What is Guest House Nursing and Rehabilitation's CMS rating?

Guest House Nursing and Rehabilitation 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 Guest House Nursing and Rehabilitation have?

Guest House Nursing and Rehabilitation has 31 deficiencies from recent inspections. None are at the Immediate Jeopardy level.

What are the staffing levels at Guest House Nursing and Rehabilitation?

Guest House Nursing and Rehabilitation has a two-star staffing rating from CMS with 0.23 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 Guest House Nursing and Rehabilitation located?

Guest House Nursing and Rehabilitation is located in WEST MONROE, LA. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does Guest House Nursing and Rehabilitation have?

Guest House Nursing and Rehabilitation has 140 certified beds.

Who owns Guest House Nursing and Rehabilitation?

Guest House Nursing and Rehabilitation is a for profit - limited liability company facility and operates independently (not part of a chain).

Is Guest House Nursing and Rehabilitation safe?

Guest House Nursing and Rehabilitation has a clean safety record with no substantiated abuse findings, no immediate jeopardy citations, and is not on any federal watch list.

Do nurses at Guest House Nursing and Rehabilitation stick around?

Guest House Nursing and Rehabilitation has high staff turnover at 63%. High turnover can mean less continuity of care as staff change frequently.

Was Guest House Nursing and Rehabilitation ever fined?

No, Guest House Nursing and Rehabilitation has no federal fines on record, indicating a clean compliance history with Medicare and Medicaid requirements.

Is Guest House Nursing and Rehabilitation on any federal watch list?

No, Guest House Nursing and Rehabilitation 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 Guest House Nursing and Rehabilitation?

Medicare inspectors have found 31 deficiencies at Guest House Nursing and Rehabilitation: 31 moderