Practical Nurse). She confirmed Resident #3 had a fall on 05/24/2024 at 12:00 p.m., then during physical therapy complained of pain to the left leg. S4LPN notified the nurse practitioner of Resident #3's complaint of pain and received an order for an x-ray to the left leg. S4LPN stated on 05/28/2024, the x-ray was not completed and was reordered. On 06/10/2024 at 12:19 p.m., an interview was conducted with S3ADON (Assistant Director of Nursing). She confirmed Resident #3 had an order written on 05/24/2024 for an x-ray of the left leg. S3ADON confirmed the x-ray ordered on 05/24/2024 was not completed until 05/28/2024. S3ADON stated the x-ray should have been completed by 05/25/2024. On 06/10/2024 at 2:48 p.m., a telephone interview was conducted with the contracted radiology service who confirmed they had not received an order for Resident #3 for an x-ray of the left leg on 05/24/2024. She confirmed an order was received for Resident #3 on 05/28/2024 for an x-ray and was completed on 05/28/2024 and did not reveal a fracture of the left hip. She stated on 06/01/2024, they received an order for Resident #3 for an x-ray that was completed on the same day which revealed a left femur fracture.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected multiple residents

Based on observations, interviews, and record reviews, the facility failed to protect the resident's rights to be free from neglect by failing to ensure the availability of supplies in sufficient numb...

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Based on observations, interviews, and record reviews, the facility failed to protect the resident's rights to be free from neglect by failing to ensure the availability of supplies in sufficient number the residents required necessary to provide care to residents as evidenced by: 1. Failing to provide appropriate sized incontinence briefs to 74 incontinent residents; and 2. Failing to provide a sufficient number of clean linens, when the facility was observed not having an adequate amount of clean towels and washcloths available. This had the potential to affect the census of 89. Findings: On 06/10/2024 at 9:30 a.m., an observation was made of S6CNA (Certified Nursing Assistant) assembling 4 incontinence briefs together. S6CNA stated the facility ran out of the size 2XL (extra-large) and 3XL incontinence briefs. S6CNA stated she was assembling the incontinence briefs together because she was told to get creative because the appropriate size briefs were not available. On 06/10/2024 between 1:00 p.m. and 1:25 p.m., an observation of the facility's supply closets for incontinence briefs revealed: Hall A - a partial pack of size XL (extra-large) and no size large, 2XL or 3XL available. Hall B - a partial pack of size large and no size XL, 2XL, or 3XL available. Hall C - no size large, XL, 2XL, or 3XL available. Hall D - a partial pack of size 2XL and no size large, XL, or 3XL available. Staff interviews were conducted at that time with S4LPN (Licensed Practical Nurse), S5LPN, S6CNA, and S7CNA. They verbalized there were not enough briefs in the appropriate sizes to provide incontinence care to the residents who required them. They stated last week, the facility weekly run out of the large, XL, 2XL, and 3XL which are the most frequently used sizes to fit the residents. On 06/10/2024 at 12:19 p.m., an interview was conducted with S3ADON (Assistant Director of Nursing) who stated most of the incontinent residents residing in the facility wore sizes large, XL, 2XL, or 3XL. She stated these sizes of incontinence briefs were the most frequently used for incontinent care, but each size was not available in central supply. On 06/10/2024 at 12:35 p.m., an interview was conducted with S2DON (Director of Nursing) who confirmed the facility had been out of the larger size briefs, including large, XL, 2XL, and 3XL since last week. On 06/10/2024 at 1:31 p.m., an interview was conducted with S12MR/CS (Medical Records/Central Supply). She confirmed she was responsible for completing the order supply lists for the facility including briefs. S12MR/CS stated the list of items for order are given to S1ADN (Administrator) for review. S1ADN reviews, approves, and submits orders himself to ensure the order is within the facility's budget. S12MR/MC further stated S1ADN would remove critically needed items from the order to fit the facility's budget, like gloves and briefs which puts the staff in a bind for supplies. She stated the facility would run out of incontinence briefs for the residents. On 06/10/2024 at 1:52 p.m., an interview was conducted with S1ADN who confirmed he submits the supply orders, including briefs, for the facility. On 06/10/2024 at 2:00 p.m., an observation and interview was conducted with S12MR/CS in the central supply. Observations of the central supply room revealed 20 packs of size large briefs and no size XL, 2XL, or 3XL briefs. S12MR/CS confirmed there were no briefs in XL, 2XL, or 3XL in the central supply room. S12MR/CS stated the facility ran out of incontinence briefs last week. Observations of the supply drop off area next to the locked central supply room revealed 3 boxes of size XL briefs, 2 boxes of size 2XL, and 5 boxes of size 3XL briefs. S12MR/CS stated these supplies had just arrived today on 06/10/2024. The facility failed to provide a policy for the provision of sufficient supplies including briefs. 2. On 06/10/2024 between 12:50 p.m. and 1:10 p.m., an observation of the clean linen supply closets revealed: Hall A- no towels and no washcloths Hall B- 5 towels and 7 washcloths Hall C- 11 towels and no washcloths Hall D- 8 towels and no washcloths. Staff interviews were conducted at that time with S4LPN (Licensed Practical Nurse), S5LPN, S6CNA (Certified Nursing Assistant), and S7CNA. They stated they use towels and washcloths to provide personal hygiene needs, including incontinent care for the residents. They stated they often run out of them in the clean linen supply closet and have to go to other hallways to get them or have to wait for laundry to distribute more. On 06/10/2024 at 1:15 p.m., an interview was conducted with S2DON. She confirmed that towels and washcloths were utilized for providing personal hygiene needs, including incontinence care for the residents. She further stated the facility did not utilize or have any disposable wipes. She confirmed that all clean linens available for usage are stored in the clean linen supply closets on the units. A review of the linen counts was conducted with S2DON. She confirmed that number currently available for usage was not an adequate number to care for all the resident's needs. She stated she would go to the laundry room to see what was available. An observation was made of the facility's laundry room with S2DON. A load of what appeared to be linens, including towels and washcloths, was in one of the two washers and another load was in one of the two dryers. S10HLS (Housekeeping/Laundry Staff) verbalized it takes about 30 minutes to wash, and another 30 minutes to dry. An observation of the clean linen table revealed 27 towels and 12 washcloths. S2DON confirmed the total available wash cloths and towels at this time for usage was 51 towels and 19 washcloths, which was not an adequate amount for the number of residents. S2DON then stated that S1ADN (Administrator) reported they should have an additional supply of linens in the storage supply closet and to put those in circulation. Upon observation of the storage supply closet with S2DON, there were no towels or washcloths available. During an interview with S1ADN on 06/10/2024 at 3:40 p.m., he stated he had spoken with the laundry staff and linens were delivered to the clean linen supply closets on each unit about an hour ago. He voiced he thought they had an additional supply of extra washcloths and towels available in the storage supply closet but was told there were none. On 06/10/2024 between 3:45 p.m. and 4:00 p.m. a second observation of the clean linen supply closets revealed: Hall A- 18 towels and 14 washcloths Hall B- 16 towels and 17 washcloths Hall C- 25 towels and 4 washcloths Hall D- 15 towels and 13 washcloths Staff interviews were conducted at that time with S8CNA who stated she has ran out of washcloths at times and have had to cut towels into pieces to make additional washcloths. S9CNA stated this was usually the last time any linens were delivered for the day and this supply would have to last until the following morning. On 06/10/2024 at 4:05 p.m. an interview was conducted with S11HLM (Housekeeping/Laundry Manager). He stated he was a contract employee and was not responsible for the purchase of linens, such as towels and washcloths, and voiced there was a shortage of linen supplies available. He stated that at this time, the last load of linen for today was in the dryer and would be distributed once completed, and it would be tomorrow morning before anymore would be restocked. The facility provided no policy for the provision of linens, including towels and washcloths.

Apr 2024 6 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the residents' assessment accurately reflected the status of...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the residents' assessment accurately reflected the status of 1 (#61) out of a total of 33 sampled residents, by failing to ensure MDS (Minimum Data Set) assessment was coded correctly for antidepressant use. Findings Review of Resident # 61's Electronic Health Record revealed he was admitted to the facility on [DATE] with diagnoses that included, but were not limited to, Emphysema, Diabetes Mellitus II, and Legal Blindness. Review of Resident # 61's Annual MDS assessment with an ARD (Assessment Reference Date) of 02/14/2024 revealed in Section N - High-Risk Drug Classes Antidepressant was coded 1, indicating the resident was taking an antidepressant. Review of Resident # 61's February 2024 Physician Orders revealed no orders for use of antidepressants. On 04/24/2024 at 10:15 a.m., an interview and review of Resident #61's Electronic Health Record was conducted with S4MDS nurse. She confirmed the resident was not prescribed an antidepressant. She also confirmed that the MDS assessment with an ARD of 02/14/2024 was coded to reflect Resident #61 used an antidepressant. S4MDS nurse stated Resident #61 should not have been coded as using an antidepressant in Section N of the Annual MDS assessment dated [DATE].

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

PASARR Coordination (Tag F0644)

Could have caused harm · This affected 1 resident

Based on record review and interview, the facility failed to refer a resident with a newly diagnosed mental disorder to the appropriate state-designated authority for Level II PASARR (Preadmission Scr...

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Based on record review and interview, the facility failed to refer a resident with a newly diagnosed mental disorder to the appropriate state-designated authority for Level II PASARR (Preadmission Screening and Resident Review) evaluation and determination for 1 (#55) of 4 (#6, #13, #55, #68) residents investigated for PASARR in a final sample of 74 residents. Findings: A review of Resident #55's record revealed an admission date of 01/14/2024. Further review revealed he was diagnosed with Delusional Disorder on 01/19/2024. Further review of Resident #55's record revealed a Level 1 PASARR (Preadmission Screening and Resident Review) dated 11/28/2023. No PASARR Level II was noted in Resident #55's record. On 04/24/2024 at 3:58 p.m., an interview was conducted with S3ADON (Assistant Director of Nursing). S3ADON confirmed Resident #55 received a qualifying diagnosis of Delusional Disorder after his admission date. She confirmed the facility had not resubmitted for a Level II PASARR review and was unaware that this was required.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to implement a comprehensive person-centered care plan that included m...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to implement a comprehensive person-centered care plan that included monitoring for adverse reactions for antibiotic use for 1 (#10) out of 33 sampled residents. Findings: A review of Resident #10's electronic health record revealed she admitted to the facility on [DATE] with diagnoses that included but were not limited to Cerebral Infarction. Other diagnoses included Retention of Urine and Urinary Tract Infection (UTI). A review of Resident #10's physician orders revealed an order dated 04/17/2024 for Bactrim DS Oral Tablet 800-160 milligram (mg) give 1 tablet by mouth two times a day for UTI (Urinary Tract Infection) for 10 days. A further review of Resident #10's physician orders failed to reveal an order to monitor for adverse reactions of antibiotic use. A review of Resident #10's care plan revealed the following in part .The resident is on Antibiotic therapy Bactrim DS po (oral) until 04/27/2024. Interventions included in part .Any antibiotic may cause diarrhea, nausea, vomiting, anorexia, and hypersensitivity/allergic reactions. Monitor every (q) shift for adverse reaction. Observe for possible side effects every shift. A review of Resident #10's April 2024 Medication Administration Record (MAR) revealed documentation the resident received Bactrim DS Oral Tablet 800-160 mg give 1 tablet by mouth two times a day beginning on 04/17/2024 at 4:00 p.m. Further review of the MAR revealed no documentation the resident was monitored for adverse reactions of antibiotic use. A review of Resident #10's Nurses Progress Notes that revealed no documentation of monitoring for adverse reactions of antibiotic use. On 04/23/2024 at 1:13 p.m., an interview was conducted with S7LPN (Licensed Practical Nurse) who confirmed that Resident #10 was on antibiotics. She reviewed Resident #10's MAR for April 2024 and confirmed there was no order to monitor for adverse reactions of antibiotic use. S7LPN further reviewed Resident #10's nurse notes that revealed no monitoring for adverse effects. On 04/23/2024 at 1:27 p.m., an interview was conducted with S3ADON (Assistant Director of Nursing/Infection Preventionist) who confirmed the nurses should monitor for adverse effects and document each shift for the duration of the use of antibiotics. On 04/23/2024 at 3:05 p.m., a record review and interview was conducted with S4MDS (Minimum Data Set). She confirmed the resident had a physician order dated 04/17/2024 for Bactrim DS 800-160 mg. S4MDS confirmed Resident #10's care plan included monitor every shift for adverse reactions. S4MDS further reviewed Resident #10's April 2024 MAR and nurse's progress notes and confirmed there was no documentation that adverse reactions were monitored each shift and they should have been.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

Based on observations, and interview, the facility failed to store food in accordance with professional standards for food service, and ensure sanitary conditions were maintained in the kitchen as evi...

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Based on observations, and interview, the facility failed to store food in accordance with professional standards for food service, and ensure sanitary conditions were maintained in the kitchen as evidenced by: 1. a thick layer of debris and food residue on the deep fryer cooking oil collection area; 2. expired foods from the kitchen refrigerator, freezer, and dry storage area; and 3. sticky residue with food debris on the cart used to bring food items from one part of the kitchen to another. This deficient practice had the potential to affect the 72 residents who consumed food from the kitchen. Findings: On 04/22/2024 at 8:30 a.m., a tour of the facility's kitchen was conducted with S1DietarySup (Dietary Supervisor), who stated that she was responsible for the day to day management of the kitchen. On 04/22/2024 at 8:35 a.m., an observation of the deep fryer was conducted with S1DietarySup that revealed the cooking oil collection area had a thick layer of debris and a large piece of fried food material. S1DietarySup stated the deep fryer was last used on 04/21/2024 and confirmed that is was not cleaned after it was used and should have been. On 04/22/2024 at 8:42 a.m., an observation of the stand-up refrigerator was conducted with S1DietarySup and revealed a plastic gallon bag labeled lettuce, dated 04/04/2024. The lettuce was observed with discoloration, texture changes, and a brown watery substance at the bottom of bag that indicated the food was spoiled. Further observation of the refrigerator revealed two opened containers of beef base broth with an expiration date of 04/16/2024. S1DietarySup confirmed the food items were spoiled/expired and should have been removed from the refrigerator then discarded. On 04/22/2024 at 8:50 a.m., an observation of the stand-up freezer was conducted with S1DietarySup that revealed an opened container of English muffins with a written date of 11/23, (2023) with an expiration date of 03/22/2024. Further observation of the freezer revealed a plastic gallon bag labeled fried okra, dated 11/10/2023. The fried okra had gray discoloration and frozen chucks of ice. S1DietarySup confirmed the food items were expired and should have been discarded. On 04/22/2024 at 9:12 a.m., an observation of the dry storage room was conducted with S1DietarySup and revealed a plastic gallon bag of raisin bran dated 03/17/2024. S1DietarySup confirmed the food item was expired and should have been discarded. On 04/22/2024 at 12:15 p.m., an observation of the food service line was conducted. Cold drinks with lids were removed from the refrigerator and placed on a cart for tray distribution. Further observation of the cart revealed multiple areas of a red sticky residue and food debris on both sides of the cart. At 12:18 p.m., an interview and cart observation was conducted with S1DietarySup, who stated that the carts were to be cleaned after each use and confirmed the cart was not cleaned from previous use and should have been.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Administration (Tag F0835)

Could have caused harm · This affected multiple residents

Based on record review, observations and interviews, the facility was not administered in a manner that enabled it to use its resources effectively to attain or maintain the highest practicable physic...

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Based on record review, observations and interviews, the facility was not administered in a manner that enabled it to use its resources effectively to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility's administration failed to implement the facility's Enhanced Barrier Precautions (EBP) policy for residents with infection or colonization with a multi-drug resistant organisms (MDRO) or for any resident who has a chronic wound and/or indwelling medical device. The deficient practice was observed for 8 (#17, #24, #30, #35, #48, #68, #75, #232) out of 14 residents who met criteria for Enhanced Barrier Precautions. Findings: Cross reference findings to F880. A review of the facility's policy titled Infection Prevention and Control Manual - Enhanced Barrier Precautions written on 08/21/2023 revealed in part . Enhanced Barrier Precautions are an infection control intervention designed to reduce transmission of multi-drug resistant organisms (MDRO) in nursing homes. Enhanced Barrier Precautions involve gown and glove use during high contact resident care activities for residents known to be colonized or infected with a multi-drug resistant organisms (MDRO) as well as those at increased risk for MDRO acquisition (such as residents that have wounds or indwelling medical devices). Enhanced Barrier Precautions are recommended for residents with any of the following: 1) Infection or colonization with a MDRO or 2) A wound or indwelling medical device, even if the resident is not known to be infected or colonized with a MDRO. Indwelling medical devices include central venous catheters, urinary catheters, feeding tubes, tracheostomies/ventilators. Observations were made throughout the survey process that revealed the facility did not implement Enhanced Barrier Precautions for Residents #17, #24, #30, #48, #75, #232 who had indwelling urinary catheters; Residents #35 and #68 who had PEG (Percutaneous Endoscopic Gastrostomy) tubes; Residents #30 and #232 who had chronic wounds. An interview was conducted on 04/23/2024 at 1:22 p.m. with S4ADON (Assistant Director of Nursing). S4ADON stated that prior to yesterday (04/22/2024), she was unaware of the requirement and criteria for EBP. She confirmed that none of the residents that fit EBP criteria, such as urinary catheters, chronic wounds, and PEG (Percutaneous Endoscopic Gastrostomy) tubes, were on EBP and should have been. On 04/24/2024 at 4:10 p.m., an interview was conducted with S2ADM (Administrator) and S8RDO (Regional Director of Operations). S2ADM confirmed the Enhanced Barrier Precautions Policy was written and effective on 08/21/2023. S2ADM confirmed he was aware the Enhanced Barrier Precautions had not been implemented. S2ADM stated he did not know if he was part the governing body or who was the governing body. S8RDO stated the facility's Administrator (S2ADM), himself (S8RDO), the regional nurse, and S9IDM were part of the governing body. S8RDO confirmed the facility's administration failed to ensure Enhanced Barrier Precautions was implemented per the facility's the policy for residents meeting the criteria. On 04/24/2024 at 4:21 p.m., a telephone interview was conducted with S9IMD (Interim Medical Director). S9IMD stated he was not aware of the facility's Enhanced Barrier Precautions policies and procedures. He further stated he was not aware the facility had not implemented Enhanced Barrier Precautions for the residents who met criteria.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #75 Review of Resident #75's electronic health record revealed he was admitted to the facility on [DATE] with diagnoses...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #75 Review of Resident #75's electronic health record revealed he was admitted to the facility on [DATE] with diagnoses that included, but were not limited to, Hematuria and Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms. Review of Resident #75's Quarterly MDS (Minimum Data Set) assessment with an ARD (Assessment Reference Date) of 03/26/2024 revealed Section H - Bladder and Bowel: Appliances A. Indwelling Catheter was indicated for use. Review of Resident #75's physician's orders revealed an order for Urinary Catheter. Review of Resident #75's care plan failed to reveal goals or interventions for enhanced barrier precautions. On 04/23/2024 at 9:13 a.m., an observation was made of Resident #75 who had an indwelling urinary catheter. Further observation of the resident's room failed to reveal signage indicating the use of EBP (Enhanced Barrier Precautions). Further observation revealed required PPE (Personal Protective Equipment) was not available for staff usage, and there were no biohazard bins to discard PPE. On 04/23/2024 at 1:25 p.m., an interview was conducted with S5LPN (Licensed Practical Nurse). S5LPN confirmed Resident #75 had a urinary catheter in place. She stated she had no knowledge of what Enhanced Barrier Precautions were and confirmed Resident #75 was not under any precautions. Based on observation, interview and record review, the facility failed to implement/maintain infection control practices to help prevent and control the spread of an infectious communicable disease. The facility failed to ensure all staff adhered to Enhanced Barrier Precautions for 8 (Resident #17, Resident #24, Resident #30, Resident #35, Resident #48, Resident #68, Resident #75, Resident #232) of 8 (Resident #17, Resident #24, Resident #30, Resident #35, Resident #48, Resident #68, Resident #75, Resident #232) residents reviewed for infection control. The deficient practice had the potential to affect 14 out of 74 total residents with chronic wounds or indwelling medical devices. Findings: A review of the facility's policy titled Infection Prevention and Control Manual - Enhanced Barrier Precautions written on 08/21/2023 revealed in part . Enhanced Barrier Precautions involve gown and glove use during high contact resident care activities for residents known to be colonized or infected with a multi-drug resistant organisms (MDRO) as well as those at increased risk for MDRO acquisition (such as residents that have wounds or indwelling medical devices). Enhanced Barrier Precautions are recommended for residents with any of the following: 1) Infection or colonization with a MDRO or 2) A wound or indwelling medical device, even if the resident is not known to be infected or colonized with a MDRO. Indwelling medical devices include central venous catheters, urinary catheters, feeding tubes, tracheostomies/ventilators. An interview was conducted on 04/23/2024 at 1:22 p.m. with S4ADON (Assistant Director of Nursing). S4ADON stated, that prior to yesterday (04/22/2024), she was unaware of the requirement for EBP (enhanced barrier precautions) as well as the criteria for EBP. She confirmed that none of the residents that fit that criteria, such as urinary catheters, chronic wounds, and PEG (Percutaneous Endoscopic Gastrostomy) tubes, were on EBP and should have been. Resident #24 On 04/23/2024 at 12:55 p.m., an observation was made of Resident #24 and was noted to have a urinary catheter. Further observation of the resident's room failed to reveal signage indicating EBP (Enhanced Barrier Precautions), required PPE (personal protective equipment) was not available for staff usage, and there were no red biohazard bins nearby. On 04/23/2024 at 01:13 p.m., an interview was conducted with S7LPN. S7LPN confirmed Resident #24 had a foley catheter. S7LPN stated she was not aware of Enhanced Barrier Precautions or what it consisted of. She confirmed the Resident was not on Enhanced Barrier Precautions and there was no biohazard bins in the resident's room. Resident #232 Review of Resident # 232's electronic health record revealed he was admitted to the facility on [DATE] with diagnoses that included, but were not limited to Neurogenic Bladder. Review of Resident # 232's Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/23/2024 revealed Section H - Bladder and Bowel: Appliances A. Indwelling Catheter was checked. Review of Resident #232's Care Plan revealed no enhanced barrier precautions. On 04/23/2024 at 01:13 p.m., an interview was conducted with S7LPN. S7LPN confirmed Resident #24 had a foley catheter. S7LPN stated she was not aware of Enhanced Barrier Precautions or what it consisted of. She confirmed the Resident was not on Enhanced Barrier Precautions and there was no biohazard bins in the resident's room. Resident #17 Review of Resident # 17's electronic health record revealed he was admitted to the facility on [DATE] with diagnoses that included, but were not limited to Hydronephrosis. Review of Resident # 17's Annual MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 04/02/2024 revealed Section H - Bladder and Bowel: Appliances A. Indwelling Catheter was checked. Review of Resident # 17's physician's ordered revealed orders 03/20/2024 - Foley Catheter, 16F (French)/10ml (Milliliters) change every month and PRN (As Needed) dislodgement and 10/20/2023 - Flush foley catheter daily with 50ml of NS (Normal Saline). Review of Resident #17's Care Plan revealed no evidence of enhanced barrier precautions. Resident #30 Review of Resident # 30's electronic health record revealed he was admitted to the facility on [DATE] with diagnoses that included, but were not limited to Hydronephrosis. Review of Resident # 30's Annual MDS with an ARD of 03/12/2024 revealed Section H - Bladder and Bowel: Appliances A. Indwelling Catheter was checked. Review of Resident #30's Care Plan revealed resident had a supra pubic catheter and failed o address Enhanced Barrier Precautions. Resident #48 Review of Resident # 48's electronic health record revealed he was admitted to the facility on [DATE] with diagnoses that included, but were not limited to Retention of Urine. Review of Resident # 48's admission MDS with an ARD of 02/23/2024 revealed Section H - Bladder and Bowel: Appliances A. Indwelling Catheter was checked. Review of Resident #48's Care Plan revealed resident had an indwelling catheter and failed to address Enhanced Barrier Precautions. On 04/23/2024 at 1:00 p.m., an interview was conducted with S6LPN (Licensed Practical Nurse). She stated she was not sure what enhanced barrier precautions were. S6LPN confirmed Resident #17, Resident #30 and Resident #48 had an indwelling catheter. S6LPN also confirmed there was no signage for enhanced barrier precautions and no PPE available at resident door for use when caring for a resident. Resident #35 During an interview and observation with S6LPN (Licensed Practical Nurse) on 04/23/2024 at 1:02 p.m., she confirmed that Resident #35 had PEG (Percutaneous Endoscopic Gastrostomy) tubes. S6LPN acknowledged that a PEG tube was considered an indwelling medical device inserted into the stomach through a surgical wound in the abdomen and this could make someone with a PEG susceptible to infection. S6LPN was questioned regarding any awareness of Enhanced Barrier Precautions. S6LPN admitted she was not familiar with what it entailed or any of the requirements. S6LPN verified there was no signage on the door or near the entrance to the rooms of Resident #35 or Resident #68, announcing and explaining the need for Enhanced Barrier Precautions. S6LPN confirmed there was no PPE (Personal Protective Equipment) readily available near the entrance to Resident #35 or #68's room. S6LPN also verified there was no red biohazard waste receptacle in Resident #35 or #68's room, for disposal of PPE after use. S6LPN admitted that she and other direct care staff had provided direct patient care to Resident #35 and #68 without awareness of Enhanced Barrier Precautions, and without donning PPE. Resident #68 During an interview and observation with S6LPN (Licensed Practical Nurse) on 04/23/2024 at 1:02 p.m., she confirmed that Resident #68 had PEG (Percutaneous Endoscopic Gastrostomy) tubes. S6LPN acknowledged that a PEG tube was considered an indwelling medical device inserted into the stomach through a surgical wound in the abdomen and this could make someone with a PEG susceptible to infection. S6LPN was questioned regarding any awareness of Enhanced Barrier Precautions. S6LPN admitted she was not familiar with what it entailed or any of the requirements. S6LPN verified there was no signage on the door or near the entrance to the rooms of Resident #68, announcing and explaining the need for Enhanced Barrier Precautions. S6LPN confirmed there was no PPE (Personal Protective Equipment) readily available near the entrance to Resident #68's room. S6LPN also verified there was no red biohazard waste receptacle in Resident #68's room, for disposal of PPE after use. S6LPN admitted that she and other direct care staff had provided direct patient care to Resident #68 without awareness of Enhanced Barrier Precautions, and without donning PPE.

Apr 2024 4 deficiencies 1 Harm

SERIOUS (G) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Actual Harm - a resident was hurt due to facility failures

Free from Abuse/Neglect (Tag F0600)

A resident was harmed · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews; the facility failed to protect the resident's right to be free from abuse...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews; the facility failed to protect the resident's right to be free from abuse for 3 (#1, #2, #3) of 7 (#1, #2, #3, #4, #5, #6, #7) sampled residents. The facility failed to protect: 1. Resident #1 from sexual abuse by Resident #2. 2. Resident #2 from physical abuse by Resident #5. 3. Resident #3 from physical abuse by Resident #4. This deficient practice resulted in: 1. psychosocial harm for Resident #1 on 03/02/2024 at 4:42 p.m., when Resident #2 grabbed her breasts. Resident #1 was observed startled by staff at the time of the incident. The resident's responsible party stated that she would have been panicked, very fearful, and not happy at all. 2. physical harm for Resident #2 on 03/14/2024 at 8:54 p.m., when Resident #5 struck Resident #2 on the top of his head with a cane resulting in a laceration that required sutures. 3. physical harm for Resident #3 on 03/09/2024 at 1:42 p.m., when Resident #4 hit Resident #3 in the eye that resulted in a contusion to the area with subsequent complaints of headaches and pain. Findings: On 04/08/2024, a review of the facility's Abuse Neglect Policy dated 01/2024 read in part: Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff or other residents .The facility prohibits mistreatment, neglect, or abuse of residents .The resident must not be subjected to abuse by anyone. 1. A record review of Resident #2's EHR (Electronic Health Record) revealed he was admitted to the facility on [DATE] with diagnoses in part: Vascular Dementia, Aphasia, Mood Disorder, Sexual Dysfunction, Disorder of Adult Personality and Behavior. A record review of Resident #2's quarterly MDS (Minimal Data Set) dated 03/08/2024 revealed that the resident had a Brief Interview for Mental Status (BIMS) that could not be completed due to the resident rarely understood. A staff assessment for mental status was conducted and indicated the resident's cognitive skills for daily decision making was severely impaired. A review of Resident #2's progress notes revealed the following: 03/02/2024 4:42 p.m .observed in dining room physical inappropriately touched another resident's (Resident #1) breast. A review of Resident #2's care plan, failed to identify the resident's diagnosis of Sexual Dysfunction. Review of Incident Report, dated 03/02/2024 at 16:24 (6:24 p.m.), revealed the section titled Incident Description read: Resident observed inappropriately touching a female resident (Resident #1) on the breast. Immediate Action Taken read: Redirected to another area away from female resident and supervisor, doctor, and family notified, one on one staff assigned to resident in his room, psych med increased until physician can assess resident for behavior. Further review of the incident report revealed a witness stated written by S8CNA (Certified Nursing Assistant) stating Resident #1 was startled and upset at first. On 04/04/2024 at 1:15 p.m., an observation was made of Resident #2 sitting in his wheelchair propelling self in and out of dining areas in the memory care unit, in view and observation of staff. An attempt for an interview was made at that time but was unsuccessful as he did not respond to any questions or conversation. On 04/04/2024 at 3:15 p.m., an interview was conducted with S1ADON (Assistant Director of Nursing). S1ADON confirmed the incident in which Resident #2 grabbed Resident #1 breasts. She stated that the doctor was immediately notified of the incident; a medication change was immediately put into place, and Resident #2 was immediately placed on 1 on 1 observation. The doctor also assessed Resident #2 the next morning. S1DON stated the medication change was effective and he has had no other incidents of sexually inappropriate behavior. 04/08/2024 at 3:40 p.m. and on 04/09/2024 at 4:00 p.m.,phone interview attempts with S8CNA were unsucessful. On 04/08/2024 at 4:00 p.m., an interview was conducted with S3LPN (Licensed Practical Nurse). S3LPN confirmed she was the nurse on duty for 03/02/2024 when Resident #2 grabbed Resident #1's breast. She stated the incident was immediately reported to her by the S8CNA. S8CNA reported to her that Resident #2 reached and grabbed the female's breast from behind her. She stated they immediately separated the two residents, redirected Resident #2, and initiated 1-on-1 observation for Resident #2. She then notified the administrator; the police; the doctor; responsible parties for both involved residents; and completed an incident report. On 04/09/2024 at 2:20 p.m., a phone interview was conducted with the Resident #1's RP (Responsible Party). He stated that his grandmother would have panicked, would not have been happy at all and would have been very fearful if the incident with Resident #2 had occurred prior to her Dementia diagnosis. On 04/09/2024 at 4:00 p.m., an interview was conducted with S6ADM (Administrator). S6ADM acknowledged he was aware of the sexual abuse incident that occurred on 03/02/2024 perpetrated by Resident #2 onto Resident #1. 2. Review of Resident #5's EHR revealed he was admitted to the facility on [DATE] with the following diagnoses, in part: Cerebral Infarction, Vascular Dementia-Unspecified Severity with Other Behavioral Disturbance, Sepsis, Metabolic Encephalopathy, and Acute Cystitis with Hematuria. Review of Resident #5's 5- Day MDS Assessment with an ARD (Assessment Reference Date) of 03/07/24 revealed a BIMS score of 09 indicating moderate cognitive impairment. Review of Resident #5's nursing progress notes dated 03/14/2024 at 8:54 p.m. per S3LPN (Licensed Practical Nurse) revealed Resident #5 being sent to hospital for behavior, hit roommate (Resident #2) in the head with his walking stick because Resident #2 bumped in Resident #5's bed and woke him up. Review of a form titled Incident Report revealed the incident occurred and was discovered on 03/14/2024 at 8:30 p.m. and entered into the state's electronic reporting system on 03/14/2024 at 8:43 p.m. Resident #2 was identified as the victim with an injury sustained of a laceration that required evaluation in the ER (Emergency Room) and the accused was identified as Resident #5 for an allegation of physical abuse. Further review of the Incident Report dated 03/14/2024 revealed Resident #5 was laying in his bed when his roommate, Resident #2, was trying to get by and bumped into Resident #5's bed. Resident #5 then hit Resident #2. Resident #5 is being sent to the hospital for psychological evaluation and Resident #2 is being sent to ER. Police have been notified. Review of S3LPN's handwritten statement revealed: Resident #2 was hit in the head by Resident #5; his roommate. Reason - he bumped his bed and keeps going in/out of his room waking him up and stares at him all day at 8:35 p.m. Review of S8CNA's (Certified Nursing Assistant) typed statement read: I was in the dining room with other residents when the nurse informed me that Resident #5 stated he hit Resident #2 in the head with his cane. I went down to the residents' room and observed Resident #2 laying on the bed bleeding from his head. I put a towel on the wound while the nurse called for help. On 04/08/2024 at 3:40 p.m., 04/09/2024 at 8:20 a.m., and 4/09/2024 at 4:30 p.m., interview attempts with S8CNA were unsuccessful. On 04/08/2024 at 5:15 p.m., an interview was conducted with S3LPN. S3LPN confirmed she was working the night of 03/14/2024 when the incident occurred between roommates Resident #2 and Resident #5. She stated Resident #5 came up to her at the nursing station and casually informed her that he had hit Resident #2 in the head with his cane and there was a lot of blood in their room. S3LPN assessed Resident #2 and observed a laceration on top of his head that required ER visit for sutures. Resident #5 was no longer in the facility. He had been discharged to home with family after the incident occured. 3. Review of Resident #3's EHR revealed he was admitted to the facility on [DATE] with the following diagnoses in part: Acute Respiratory Failure, Muscle Wasting and Atrophy, Liver Cell Cancer, Anxiety Disorder, Atrial Fibrillation and Cerebral Vascular Accident. Review of Resident #3's Significant Change MDS assessment revealed a BIMS score of 15 indicating he was cognitively intact. Resident #3 was unable to be interviewed due to actively transitioning on hospice services. Review of Resident #4's EHR revealed he was admitted to the facility on [DATE] with the following diagnoses in part: Unspecified Dementia- Unspecified Severity with Other Behavioral Disturbance, Major Depressive Disorder- Recurrent Severe with Psychotic Symptoms, Anxiety Disorder and Bipolar Disorder. Review of Resident #4 quarterly MDS assessment dated [DATE] revealed a BIMS score of 13 indicating his cognition was intact. Review of Resident #3's nursing progress notes revealed an entry dated 03/09/2024 at 1:42 p.m. per S4LPN: This Resident in dining room visiting with other residents when another resident started cursing and yelling. This resident told him to be quiet. Other resident did not stop cursing and this resident got up and went to his table and told him again to be quiet. Other resident then put fist up and said come on This resident states go ahead and hit me. Other resident then hit this resident in the eye. No other fighting noted. Very light pink area noted to this resident's outer eye. This resident is not complaining of pain. Family here and aware. Review of a form titled Incident Report revealed the incident occurred and was discovered on 03/09/2024 at 11:30 a.m. and entered into the state's electronic reporting system on 03/09/2024 at 12:52 p.m. Resident #3 was identified as the victim with an injury of redness to his eye. Resident #4 was identified as the accused for allegation of physical abuse. Further review of the Incident Report dated 03/09/2024 revealed Resident #4 and Resident #3 were playing bingo in the dining room. Resident #4 spoke ugly to another resident (Resident #6) so Resident #3 was defending her asking Resident #4 to stop speaking to her like that. Resident #4 then wheeled in his wheelchair to Resident #3 and hit Resident #3 in the eye. Resident #3's eye is red. Review of a handwritten statement per a family member of an unidentified resident/volunteer dated 03/09/2024 revealed, in part: I call 1 game of bingo and Resident #4 started after that game of Bingo was over and Resident #4 went off on Resident #6. Resident #4 told her to shut the f#@% up and that's when Resident #3 got up from his chair and Resident #4 was telling him to come on and Resident #3 went by Resident #4 and hit Resident #4 on the corner of his eye. Review of a handwritten statement per S10CNA dated 03/09/2024 revealed: Witnessed Resident #4 and Resident #3 getting into it. The 2 residents was passing licks (hitting/slapping) so she and the kitchen workers stopped them and Resident #4 was removed from the dining room .The kitchen staff told me that Resident #4 wanted to move Resident #6 and Resident #3 said get your hands off of her and Resident #4 said don't mess with me old man and Resident #3 then hit Resident #4. Review of S11NP's progress note (Nurse Practitioner) dated 03/15/2024 revealed Resident #3 was assessed for complaints of a headache and eye pain. S11NP's assessment revealed with recent contusion right eye, now with complaints of eye pain and headaches. Resident is currently alert, appropriate. Able to follow commands with normal eye movement, slight fading discoloration to eyelid; resident c/o (complaint of) pain to right eye periorbital and headache with pain level of 3/10. Skin inspection revealed redness to right periorbital area; Assessment and Plan= New Diagnoses: Headache and contusion right eye and plan to complete neuro (neurological) vital signs, prn (as needed) pain meds, may need further work up if any changes & continue hospice services. On 04/09/2024 at 10:10 a.m. an interview was conducted with Resident #4. The resident stated he felt safe living at the facility. The resident explained he recalled the incident last month when he was playing bingo in the dining room when Resident #3 started swinging at him so Resident #4 swung back striking Resident #3 in the eye. On 04/09/2024 at 11:35 a.m., an interview was conducted with S10CNA. S10CNA stated she recalled the incident between Resident #4 and Resident #3 on 03/09/2024 and confirmed she was working that day when the two were with other residents in the dining room playing bingo. She explained that the kitchen staff told her that Resident #4 wanted to move Resident #6 and Resident #3 said get your hands off of her and Resident #4 said don't mess with me old man and Resident #3 said hit me and then that's when the fight started. Resident #4 punched Resident #3 in the eye with his fist. S10CNA recalled Resident #3's eye was red. On 04/09/2024 at 1:00 p.m., an interview was conducted with S4LPN. S4LPN stated she was familiar with Resident #3 and Resident #4. She stated she was working on 03/09/2024 when she was informed Resident #4 hit Resident #3 in the eye during Bingo in the dining room. She stated that Resident #3 had redness noted to his eye and required in house monitoring only.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Respiratory Care (Tag F0695)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews the facility failed to properly store respiratory equipment for 1 resident (#7) out of 1 re...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews the facility failed to properly store respiratory equipment for 1 resident (#7) out of 1 resident (#7) investigated for respiratory care. Findings: Review of Resident #7's electronic health record revealed that she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Chronic Obstructive Pulmonary Disease, Chronic Respiratory Failure with Hypoxia, and Unspecified Diastolic Congestive Heart Failure. Review of Resident #7's MDS (Minimum Data Set) with an ARD (Assessment Review Date) of 01/16/2024 Section C (Cognitive Patterns) revealed she had a BIMS (Brief Interview for Mental Status) of 15, indicating she was cognitively intact. Further review of this MDS Section O, (Special Treatments, Procedures and Programs) revealed she was coded for Non-Invasive Mechanical Ventilator. Review of Resident #7's physician's orders revealed in part, BiPAP (Bi-level positive airway pressure) on for sleep at bedtime. Levalbuterol HCL (Hydrochloride) nebulization solution 1.25 mg (milligram)/3ml (millileter) 1 vial, inhale orally via nebulizer every 8 hours as needed for SOB (shortness of breath). On 04/04/2024 at 3:23 p.m., an observation and interview was conducted with Resident #7. An observation was made of this resident lying in her bed. She is awake, alert and oriented to person, place, and time. It was observed that her BiPAP mask was lying on her bedside table not stored properly and there was nothing available for storage. There was also a nebulizer mask dated 03/22/2024 on the mask that was also lying on the bedside table. There was no storage observed for the nebulizer mask. Resident #7 stated that she wore her BiPAP every night and that the staff placed in on her. She also stated that she received a nebulizer treatment when she was short of breath provided by the staff. Resident #7 stated that her BiPAP mask and her nebulizer mask were always left on her bedside table. On 04/04/2024 at 3:47 p.m., an observation and interview with S7LPN (Licensed Practical Nurse) was conducted. She confirmed that Resident #7's BiPAP mask and nebulizer mask was on her bedside table and not properly stored. She also confirmed that the date of 03/22/2024 on her nebulizer mask was outdated. She stated that the BiPAP should have been bagged and the nebulizer mask should have been changed weekly and both had not been done. On 04/08/2024 at 2:13 p.m., an observation and interview with S1ADON (Assistant Director of Nursing) was conducted. Resident #7's BiPAP mask was lying on resident's bedside table, not stored properly. S1ADON confirmed that Resident #7's BiPAP mask was not stored properly and that it should have been stored in a bag. A policy for respiratory storage was requested from S1ADON and never received. On 04/09/2024 at 9:30 a.m., a policy on respiratory equipment storage was requested from S6ADM (Administrator). He stated that he would look for one. No policy was received. On 04/09/2024 at 1:25 p.m., a second request was made for a policy on respiratory equipment storage to S1ADON. She stated that she could not provide a policy and that respiratory equipment such as Resident #7's BiPAP and nebulizer should be stored in a bag and in addition the nebulizer mask should have been labeled.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0568 (Tag F0568)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to provide quarterly statements of personal funds for 1 (Resident #7)...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to provide quarterly statements of personal funds for 1 (Resident #7) of 1 resident investigated for personal funds. The deficient practice had the potential to affect a census of 80 residents. Findings: Review of Resident #7's electronic health record revealed that she was admitted to the facility on [DATE] with diagnoses that included Chronic Obstructive Pulmonary Disease, Chronic Respiratory Failure with Hypoxia, and Unspecified Diastolic Congestive Heart Failure. Review of Resident #7's MDS (Minimum Data Set) with an ARD (Assessment Review Date) of 01/16/2024 Section C (Cognitive Patterns) revealed she had a BIMS (Brief Interview for Mental Status) of 15, indicating she was cognitively intact. On 4/04/2024 at 3:23 p.m., an interview was conducted with Resident #7. She stated that the facility was in charge of her funds and that she had not been given a statement in over 2 years. She stated that she would like to know what was in her account. On 4/09/2024 at 10:00 a.m., an interview was conducted with S9BOM (Business Office Manager) in regards to Resident #7's personal funds statements. She stated that she had provided Resident #7 with her quarterly statement in January 2024 for the last quarter of the year 2023, but she did not have any documentation that she had done this. S9BOM confirmed that there was no documentation of Resident #7 receiving any quarterly statements for 2023 and there should be.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews, the facility failed to develop a resident centered comprehensive care plan...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews, the facility failed to develop a resident centered comprehensive care plan for 3 (#2, #4, #7) out of a finalized sample of 7 residents as evidenced by: 1. Failing to identify and plan for Resident #2's diagnosis of Sexual Dysfunction, 2. Failing to follow physician's orders to increase Resident #4's medication, 3. Failing to identify and plan for Resident #7's BIPAP (Bi-level Positive Airway Pressure) machine, 4. Failing to follow physician's orders to apply creams, change oxygen tubing, and clean oxygen concentrator filter for Resident #7. This deficient practice had the potential to affect a total census of 80 residents. Findings: 1. Resident #2 A record review of Resident #2's EHR (Electronic Health Record) revealed he was admitted to the facility on [DATE] with diagnoses in part: Vascular Dementia, Aphasia, Mood Disorder, Sexual Dysfunction, and Disorder of Adult Personality and Behavior. A review of Resident #2's care plan revealed the facility failed to identify the resident's Sexual Dysfunction diagnosis. A review of Resident #2's Nurse's Notes revealed documentation of the following behaviors: 09/01/2023 6:41 a.m .Fondling himself at the table, counseled at this time. 09/01/2023 7:56 a.m .fondling himself again. 09/09/2023 4:35 p.m .resident motioning for female resident to follow him. 09/10/2023 11:30 a.m .noted to be fondling self in dining room in front of female residents. 09/15/2023 10:39 a.m .touching the aide inappropriate ways on her bottom .continued to touch aid on her bottom. 09/16/2023 7:30 p.m .noted on two separate occasions, patted them on the bottom. 09/30/2023 2:13 a.m .observed resident to be masturbating. 12/23/2023 6:43 p.m .resident took off brief in dining area in front of other residents. 03/02/2024 4:42 p.m .observed in dining room physical inappropriately touched another residents breast. 03/02/2024 9:15 p.m .observed on 1:1 (continuous observation), rubbing his penis through clothing attempting to masturbate. On 04/04/2024 at 3:00 p.m., an interview was conducted with S2MDS (Minimum Data Set). S2MDS confirmed she is responsible for developing and updating all resident care plans. S2MDS confirmed that Resident #2 had a diagnosis of Sexual Dysfunction upon admission. She reviewed Resident #2's care plan and nurse's notes, and confirmed that neither the diagnosis for Sexual Dysfunction, nor any of his sexual behaviors were identified in his plan of care and should have been. On 04/09/2024 at 1:15 p.m., an interview was conducted with S1ADON (Assistant Director of Nursing). She confirmed Resident #2's admission diagnosis of Sexual Dysfunction as well as the documented incidents' of sexual behaviors. She viewed and confirmed that neither the resident's diagnosis for Sexual Dysfunction, nor his sexual behaviors were identified in his care plan and should have been. Resident #7 Findings: Review of Resident #7's electronic health record revealed that she was admitted to the facility on [DATE] with diagnoses that included Chronic Obstructive Pulmonary Disease, Chronic Respiratory Failure with Hypoxia, and Unspecified Diastolic Congestive Heart Failure. Review of Resident #7's MDS (Minimum Data Set) with an ARD (Assessment Review Date) of 01/16/2024 Section C (Cognitive Patterns) revealed she had a BIMS (Brief Interview for Mental Status) of 15, indicating she was cognitively intact. Further review of this MDS Section O (Special Treatments, Procedures and Programs) revealed she was coded for Non-Invasive Mechanical Ventilator and receiving Oxygen Therapy. Review of Resident #7's active care plan revealed it did not include a plan of care for BiPAP. Review of active physician's orders for Resident #7 revealed the following orders: 1. Apply antifungal powder and pillow case to bilateral breasts for redness BID (twice a day) and PRN (as needed) every day and evening shift for redness under breast. 2. Apply Barrier Cream to Coccyx Daily and PRN as preventative every shift for preventative. 3. BiPAP (Bi-level positive airway pressure) on for sleep at bedtime related to Chronic Obstructive Pulmonary Disease, Unspecified. 4. Oxygen - clean oxygen concentrator filter weekly every night shift every Thursday for maintenance. 5. Oxygen 2L(Liters)/NC(Nasal Cannula) continuously every shift for SOB (Shortness of Breath). 6. Oxygen Tubing- Change Weekly every night shift every Thursday. 7. Triamcinolone cream apply to outer right ear and left forearm bid (two times a day) please have padding to her glasses and oxygen tubing that goes over right ear two times a day. Review of the TAR (Treatment Administration Record) for January 2024 through April 2024 revealed the following: Oxygen tubing changing weekly on Thursdays had not been done for 3 Thursdays. Oxygen concentrator filter cleaning weekly on Thursdays had not been done for 3 Thursdays. The application of the antifungal powder had not been applied for a total of 11 doses. The application of the barrier cream to coccyx had not been applied for a total of 14 doses. The Triamcinolone cream to outer right ear had not been done for a total of 18 doses. On 04/04/2024 at 3:23 p.m., an interview was conducted with Resident #7. She stated that staff had not been applying her barrier cream to coccyx and antifungal powder underneath her breasts as they should have been. On 4/04/2024 at 4:18 p.m., an interview and record review with S2MDSN (Minimum Data Set Nurse) was conducted. S2MDSN confirmed that Resident #7 was not care planned for BiPAP and she should have been. On 4/08/2024 at 1:48 p.m., a record review and interview was conducted with S1ADON of Resident #7's TAR for January 2024 through April 2024. She confirmed that the oxygen tubing had not been changed weekly, oxygen concentrator filter had not been changed weekly and that the barrier cream, antifungal powder and triamcinolone cream all had multiple doses missing and that these should have been performed. 2. Resident #4 Review of Resident #4's EHR revealed he was admitted to the facility on [DATE] with the following diagnoses in part: Unspecified Dementia- Unspecified Severity with Other Behavioral Disturbance, Major Depressive Disorder- Recurrent Severe with Psychotic Symptoms, Anxiety Disorder and Bipolar Disorder. Resident #4 was care planned for having a behavior problem r/t (related to) history of cursing staff, threatening staff, disorganized thinking. Dx (Diagnoses) of Bipolar D/o (Disorder), anxiety, depression with an intervention to administer medications as ordered. Review of Resident #4's active April 2024 physician's orders revealed an order with a start date of 09/10/2021 for Buspirone tablet- Give 5 mg (milligram) by mouth two times a day for anxiety. Review of Resident #4 EHR revealed he was hospitalized at an inpatient behavioral hospital from [DATE] thru 03/22/2024. His admission treatment plan dated 03/10/2024 revealed an order to increase Buspirone (Buspar) 5 mg tablet to TID (three times daily). Review of Resident #4's discharge medication list dated 03/22/2024 revealed to continue taking Buspirone 5 mg oral tablet three times a day for anxiety. Review of Resident #4's March 2024 eMAR (electronic Medication Administration Record) revealed he was administered Buspirone 5 mg oral tablet two times a day from 03/22/2024 thru 03/31/2024. Review of Resident #4's April 2024 eMAR revealed he was administered Buspirone 5 mg oral tablet two times a day from 04/01/2024 thru 04/09/2024. On 04/09/2024 at 10:26 a.m., an interview was conducted with S5LPN who verified she was the nurse for Resident #4. She stated he did have a diagnosis of anxiety and reviewed the resident's current eMAR. S5LPN confirmed Resident #4 received ordered Buspirone 5 mg oral tab two times a day. On 04/09/2024 at 1:51 p.m., an interview was conducted with S1ADON (Assistant Director of Nursing) who explained either herself or the DON (Director of Nursing) reviewed readmission paperwork, including hospital records, for residents who were readmitted to facility from a hospital. S1ADON confirmed Resident #4 was hospitalized at an inpatient behavioral hospital from [DATE] thru 03/22/2024 and that the former DON reviewed his readmission paperwork. S1ADON confirmed Resident #4 was administered Buspirone 5 mg oral tablet twice a day from 03/22/2024 through 04/09/2024. S1ADON reviewed Resident #4's EHR and confirmed his Buspirone 5 mg oral tablet should have been increased to three times a day per the behavioral hospital's discharge medication list dated 03/22/2024 and was not increased.

Mar 2024 2 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to obtain routine medication as ordered by the physician to meet the...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to obtain routine medication as ordered by the physician to meet the needs of 1 (#3) out of 3 (#1, #2, #3) sampled residents. Findings: Resident #3 was admitted to the facility on [DATE] at 6:30 p.m. with diagnoses that included in part, Encephalopathy, Type 2 Diabetes Mellitus, Hypertensive Heart Disease with Heart Failure, Nonalcoholic Steatohepatitis, Low Back Pain, and Fibromyalgia. On 03/25/2024, a review of Resident #3's admitting Physician Orders revealed the following orders: 03/01/2024 Atorvastatin 40 milligrams (mg) -Give by mouth one time a day 03/01/2024 Carboxymethylcellulose sodium ophthalmic Gel 1% - Instill 1 drop in both eyes every 4 hours as needed for pain 03/02/2024 Furosemide 20 mg -Give 20 mg one time a day 03/02/2024 Insulin Glargine -Inject 28 units subcutaneously two times a day 03/02/2024 Insulin Lispro -Inject 5 units subcutaneously three times a day 03/01/2024 Lactulose - Give 40 milliliters (ml) by mouth three times a day 03/02/2024 Metoprolol tartrate 50 mg -Give 50 mg by mouth two times a day 03/02/2024 Miconazole Nitrate Powder 2% - Apply to vaginally topically as needed for dry skin 03/02/2024 Miconazole Nitrate Powder 2% - Apply to vaginally topically two times a day 03/01/2024 Ondansetron 4 mg - Give 4 mg by mouth every 8 hours as needed for Nausea/ Vomiting 03/01/2024 Pantoprazole Sodium -Give 40 mg by mouth one time a day 03/01/2024 Spironalectone 25mg - Give 25 mg by mouth two times a day 03/01/2024 Aquaphor External Ointment - Apply to buttocks topically as needed for dry skin 03/02/2024 Glucagon Emergency Injection Kit 1 mg - Inject 1 mg intramuscularly as needed A review of Resident #3's Electronic Health Record revealed the following Nurse Notes in part: On 03/02/2024 at 10:51 a.m., Resident complained of (c/o) pain (no pain meds present). BS (blood sugar): 189 (no insulin present). A review of Resident #3's Medication Administration Record (MAR) for March 2024 revealed medications scheduled for 03/02/2024 at 8:00 a.m. (Insulin Glargine 28 units, Miconazole Nitrate topical, Spironalactone 25 mg, and Lactulose 40 ml) contained the number 9 (Chart Code 9=hospitalized ) in the box where nurses initial as administered. Further review, revealed medications scheduled for 03/02/2024 at 9:00 a.m. (Atorvastatin 40 mg, Furosemide 20 mg, Pantoprazole Sodium 40 mg, Metoprolol Tartrate 50 mg, Insulin Lispro 5 units) also contained a 9 indicating the resident was hospitalized . On 03/26/2024 at 10:44 a.m., an interview was conducted with S4LPN (Licensed Practical Nurse). S4LPN stated that she provided care for Resident #3 on 03/02/2024 and did not have any medications available to administer. S4LPN stated Resident #3's blood sugar was high and she complained of pain, but there was no pain medication or insulin for the resident. On 03/26/2024 at 12:35 p.m., a review of Resident #3's EHR (electronic health record) and interview with S2DON (Director of Nursing) and S3ADON (Assistant Director of Nursing) was conducted. S3ADON reviewed Resident #3's MAR for March 2024 and confirmed her medications were not administered. S2DON confirmed the ordered medications were not available in the facility and should have been. On 03/26/2024 at 2:42 p.m., a telephone interview was conducted with the pharmacist who stated Resident #3's physician orders was received via fax on 03/02/2024 at 2:34 a.m. She stated the pharmacy hours are Monday through Friday from 7:00 a.m. to 5:00 p.m. She was not aware of the orders until the morning of 03/04/2024. She stated the facility should have called the called to inform the pharmacy of new orders in addition to faxing them and the medications would have been filled and delivered. On 03/26/2024 at 3:56 p.m., an additional interview was conducted with S2DON. S2DON confirmed the physician orders should have been faxed to the pharmacy and the nurse should have called to the pharmacy to notify them of the new orders.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0760 (Tag F0760)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure residents are free significant medication errors for 1 (#3)...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure residents are free significant medication errors for 1 (#3) out of 3 (#1, #2, #3) sampled residents. Findings: Resident #3 was admitted to the facility on [DATE] at 6:30 p.m. with diagnoses that included in part, Encephalopathy, Type 2 Diabetes Mellitus, Hypertensive Heart Disease with Heart Failure, Nonalcoholic Steatohepatitis, Low Back Pain, and Fibromyalgia. On 03/25/2024, a review of Resident #3's admitting Physician Orders revealed the following orders: 03/01/2024 Atorvastatin 40 milligrams (mg) -Give by mouth one time a day 03/01/2024 Carboxymethylcellulose sodium ophthalmic Gel 1% - Instill 1 drop in both eyes every 4 hours as needed for pain 03/02/2024 Furosemide 20 mg -Give 20 mg one time a day 03/02/2024 Insulin Glargine -Inject 28 units subcutaneously two times a day 03/02/2024 Insulin Lispro -Inject 5 units subcutaneously three times a day 03/01/2024 Lactulose - Give 40 milliliters (ml) by mouth three times a day 03/02/2024 Metoprolol tartrate 50 mg -Give 50 mg by mouth two times a day 03/02/2024 Miconazole Nitrate Powder 2% - Apply to vaginally topically as needed for dry skin 03/02/2024 Miconazole Nitrate Powder 2% - Apply to vaginally topically two times a day 03/01/2024 Ondansetron 4 mg - Give 4 mg by mouth every 8 hours as needed for Nausea/ Vomiting 03/01/2024 Pantoprazole Sodium -Give 40 mg by mouth one time a day 03/01/2024 Spironalectone 25mg - Give 25 mg by mouth two times a day 03/01/2024 Aquaphor External Ointment - Apply to buttocks topically as needed for dry skin 03/02/2024 Glucagon Emergency Injection Kit 1 mg - Inject 1 mg intramuscularly as needed A review of Resident #3's Medication Administration Record (MAR) for March 2024 revealed medications scheduled for 03/02/2024 at 8:00 a.m. (Insulin Glargine 28 units, Miconazole Nitrate topical, Spironalactone 25 mg, and Lactulose 40 ml) contained the number 9 (Chart Code 9=hospitalized ) in the box where nurses initial as administered. Further review, revealed medications scheduled for 03/02/2024 at 9:00 a.m. (Atorvastatin 40 mg, Furosemide 20 mg, Pantoprazole Sodium 40 mg, Metoprolol Tartrate 50 mg, Insulin Lispro 5 units) also contained a 9 indicating the resident was hospitalized . On 03/26/2024 at 12:35 p.m., a review of Resident #3's EHR (Electronic Health Record) and interview with S2DON (Director of Nursing) and S3ADON (Assistant Director of Nursing) was conducted. S3ADON reviewed Resident #3's MAR for March 2024 and confirmed her medications scheduled for 03/02/2024 at 8:00 a.m. and 9:00 a.m. were not administered. S4DON confirmed the medications were not available in the facility and should have been available and administered per the physician's orders.

Jan 2024 3 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Transfer Notice (Tag F0623)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to notify the State Long Term Care Ombudsman of facility-initiated tra...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to notify the State Long Term Care Ombudsman of facility-initiated transfers for 1 (Resident #1) out of 3 (#1, #2, #3) sampled residents. The deficient practice has the potential to affect a census of 61. Findings: On 01/30/2024, a request was made for the facility's policy for Ombudsman notifications of hospital transfers. No policy was provided by the time of exit. Review of Resident #1's medical record revealed that the resident was admitted to the facility on [DATE] with diagnoses that read in part; Interstitial Pulmonary Disease, Unspecified Dementia, and Parkinsonism. Review of Resident #1's nurses' notes revealed on 12/31/2023 at 14:42 (2:24 p.m.), the resident was sent to the hospital and returned on 12/31/2023 at 19:56 (7:56 p.m.). Review of the Emergency Transfer Log for December 2023 revealed no documented evidence that Resident #1's transfer to the hospital on [DATE] was not identified on the log. On 01/29/2024 at 3:45 p.m., an interview was conducted with S4SSD. She confirmed she was responsible for the Emergency Transfer Log. S4SSD reviewed the Resident #1's EMR (Electronic Medical Record) and confirmed the resident was transferred to the hospital on [DATE]. She reviewed the Emergency Transfer Log for December 2023 and confirmed the resident was not listed as having been transferred on that date. She stated she thought that only facility discharges that resulted in hospital admissions were documented on the log and was unaware that the log should also identify facility initiated transfers. On 01/30/2024 at 12:15 p.m., an interview was conducted with S2DON. S2DON reviewed Resident #1's EMR and confirmed he was transferred to the hospital on [DATE]. S2DON reviewed the facility's Emergency Transfer Log for December 2023 and confirmed that Resident #1's hospital transfer on 12/31/2023 was not on the log and should have been.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record reviews, the facility failed to implement a residents' plan of care by failing to provide docume...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record reviews, the facility failed to implement a residents' plan of care by failing to provide documented evidence that monitoring of behaviors and adverse reactions was conducted for 2 (#1 and #3) out of 3 (#1, #2, #3) residents who received an antipsychotic and/or antidepressant medications. Findings: Resident #1 Review of Resident #1's medical record revealed that the resident was admitted to the facility on [DATE] with diagnoses that read in part; Interstitial Pulmonary Disease, Unspecified Dementia, and Parkinsonism. Review of Resident #1's physician's orders dated 01/01/2024 - 01/31/2024 revealed an order for Seroquel (an antipsychotic medication) 25mg (milligram) by mouth two times a day. Review of Resident #1's care plan revealed, in part, to include the following: The resident is at risk for adverse reactions r/t (related to) antipsychotic medication .Monitor for possible signs and symptoms of adverse drug reactions. Further review of the care plan revealed, in part, The resident has a behavior problem .Monitor behavior episodes. Review of Resident #1's EMAR (Electronic Medication Administration Record) revealed there was no documented evidence that monitoring was performed. On 01/29/2024 at 3:00 p.m., an interview was conducted with S3ADON who reported residents who received an antipsychotic medication must be monitored for behaviors and adverse reactions and it should be documented on the resident's EMAR. S3ADON confirmed Resident #1 was receiving an antipsychotic medication and confirmed the monitoring was not documented on the resident's EMAR and it should have been. Resident #3 Review of Resident #3's medical record revealed that the resident was admitted to the facility on [DATE] with diagnoses that read in part; Rhabdomyolysis, Depression, Chronic Kidney Disease Stage 3, and Unspecified Dementia. Review of Resident #3's physician's orders for the month of January 2024 revealed an order for Venlafaxine (an antidepressant medication) 75mg (milligram) by mouth two times a day. Review of Resident #3's care plan revealed, in part, to include the following: The resident is at risk for adverse reactions r/t (related to) antidepressant medication .Monitor for possible signs and symptoms of adverse drug reactions. Further review of the care plan revealed, in part, The resident depression .monitor/document/report to MD PRN (occasional) ongoing signs of depression. Review of Resident #3's EMAR (Electronic Medication Administration Record) revealed there was no documented evidence that monitoring was performed. On 01/30/2024 at 12:15 p.m., an interview was conducted with S2DON who reported residents who received antidepressant medications must be monitored for behaviors and adverse reactions. She stated the nurse's should document the monitoring on the resident's EMAR. S2DON confirmed Resident #3 was receiving an antidepressant medication and confirmed the monitoring was not documented on the resident's EMAR and should have been.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interview, the facility failed to ensure quality of care in accordance with professional standards o...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interview, the facility failed to ensure quality of care in accordance with professional standards of practice for 1 (#1) of 3 (#1, #2, #3) sampled residents for unwitnessed falls. This was evidenced when 72 hours of neuro-checks were not complete after an unwitnessed fall and hit their head. Findings: A review of the facility's policy titled, Neurological Assessment read in part: 1. Neurological assessments will be completed .b. following an unwitnessed fall c. Following a fall or other accident/injury involving head trauma. 3. Neurological assessments (neuro checks) will be done every 15 minutes for the first hour, then every 30 minutes x2, every hour x6, every 4 hours x4, every 8 hours x6 for a total of 72 hours. A. if the schedule should be interrupted due to transfer to hospital, the schedule will be resumed upon return from the hospital. Review of Resident #1's medical record revealed that the resident was admitted to the facility on [DATE] with diagnoses that read in part; Interstitial Pulmonary Disease, Unspecified Dementia, and Parkinsonism. Review of the facility's incident reports revealed Resident #1 had an unwitnessed fall on 12/31/2023 in which he sustained an injury to his head. Review of Resident #1's EMR (Electronic Medical Record) failed to contain documentation of any neuro checks. An interview and review of Resident #1's EMR was done on 01/29/2024 at 3:00 p.m. with S3ADON. S3ADON confirmed the resident's unwitnessed fall with a head injury from 12/31/2023 and that this injury required neuro checks. Further review of the residents EMR confirmed there was no evidence that neuro checks were conducted.

Dec 2023 1 deficiency

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident 3 Resident #3 was admitted to the facility on [DATE] with diagnoses that included Hypertension, Anemia, Chronic Kidney ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident 3 Resident #3 was admitted to the facility on [DATE] with diagnoses that included Hypertension, Anemia, Chronic Kidney Disease, Anxiety Disorder and Atrial Fibrillation. Review of Resident #3's physician's orders dated 06/22/2022 revealed an order to apply barrier cream every shift for preventative measures. Further review of the physician's orders revealed an order began 10/27/2023 for Hydralazine HCL oral tablet 10 mg (milligram), give 2 tablets by mouth two times a day for Hypertension - Hold for Systolic Blood Pressure less than 110 mmHg (millimeters of mercury). Review of the MAR/TAR (Medication Administration Record/Treatment Administration Record) for November 2023 revealed 29 missed doses of barrier cream. Review of the December 2023 MAR/TAR revealed a total of 14 missed doses of barrier cream. Further review of the MAR/TAR for November 2023 revealed 12 doses where Hydralazine was administered when the blood pressure was less than 110 mmHg. Review of the December 2023 MAR/TAR revealed Hydralazine was administered a total of 7 doses when the systolic blood pressure was less than 110 mmHg. On 12/28/2023 at 1:39 p.m., a record review and interview was conducted with S3LPN (Licensed Practical Nurse). Review of Resident #3's MAR for December 28, 2023 revealed that Hydralazine 10 mg had been administered and a systolic blood pressure of 104 mmHg was documented. S3LPN confirmed that she had administered the medication to the resident for this dose and that the medication should not have been given with a systolic blood pressure of 104 mmHg. On 12/28/2023 at 1:58 p.m., a record interview and immediate interview was conducted with S1DON (Director of Nursing) and S2ADON (Assistant Director of Nursing). A review of Resident #3's MAR/TAR for November 2023 and December 2023. S1DON and S2ADON both confirmed that the barrier cream had not been administered as ordered and included multiple missing doses. S1DON and S2ADON also confirmed that Hydralazine 10 mg had been given for multiple systolic blood pressures of less than 110 mmHg and should not have been given. Based on record reviews and interviews, the provider failed to ensure nursing personnel and/or other direct care personnel followed physician's orders for 3 (#1, #2, and #3) of 3 sampled residents. The facility census was 64. Findings Resident #1 Review of resident #1's medical records revealed she was admitted to the facility on [DATE] with diagnoses including Psychotic Disturbance, Mood Disturbance, Anxiety Disorder, Essential Hypertension, Hyperlipidemia, Essential Tremor, Major Depressive Disorder, Dysphagia, Drug Induced Subacute Dyskinesia, Non-Rheumatic Aortic Valve Stenosis, Personal History of TIA (Transient Ischemic Attack) and Cerebral Infarction without Residual Deficits, and Presence of a Cardiac Pacemaker. Review of current physician's orders for Resident #1 indicated a start date of 08/13/2023 for Resident #1 was to have barrier cream applied to her sacral/coccyx area every shift. Review of Resident #1's December 2023 TAR (Treatment Administration Record) indicated that barrier cream was not applied to Resident #1's sacral/coccyx area on the day shifts of December 2nd, 8th, and 28th; on the evening shifts of December 2nd, 10th, 12th, 23rd, and 24th; and on the night shifts of December 4th, 5th, 10th, 22nd, and 23rd. During a staff interview conducted with S2ADON (Assistant Director of Nursing) on 12/28/2023 at 4:35 p.m., she confirmed that nurses and nurse aids were scheduled to work three shifts throughout a 24 hour day. She stated those shifts were the day shift from 7:00 a.m. to 3:00 p.m., the evening shift from 3:00 p.m. to 11:00 p.m., and the night shift from 11:00 p.m. to 7:00 a.m. S2ADON verified that any physician's order that indicated it was to be administered each shift was understood to be given 3 times each day, once during each shift. S2ADON confirmed Resident #1's physician's orders were current. When a review of Resident #1's December 2023 TAR was conducted with S2ADON, she verified that there was no indication that barrier cream was applied to Resident #1's sacral/coccyx area on the day shifts of December 2nd, 8th, and 28th; on the evening shifts of December 2nd, 10th, 12th, 23rd, and 24th; and on the night shifts of December 4th, 5th, 10th, 22nd, and 23rd. Resident #2 Review of resident #2's medical record indicated she was initially admitted to the facility on [DATE] with diagnoses that included COPD (Chronic Obstructive Pulmonary Disease), Acute & Chronic Respiratory Failure, Cognitive Communication Deficit, Morbid (Severe) Obesity, Anxiety Disorder, Hypertension, Polyneuropathy, Hypertensive Heart Disease with Heart Failure, Hyperlipidemia, Bipolar Disorder, Vitamin Deficiency, Iron Deficiency, Cerebrovascular Disease, Chronic Arterial Fibrillation, Dyspnea, Bipolar Disorder with Psychotic episodes, Hypothyroidism, Major Depressive Disorder, Osteoarthritis, and GERD (Gastroesophageal Reflux Disease). Review of current physician's orders for Resident #2 indicated a start date of 03/03/2023 for antifungal powder to be applied to bilateral breasts twice daily, every day and evening shift. Also, an order to apply barrier cream to her buttock every shift began 09/07/2023. Another order instructed to apply skin prep to her right heel every day shift, beginning 12/05/2023. Lastly, an order to apply Triamcinolone cream to her outer right ear and left forearm, and to have padding to her glasses and oxygen tubing that goes over her right ear began 07/27/2022. Review of Resident #2's December 2023 TAR failed to indicate: - antifungal powder was applied to bilateral breasts twice daily, every day and evening shift, - barrier cream was applied to her buttock every shift, - skin prep was applied to her right heel every day shift, beginning 12/05/2023, - Triamcinolone cream was applied to her outer right ear and left forearm, and her glasses and oxygen tubing that goes over her right ear were padded. During a staff interview conducted with S2ADON on 12/28/2023 at 4:35 p.m., she again confirmed that nurses and nurse aids were scheduled to work three shifts throughout a 24 hour day, as defined above. S2ADON confirmed that Resident #2's physician's orders were current. When a review of Resident #2's December 2023 TAR was conducted with S2ADON, she verified that there was no indication that antifungal powder was applied to her breasts on the day shifts of December 2nd through 5th, 12th, and 24th, and during the evening shifts of December 6th, 24th and 25th, as ordered. Further review of Resident #2's December 2023 TAR, with S2ADON, confirmed there was no indication that skin prep was applied to Resident #2's right heel on December 5th, 12th, and 24th. S2ADON also confirmed that the December 2023 TAR failed to indicate that Triamcinolone cream was applied to her outer right ear and left forearm, and that padding to Resident #2's glasses and oxygen tubing over her right ear was indicated on the day shift of December 2nd - 5th, 12th, and 24th, and on the evening shifts of December 6th, 24th and 25th. Lastly, S2ADON confirmed that Resident #2's December TAR failed to indicate that barrier cream was applied to her buttock, as ordered for each shift, specifically, during the day shifts on December 2nd - 5th, 12th, and 24th; evening shifts of December 6th, 24th and 25th; and night shifts of December 4th, 5th, 10th, 16th, and 22nd.

Sept 2023 4 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0554 (Tag F0554)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to assess 1 (#1) out of 1 (#1) residents for self-administration of m...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to assess 1 (#1) out of 1 (#1) residents for self-administration of medication by the Interdisciplinary Team (IDT) to determine that this practice is clinically appropriate in a sample of 3 (#1, #2, #3) residents. Findings: A review of Resident #1's clinical record revealed that he was admitted to the facility on [DATE] with diagnoses that included in part: Chronic Obstructive Pulmonary Disease (COPD), Chronic Respiratory failure with Hypoxia, Hypertensive Heart Disease, Heart Failure, Dependence on Supplemental Oxygen, Tobacco use, and Peripheral Vascular Disease (PVD). A review of Resident #1's Minimum Data Set (MDS) Annual assessment with an Assessment Reference Date (ARD) of 07/27/2023 revealed that he had a Brief Interview for mental status (BIMS) score of 15 which indicated resident was cognitively intact. A review of Resident #1's care plan included: Resident #1 wishes to self- administer nebulizer treatments. Interventions included the following in part: Obtain order for self-administration from attending provider. Perform medication self -administration assessment. Review ability to self-administer medication at least quarterly. A review of Resident #1's electronic medical record revealed a physician's order dated 09/03/2021 that read: Ipratropium-Albuterol solution 0.5-2.5 (3 milligrams (mg)/ 3 milliliters (ml) 1 vial inhale orally every 4 hours for shortness of breath (SOB). Resident may keep at bedside. A further review of Resident #1's physician orders revealed there was no order for self-administration from the attending physician. A further review of Resident #1's electronic medical record revealed there was no assessment for Resident Self Administration of medication since he admitted on [DATE]. A review of Resident #1's Electronic Medical Record (EMAR) for September 2023 revealed that he received Ipratropium-Albuterol solution 0.5-2.5 (3mg/3ml) 1 vial inhale orally every 4 hours as ordered. On 09/20/2023 at 2:46 p.m., an interview was conducted with S3LPN who confirmed Resident #1 self-administered his nebulizer treatments every 4 hours. S3LPN stated that she only reminded resident when it was time to administer treatment. On 09/21/2023 at 7:00 a.m., an interview was conducted with S4RN who confirmed Resident #1 self-administered his nebulizer treatments every 4 hours as ordered. S4RN confirmed that she only provided reminders to Resident #1 to self-administer nebulizer treatment as ordered. On 09/21/2023 at 3:40 p.m., an interview was conducted with S7MDS (Minimum Data Set Nurse), who confirmed Resident #1 did not have a Resident Self-Administration assessment since he admitted on [DATE]. She confirmed that Resident #1's care plan related to self-administration of nebulizer treatments included the intervention of perform medication self-administration assessment and to review quarterly. On 09/25/2023 at 10:20 a.m., an interview was conducted with S2DON who confirmed the facility did not have a policy for self-administration of medication. She confirmed Resident #1 had not been assessed nor had a physician's order to self-administer his nebulizer treatments. She confirmed the nursing staff should have administered Resident #1's nebulizer treatments.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0678 (Tag F0678)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, record review and interviews, the facility failed to ensure nursing staff provided Basic Life Support (B...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, record review and interviews, the facility failed to ensure nursing staff provided Basic Life Support (BLS), including notifying Emergency Medical Services (EMS) of a resident that was unresponsive with full code status according to the policy and procedure for 1 (#1) of 3 (#1, #2, #3) sampled residents. Findings: A review of the policy titled Emergency Procedure - Cardiopulmonary Resuscitation revealed the following in part: 7) The goal of early delivery of CPR is to try to maintain life until the emergency medical response team arrives to deliver Advanced Life Support (ALS). Staff will call 911 when CPR is initiated. Begin CPR if the adult victim is unresponsive and not breathing normally without assessing the victim's pulse. Following initial assessment, begin CPR with chest compressions rather than opening the airway and delivering rescue breathing. Provide ventilations with a compression-ventilation ratio of 30:2. A review of Resident #1's electronic medical record revealed that he admitted to the facility on [DATE] with diagnoses that included in part: Chronic Obstructive Pulmonary Disease (COPD), Chronic Respiratory failure (CRF) with hypoxia, Heart Failure, Dependence on Supplemental Oxygen, Tobacco use, and Peripheral Vascular Disease (PVD). Resident #1 had a Code status of Full Code. A review of Resident #1's Care Plan revealed the following in part: 1) The resident had CRF with hypoxia and was dependent on oxygen. Interventions included in part: Monitor for signs and symptoms of respiratory distress and report to MD (Doctor of Medicine) As needed (PRN). Interventions included: Ensure resident's wishes are honored in regard to any Advanced Directive. Code Status: Full Code. A review of Resident #1's Nurse Notes revealed the following note written by S4RN: On [DATE] at 12:50 a.m., making rounds and I found Resident #1 in the position of trying to get back in bed from being in the bathroom, he was stiff and skin purple, his left arm extended upward and right arm down and both knees bent, unable to move any of his extremities, placed him on the floor and unable to do CPR chest not moving. Notified S2DON, notified MD (medical doctor) on call and notified coroner's office. On [DATE] at 7:00 a.m., an interview was conducted with S4RN who stated that on [DATE] at 12:30 a.m., she went to Resident #1's room to take his pulse oximetry reading and found Resident #1 unresponsive. She then performed shake and shout three times with no response. The resident was on his knees on the floor laying across the bed. His right arm was up in air and his left arm was by his side. She stated at that time she did not feel for a pulse. She then turned the resident and observed his face which was purple. S4RN stated that she did not immediately begin chest compressions. She instead ran to the desk and called code blue overhead. S5CNA arrived to Resident #1's room and started chest compressions while S4RN went to get crash cart, then returned to Resident #1's room. She went to the desk to call the nurse practitioner at 12:50 a.m. and informed her of the resident's status. She returned to Resident #1's room and told S5CNA to stop chest compressions. S4RN stated she did not call Emergency Medical Service (EMS) but should have done so. On [DATE] at 12:01 p.m., an interview was conducted with S2DON who stated that on [DATE] at 1:00 a.m. she received a telephone call from S4RN to notify her that Resident #1 was found unresponsive, CPR had been initiated, and the medical doctor had been notified. S2DON stated that S4RN notified her [DATE] at 8:00 a.m. that she did not call EMS. S2DON stated that normal protocol for an unresponsive resident that had a full code status was to start chest compressions and call EMS. She stated chest compressions should continue until EMS takes over, a physician orders to stop chest compressions, or the resident is revived. S2DON confirmed that S4RN did not call EMS, but should have done so.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0726 (Tag F0726)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, record review, and interviews, the facility's staff failed to assess and monitor a resident who had a si...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, record review, and interviews, the facility's staff failed to assess and monitor a resident who had a significant change of respiratory status for 1(#1) of 3 (#1, #2, #3) residents sampled. Findings: A review of the policy titled Significant Condition Change and Notification included the following in part: To ensure that the resident's family and medical practitioner are notified of resident changes that included sudden onset of shortness of breath, significant change in/or unstable vital signs. The medical practitioner will be contacted immediately for any emergencies. Each attempt will be charted as to the time the call was made, who was spoken to, and what information was given to the medical practitioner. Charting will include an assessment of the resident's current status as it relates to the change in condition. Charting will be done each shift for 72 hours for residents with a change of condition. A review of Resident #1's electronic medical record revealed that he was admitted to the facility on [DATE] with diagnoses that included in part: Chronic Obstructive Pulmonary Disorder (COPD), Chronic Respiratory Failure (CRF) with Hypoxia, Heart Failure, Dependence on Supplemental Oxygen, and Tobacco use. A review of Resident #1's Annual Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of [DATE] revealed the following in part: Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15 that indicated he was cognitively intact. Section J - Health Conditions indicated that the resident did not have shortness of breath during the 7 day lookback period. A review of Resident #1's Care Plan revealed the following in part: 1) The resident had CRF with hypoxia and was dependent on oxygen. Interventions included monitor for signs and symptoms of respiratory distress and report to MD as needed (included in part: respirations, pulse oximetry, accessory muscle usage and skin color). The resident had oxygen via nasal prongs/mask at 2 liters continuously/humidified. A review of Resident #1's physician orders revealed the following in part: 1) [DATE] at 6:45 p.m. Dexamethasone powder Inject 4mg/ml intramuscularly stat related to CRF with hypoxia. Inject 8mgs (2mls) now. 2) [DATE] at 12:11 p.m. STAT chest x-ray. A review of Resident #1's chest x-ray dated [DATE] revealed that there were prominent bilateral interstitial lung markings that may be due to pulmonary edema or atypical pneumonitis. There were opacitites in the left lung base that may be due to the alveolar component of pulmonary edema, atelectasis, or pneumonia. A review of Resident #1's nurse notes by S3LPN revealed the following: On [DATE] at 12:11 p.m., the resident had shortness of breath, pallor, and an oxygen saturation of 56% (normal range is 95 - 100%) Oxygen was applied at 4 liters per minute via nasal cannula. Resident #1 refused to be transported to the Emergency Room. The nurse practitioner was notified and a chest x-ray was ordered. On [DATE] at 2:16 p.m., S3LPN wrote that a chest x-ray was performed on Resident #1. Further review of the notes revealed no further assessments or monitoring documented regarding Resident #1's respiratory status. On [DATE] at 9:17 p.m., S3LPN wrote that new orders were received from the nurse practitioner who recommended that the resident be sent to the emergency room, but Resident #1 refused. Dexamethasone 8 milligram (mg) IM (intramuscular injection) one time, STAT (immediately) administered in left buttock. Further review of Resident #1's record revealed no documentation that the resident had been assessed or monitored after receiving the injection at 9:17 p.m. on [DATE] until [DATE] at 12:50 a.m. On [DATE] at 12:50 a.m., S4RN wrote making rounds and I found Resident #1 in the position of trying to get back in bed from being in the bathroom, he was stiff and skin purple, his left arm extended upward and right arm down and both knees bent, unable to move any of his extremities, placed him on the floor and unable to do CPR chest not moving. Notified S2DON, notified MD (medical doctor) on call and notified coroner's office. On [DATE] at 9:45 a.m., a review of the facility's video surveillance for [DATE] at 7:00 p.m. through [DATE] at 1:00 a.m. was conducted with S1ADM. The video surveillance did not show anyone enter Resident #1's room from [DATE] at 7:00 p.m. until [DATE] at 12:45 a.m. S1ADM confirmed that there was no evidence that anyone went into Resident #1's room during that 5 hour and 45 minute time period. On [DATE] at 12:45 p.m. a further review of video surveillance was conducted with S8PRC for [DATE] revealed at 6:38 p.m. S3LPN entered Resident #1's room carrying what appeared to be a syringe consistent with a syringe the facility uses. Through review of video surveillance, no one else was in Resident #1's room from 6:38 p.m. on [DATE] until 12:45 a.m. on [DATE]. S1ADM confirmed that the video did not reveal anyone entering Resident #1's room for 6 hours from [DATE] at 6:38 p.m. until [DATE] at 12:45 a.m. On [DATE] at 2:46 p.m. an interview was conducted with S3LPN, who stated that on [DATE] between 8:00 a.m. and 10:00 a.m. Resident #1 complained of nasal congestion. He was pale and discolored. She stated she did not document or report the resident's condition to the physician nor notify anyone at that time. S3LPN stated around 12:00 p.m. on [DATE] Resident #1 was short of breath, cyanotic, stridor noted to his lungs and his oxygen saturation was in the low 50's. S3LPN stated that Resident #1 was placed oxygen via nasal cannula at 4 liters per minute then escorted him to his room. Resident #1 refused to go to the emergency room. She notified the nurse practitioner on [DATE] about 12:00 p.m. S3LPN received an order for a chest x-ray on Resident #1 on [DATE] at 2:00 p.m. S3LPN received the x-ray results via fax on [DATE] at 5:30 p.m. and she received new orders for Resident #1 for Dexamethasone 8mg IM stat on [DATE] at 6:30 p.m. S3LPN stated she administered the injection on [DATE] at 6:30 p.m. to Resident #1. S3LPN stated that she took Resident #1's vital signs after 12:00 p.m. on [DATE] but was not sure of the time. She stated that his respirations were high (unsure of exact number), was using his accessory muscles and oxygen saturations remained in the low 80's, but she did not document findings and/or report to physician. She stated that she checked on Resident #1 again between 8:00 p.m. and 9:00 p.m. and he was lying in his bed, eyes closed, breathing, and his oxygen was in place and he was not in distress. S3LPN did not see Resident #1 again for the rest of her shift that ended at 11:00 p.m. S3LPN confirmed that she did not complete an SBAR. S3LPN confirmed that Resident #1 had a change in condition and that she did not follow the facility's policy for significant change in condition. On [DATE] at 7:00 a.m., an interview was conducted with S4RN who stated on [DATE] at 11:00 p.m. shift change, she received a report from S3LPN including that Resident #1 had a change in respiratory status. S4RN stated that she started her resident rounds on her other assigned hall first and did not see Resident #1 until [DATE] at 12:30 a.m. when she went to assess him and found him unresponsive. He was laid across his bed with his knees on the floor, his right arm up in the air, his left arm was by his side. S4RN turn Resident #1 and his face was purple. S4RN went to desk and called a code blue. S4RN confirmed she was aware that Resident #1 had a change in respiratory status and should have assessed him sooner. On [DATE] at 2:30 p.m., an interview was conducted with S2DON who stated there was no policy stating how often residents should have been monitored and oxygen saturations obtained. She stated according to nursing standards the residents should have been monitored every 2 hours. She stated if Resident #1 was having respiratory issues that he should have been checked on and respiratory status monitored for rate, oxygen saturation, and lung sounds at least every 2 hours. S2DON confirmed Resident #1 should have been monitored at least every 2 hours and that had not be done. S2DON confirmed S3LPN did not report change in status nor document Resident #1's respiratory status between 8:00 a.m. and 10:00 a.m. on [DATE] when the resident complained of nasal congestion and had discoloration and pallor.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0940 (Tag F0940)

Could have caused harm · This affected 1 resident

Based on record review and interview, the facility failed to maintain documented evidence of an effective training program for all new and existing staff. This deficient practice was identified for 2 ...

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Based on record review and interview, the facility failed to maintain documented evidence of an effective training program for all new and existing staff. This deficient practice was identified for 2 (S4RN (Registered Nurse), S5CNA (Certified Nursing Assistant)) of 5 (S4RN, S5CNA, S6CNA, S7RN) personnel records review for training requirements. Findings: Review of S4RN's personnel record revealed a hire date of 09/16/2021. Further review of S4RN's personnel record revealed no documented evidence S4RN received training related to the following topics: communication, infection prevention and behavioral health. Review of S5CNA's personnel record revealed a hire date of 12/07/2021. Further review of S5CNA's personnel record revealed no documented evidence S5CNA received training related to the following topics: communication, infection prevention and control and behavioral health. During an interview with S6HR on 09/21/2023 at 1:00 p.m., she reported she had provided all the personnel files for requested staff and their training documentation. She state ifd the training documentation was not provided, the staff did not have the up to date education requirements. On 09/21/2023 at 2:58 p.m., an interview was conducted with S1ADM. He confirmed S4RN and S5CNA did not have current education documentation for communication, behavioral health or infection control. He stated he was not able to find documentation that the education was completed.

Apr 2023 1 deficiency

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0568 (Tag F0568)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide individual financial record to the resident through quarter...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide individual financial record to the resident through quarterly statements and/or upon request for 2 (#1, #2) out of 5 (#1, #2, #3, #4, #5) sampled residents. The deficiency had the potential to effect a census of 63. Findings: Resident #1 Resident #1 was admitted to facility on 07/27/2022 with diagnoses that included Chronic Diastolic Heart Failure, Chronic Obstructive Pulmonary Disease and Lymphedema. Review of resident #1's MDS (Minimum Data Set) dated 03/13/2023, revealed Resident #1had a BIMS (Brief Interview for Mental Status) score of 14 indicating resident was cognitively intact. On 04/10/2023 at 11:30 a.m., an interview was conducted with Resident #1, and his daughter. Resident stated he did not know he had money in a trust fund at the facility. Resident's daughter stated she knew he received $38 a month, but, had not gotten a statement to know what his account balance was at the facility. She stated she was the RP (Responsible Party) and had never received a statement about his funds. Resident #2 Resident #2, was admitted to facility on 09/03/2021, with diagnoses that included, but not limited to Chronic Obstructive Pulmonary Disease, Heart Disease, Hypertension, Morbid Obesity and Anxiety. Review of quarterly MDS dated [DATE] revealed Resident #2 had a BIMS score of 14, indicating she was cognitively intact. On 04/10/2023 at 11:10 a.m., during an interview with Resident #2, she reported she had not gotten a quarterly statement from the facility in a very long time. She stated she used to get them, but, they stopped getting them to her. On 04/10/2023 at 12:37 p.m., an interview was conducted with S2BOM (Business Office Manager), she confirmed the quarterly trust statements had not been mailed out or given to residents. On 04/10/2023 at 3:15 p.m., an interview was conducted with S1Adm, he confirmed he and S2BOM, looked for a confirmation of the quarterly trust statements were sent out or given to resident, but was unable to locate any type of confirmation.

Mar 2023 4 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Tube Feeding (Tag F0693)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that 1 (#106) of 2 (#52 and #106) resident's e...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that 1 (#106) of 2 (#52 and #106) resident's enteral feeding was properly labeled. This deficient practice had the potential to affect these 2 residents (#52 and #106) receiving enteral nutrition. Findings: Review of the facility's policy titled Enteral Feedings - Safety Precautions revealed, in part, that it addressed the labeling of enteral nutrition before administration. It read as follows: Preventing errors in administration 1. Check the enteral nutrition label against the order before administration. Add the following information: a. Resident name b. Type of formula c. Date and time formula was prepared or bottle was spiked d. Rate of administration (mL/hour) (milliliters) Review of Resident #106's clinical record revealed he was admitted to the facility on [DATE] with the primary diagnoses of Amyotrophic Lateral Sclerosis. Resident #106's current physician's orders, written 02/22/2023, indicated Jevity 1.2 Cal (Calorie) @ (at) 50 cc/hr (cubic centimeters per hour) with 25 cc/hr water flush every shift was to be administered. At 1:03 p.m. on 02/27/2023, an observation of the delivery of Resident #106's ongoing enteral nutrition indicated the beige liquid was being regulated by an electronic pump infusing at a rate of 50 cc/hr. The product was contained in a clear bag hung on the pole of the rolling pump stand. The product was not identified, the rate at which it was ordered by the physician to be infused was not identified, the time it was started was not written on the bag, and the staff member that initiated the infusion had not signed and/or initialed the bag. Additionally, a clear bag containing a clear liquid was also regulated by the pump. The pump indicated 25 cc from this bag was to be infused every hour. This bag had no identification, resident name, date and time initiated, and infusion rate. At 1:50 p.m. on 02/27/2023, a staff interview was conducted with S4LPN (Licensed Practical Nurse). S4LPN confirmed Resident #106's enteral nutrition was ongoing and regulated through the electronic pump at 50 cc/hr. S4LPN verified the product being administered was not identified. S4LPN verified the enteral nutrition product bag was not labeled with the product name, did not indicate the time it was initiated, the staff member that initiated it, or the rate it was ordered to be administered. S4LPN also acknowledged that the clear liquid in the clear bag that was also regulated through the pump did not identify that it was water, did not indicate who and when it was hung, or the rate it was to be infused.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0883 (Tag F0883)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide pneumococcal immunization for 1 (#31) of 5 (#11, #13, #31, ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide pneumococcal immunization for 1 (#31) of 5 (#11, #13, #31, #40, #44) residents sampled for immunizations in a final sample of 33 residents. Findings: Review of the facility's policy titled Pneumococcal Vaccine revealed in part: Prior to or upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine, and when indicated, will be offered the vaccination at the time of admission to the facility unless medically contraindicated or the resident has already been vaccinated. Before receiving the Pneumovax, the resident or legal representative shall receive information and education regarding the benefits and potential side effects of the pneumococcal vaccine Provision of such education shall be documented in the resident's medical record. Pneumococcal vaccinations will be administered to residents unless medically contraindicated, already given, or refused Refusal will be documented on the Pneumococcal Immunization Informed Consent form and will include the date, reason for refusal and signature .Administration of the pneumococcal vaccination or revaccinations will be made in accordance with current Centers for Disease Control and Prevention (CDC) recommendations at the time of vaccination. Review of CDC recommendations, Pneumococcal Vaccination Recommendations revealed in part: CDC recommends routine administration of pneumococcal conjugate vaccine (PCV15 or PCV20) for all adults 65 years or older who have never received any pneumococcal conjugate vaccine or whose previous vaccination history is unknown. Review of CDC recommendations, Pneumococcal Vaccination: Summary of Who and When to Vaccinate revealed in part: CDC recommends pneumococcal vaccination for adults who have certain chronic medical conditions .Chronic heart disease, Chronic lung disease, including chronic obstructive pulmonary disease, emphysema and asthma, and Diabetes mellitus. Review of Resident #31's clinical records revealed he was admitted to the facility on [DATE]. The resident was [AGE] years old and dependent on supplemental oxygen. He had diagnoses including Type 2 Diabetes mellitus, Emphysema, and Hypertension. Review of the resident's immunization records revealed no documentation regarding pneumococcal vaccination. Further review of the resident's clinical record failed to reveal evidence if the resident received or did not receive the pneumococcal vaccine due to medical contraindication or refusal. Review of the resident's significant change MDS (minimum data set) dated 12/14/22 revealed the resident had a BIMS (brief interview for mental status) score of 15, indicating he was cognitively intact. On 02/28/23 at 01:01 p.m., an interview was conducted with Resident #31 who stated that he never received a pneumococcal vaccine. He stated that he was not asked if wanted the vaccine upon his admission or any other time during his residency at the facility. Resident #31 stated that he would take the vaccine if it were offered to him because he had chronic lung issues. On 02/28/23 at 08:02 a.m., an interview was conducted with S3DON/IP (Director of Nursing/Infection Preventionist). She reviewed Resident #31's records and confirmed there was no evidence of the resident's pneumococcal vaccination status. She confirmed the resident was eligible for the vaccine and that he should have been offered the vaccine upon his admission to the facility. S3DON/IP stated that S2AADM (Assistant Administrator) was responsible for offering eligible residents the pneumococcal vaccine upon admission. On 03/01/23 at 08:09 a.m., S3DON/IP stated she had not found any evidence that Resident #31 was offered or educated on the pneumococcal vaccine. On 03/01/23 at 10:28 a.m., an interview was conducted with S2AADM who stated that she was responsible for assessing the resident's pneumococcal vaccination status upon admission. If the resident was not previously vaccinated, she offers the resident the vaccine. Documentation of the resident's immunization status including declinations or consents are placed in the resident's record. S2AADM reviewed Resident #31's record and confirmed there was no evidence of the resident's pneumococcal vaccination status. She stated there was no evidence that the resident received the vaccine elsewhere. She stated that she could not recall if she offered the resident the pneumococcal vaccine on his admission. S2AADM stated that upon the resident's admission, nursing staff were responsible for assessing residents' vaccination status and offering vaccinations and failed to do so.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Antibiotic Stewardship (Tag F0881)

Could have caused harm · This affected most or all residents

Based on record review and interview, the facility failed to conduct an ongoing review for antibiotic stewardship per the facility's policy by failing to implement antibiotic use protocols and a syste...

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Based on record review and interview, the facility failed to conduct an ongoing review for antibiotic stewardship per the facility's policy by failing to implement antibiotic use protocols and a system to monitor antibiotic use. The facility's census was 52. Findings: Review of the facility's policy titled, Statement of Leadership Commitment for Antibiotic Stewardship in a Skilled Nursing/Long Term Care Facility read in part: Antibiotic use protocols c). We will reassess the use of antibiotics after they are initiated. One to two days after the initiation of therapy, culture results will be available. The day that laboratory test (cultures) results become available, it shall be entered into the resident's medical record the action(s) taken in response to these results. Actions may include: discontinue antibiotics, continue antibiotics, or switch antibiotics. d). we will work with our prescribers, nurses, and our consultant pharmacist to create a system that monitors and shares reports regarding antibiotic use (consumption) in the facility. Review of the facility's Monthly Nosocomial Infection report for all nursing units November 2022 - January 2023 revealed: 7 residents with infections were prescribed antibiotics in November 2022; 8 residents with infections were prescribed antibiotics in December 2022; and 6 residents with infections were prescribed antibiotics in January 2023. On 02/28/23 at 08:02 a.m., a review of the facility's infection control program was conducted with S3DON/IP (Director of Nursing/Infection Preventionist). S3DON/IP was asked to discuss the facility's antibiotic stewardship program, the facility's antibiotic use protocols, and about the monitoring of antibiotic use for residents prescribed antibiotics November 2022 - January 2023. S3DON/IP replied, I know I hadn't been doing all of that. When asked how long she had not been implementing the antibiotic stewardship program protocols, she explained that she was not sure how long, just that she had not been doing it for a while. She went on to explain that the facility did not have any specific criteria or protocol to follow for its antibiotic stewardship program. The facility's antibiotic stewardship policy was reviewed with S3DON/IP. She confirmed she had not implemented the measures within the facility's policy. S3DON/IP stated that she was solely responsible for implementing monitoring of antibiotic use in the facility and stated that she had not been doing her part because she had many responsibilities and had not been keeping up with it.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0887 (Tag F0887)

Could have caused harm · This affected most or all residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to develop and implement policies and procedures to ensure residents w...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to develop and implement policies and procedures to ensure residents were offered and educated on the COVID-19 vaccine. The facility also failed to maintain documentation of the resident's refusal of the COVID-19 vaccine in the resident's record. This deficient practice affected 5 (#11, #13, #31, #40, #44) of 5 residents sampled for immunizations in a final sample of 33 residents. Findings: Review of the facility's infection control and vaccination policies and procedures failed to reveal a policy and procedure for resident COVID-19 vaccinations. Review of the facility's list of residents who had not received the COVID-19 included residents #11, #13, #31, #40, and #44. Review of the residents' medical records failed to reveal documentation that indicated the residents or their representative were provided education regarding the benefits and potential risks associated with COVID-19 vaccine. The records also failed to reveal documentation if the resident did not receive the COVID-19 vaccine due to medical contraindications or refusal. Resident #44 was admitted to the facility on [DATE]. The resident's annual MDS (Minimum Data Set) dated 12/29/22 revealed the resident had a BIMS (brief interview for mental status) score of 11, indicating she was cognitively intact. On 02/27/23 at 02:33 p.m., Resident #44 stated she was provided education, but refused the vaccine. Resident #11 was admitted to the facility on [DATE]. The resident's quarterly MDS dated [DATE] revealed the resident had a BIMS score of 15, indicating she was cognitively intact. On 02/27/23 at 02:12 p.m., Resident #11 stated she was not offered the COVID-19 vaccine. She denied being made aware of the risks and benefits to it or receiving any education. Resident #13 was admitted to the facility on [DATE]. The resident's quarterly MDS dated [DATE] revealed the resident had a BIMS score of 13, indicating he was cognitively intact. On 02/27/23 at 02:21 p.m., Resident #13 stated that he was offered the vaccine, but had been sick and had not received it yet. As of now he does not want it. Resident #31 was admitted to the facility on [DATE]. The resident's significant change MDS dated [DATE] revealed the resident had a BIMS score of 15, indicating he was cognitively intact. On 02/28/23 at 01:01 p.m., Resident #31 stated that he was offered and educated on risks and benefits of the vaccine but had refused. Resident #40 was admitted to the facility on [DATE]. The resident's quarterly MDS dated [DATE] revealed the resident had a BIMS score of 6, indicating she was not cognitively intact. On 02/27/23 at 02:07 p.m., an attempt was made to interview Resident #40, but she was not interviewable. On 02/28/23 at 11:48 a.m., a phone interview was conducted with Resident # 40's responsible party who stated that someone from the facility called and asked her if she wanted the resident to receive the COVID-19 vaccine. She stated she had declined verbally and did not sign written declination form. She further stated that the facility did not review risks and benefits of vaccine with her or provide any type of education. On 02/27/23 at 04:54 p.m., S3DON/IP (Director of Nursing/Infection Preventionist) stated that residents #11, #13, #31, #40, and #44 refused the COVID-19 vaccine. She did not have education materials including screening eligibility forms and consents provided to the resident or their representative for the COVID-19 vaccine. She further stated that she did not have documentation showing that the residents received education on and declined the vaccine. S3DON/IP was asked to provide a copy of the facility's policy for resident COVID-19 vaccination. On 02/28/23 at 07:46 a.m., S3DON/IP stated that she was still unable to find any of the residents' declination forms. On 02/28/23 at 08:02 a.m., S3DON/IP stated that S2AADM (Assistant Administrator) was responsible for offering resident COVID-19, influenza, and pneumococcal vaccinations upon their admission. Administrative nursing staff offer the vaccines annually thereafter. She stated that she still could not find the residents' declination forms or evidence showing that they were offered and educated on the COVID-19 vaccine. She was again asked to provide the facility's policy on resident COVID-19 vaccinations. On 02/28/23 at 10:14 a.m., S3DON/IP provided a copy of CDC recommendations titled, Interim Clinical Considerations for Use of COVID-19 Vaccines Currently Approved or Authorized in the United States. S3DON/IP stated that the corporate nurse told her that the facility follows CDC guidelines regarding resident vaccination. S3DON/IP confirmed the facility did not have a policy addressing resident COVID-19 vaccinations. On 03/01/23 at 10:28 a.m., an interview was conducted with S2AADM who stated that she was responsible for offering only the pneumococcal vaccine to residents upon their admission, not influenza and COVID-19 vaccines. S2AADM stated that nursing staff were responsible for ensuring residents were offered and educated on the COVID-19 vaccine. S2AADM further stated that the resident's vaccination status, consent, or refusal should be documented in each resident's record.

Nov 2022 3 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to update the care plan after an elopement episode for 1 (#2) out of 5...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to update the care plan after an elopement episode for 1 (#2) out of 5 (#1, #2, #3, #4, #5) sampled residents. Findings: A review of the facility's Elopement policy included, in part: Quality Assurance for the prevention of missing residents - a review of their individualized care plan shall be triggered for possible changes in care practices or safety precautions for that resident. Resident #2 was admitted to the facility on [DATE] with diagnoses of hemiplegia, unspecified affecting right dominant side, and dementia with other behavioral disturbance. A review of Resident #2's Annual Minimum Data Set (MDS), dated [DATE], revealed the resident had a Brief Interrview for Mental Status (BIMS) score of 00 (Severe cognitive impairment). He had 2 or more falls since admission or prior assessment. Review of Resident #2's care plan revealed he was an elopement risk/wanderer as evidenced by (AEB) impaired safety awareness forgets where he is. Interventions included: Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television. Reorient resident to where he is. Further review of the care plan revealed no revisions to prevent another elopement. On 11/1/22 at 9:15 a.m., an interview was conducted with S2ADON. She confirmed the Resident #2 had an elopement episode outside of the facility in April 2022. She stated Resident #2 was observed outside of the facility. S2ADON confirmed the care plan was not updated following Resident #2's elopement episode. On 11/01/2022 at 10:20 a.m., an interview was conducted with S3MDS who confirmed the elopement episode was not care planned and should be updated when elopement occurs.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0726 (Tag F0726)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the staff failed to conduct a head to toe assessment or an incident report after Resident...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the staff failed to conduct a head to toe assessment or an incident report after Resident #2 was found on the ground after elopement from the facility. The staff failed to conduct a head to toe assessment or accurately describe a bruise that was found on Resident #2. The deficient practice affected 1 (#2) out of 5 (#1, #2, #3, #4, #5) sampled residents. Findings: A review of the policy for Significant Condition Change and Notification revealed the following, in part: A significant change in the resident's physical, mental or psychosocial status (examples included: new wounds, bruises, or skin tears; incident of wandering or elopement). Charting will include an assessment of the resident's current status as it relates to the change in condition. Charting will be done each shift for 72 hours for residents with change of condition. Change of condition is reviewed by DON or designee for the continued need for additional documentation. A review of the policy for Skin Checks revealed the following, in part: Procedure: The staff nurse or wound care nurse will implement weekly skin checks for all residents. The Nurse will assess the individual resident's skin from head to toe, to determine if there are any new or additional skin issues present. Any new wounds or skin conditions will be assessed by the nurse finding the wound or skin issue. At the time the wound or skin condition is identified, the provider and resident representative will be notified of the newly identified issues. Resident #2 was admitted to the facility on [DATE] with diagnoses of hemiplegia, unspecified affecting right dominant side, and dementia with other behavioral disturbance. A review of Resident #2's Annual Minimum Data Set (MDS), dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 00 (Severe cognitive impairement). He had 2 or more falls since admission or prior assessment. A review of Resident #2's care plan initiated on 3/25/22 revealed he is was elopement risk/wanderer. On 5/12/22 care plan initiated for Resident #2, that he was at risk for falls that included falls on 4/21/22, 5/12/22, 5/22/22, 6/3/22, 6/7/22, 6/27/22, 8/11/22. A review of incident reports revealed Resident #2 had a fall on 4/21/22 at 5:20 p.m. with no injuries noted. Further review of Incident reports for Resident #2 from 3/16/22 to 11/1/22 did not reveal an elopement or injury incident. A review of Resident #2's Elopement Risk Assessment, dated 8/19/22, revealed the following: Resident is at risk for elopement. The following assessments did not indicate resident was at risk for elopement: 3/16/22; 5/4/22; 5/9/22; 9/1/22; 10/11/22. A review of Resident #2's progress notes related to elopement/wandering revealed resident made attempts to open locked outer doors on 4/2/22, 4/3/22, 4/30/22. A review of Resident #2's progress notes related to falls and skin revealed on 4/21/22 at 6:07 p.m., he had an unwitnessed fall, no cuts or scratches were noted. On 4/22/22 and 4/23/22, notes revealed the resident was monitored for a recent fall, no signs of distress or discomfort were noted. Progress notes on 4/30/22 revealed purplish bruises to his right thigh and behind right knee were observed by S4LPN. A review of Resident #2's Skin check weekly notes from 4/21/22 through 4/28/22 revealed no new changes. A telephone interview was conducted with S4LPN on 10/31/22 at 9:06 a.m. who confirmed that on 4/30/22, she observed a bruise to Resident #2's right leg and side. On 11/1/22 at 9:15 a.m. an interview was conducted with S2ADON who stated Resident #2 had an elopement in April 2022. She stated she saw the resident through the window outside. He was found on the ground outside. S2ADON stated staff did not complete an elopement risk assessment, incident report, or reassessment of the skin issues after bruise was observed on 4/30/22.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Administration (Tag F0835)

Could have caused harm · This affected 1 resident

Based on record review and interviews, the administration failed to be administered in a manner that enables its resources to attain or maintain the highest practicable physical, mental, and psychosoc...

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Based on record review and interviews, the administration failed to be administered in a manner that enables its resources to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident by failing to investigate an allegation of elopement and bruising of unknown origin for 1 (#2) out of 5 (#1, #2, #3, #4, #5) sampled residents. The deficient practice had to the potential to affect the total census of 57 residents. Findings: A review of the policy for elopement included to notify the Administrator immediately and document the sequence of events. Contact the State Survey Agency, call or fax a report within 24 hours of the incident and prepare a complete report at the completion of the incident. This shall be reviewed with the regional nurse prior to submission. When the resident is found, contact an ambulance if injuries are present. Otherwise, get the resident to shelter, take their vital signs, and conduct a complete head to toe assessment for injuries. The facility's QAPI Committee shall review the facility's systems, policies and procedures, and responses to elopements to identify areas of opportunity for improvement. A review of the policy for significant change and notification revealed that the resident's family and/or representative and medical practitioner are notified of resident changes (such as: an accident or incident with or without injury, new wounds, bruises or skin tears, incident of wandering or elopement). Contact the medical practitioner or medical director; if they cannot be reached contact the director of nursing or the charge nurse can make arrangements for transportation to the emergency department. All significant changes will be recorded on the communication board in (the electronic health record) and in the resident record. Change of condition is reviewed by DON or designee. A review of Resident #2's progress notes, dated 4/30/2022, revealed two purplish bruises on his right thigh and behind his right knee. S4LPN wrote she attempted to call S1ADM and there was no answer. S5RN notified S2ADON. On 5/1/22 at 12:00 a.m. Resident #2 was sent to the emergency room for behaviors and fall. A review of Resident #2's Skin check weekly notes from 4/21/22 through 4/28/22 revealed no new changes this week. A review of Resident #2's records from a local hospital revealed on 5/1/22 at 4:01 a.m., Resident #2 was in the Emergency Room, an assessment of his skin noted the skin was warm, dry, significant bruising of his right buttock, thigh and behind his right knee. A review of Resident #2's incident/accident reports revealed he had a fall on 4/21/22 and 5/1/22 with no injuries inside of the facility. On 10/31/22 at 9:06 a.m., a telephone interview was conducted with S4LPN. She stated on 4/30/22 she observed a bruise to Resident #2's right leg and side. She confirmed that she attempted to notify S1ADM, but did not get an answer. She then contacted S2ADON. On 11/1/22 at 9:15 a.m., an interview was conducted with S2ADON. S2ADON stated in April 2022, she witnessed Resident #2 outside near a locked door. When staff reached Resident #2, he was on the ground outside. She stated the incident was reported to S1ADM. S2ADON confirmed the incident was not documented. On 11/1/22 at 9:50 a.m., an interview was conducted with S1ADM. S1ADM stated she was notified in September about the bruises on Resident #2 by S4LPN. She confirmed her knowledge of Resident #2's elopement with fall outside and bruises, but could not confirm when the incident occurred. S1ADM confirmed an incident report and state notification was not completed. On 11/1/22 at 11:40 a.m. a telephone interview was conducted with S5RN. S5RN confirmed she observed bruises on Resident #2 on 4/30/22 and the attempt to notify S1ADM. S5RN stated S2ADON was notified of Resident #2's bruises.

Holly Hill House

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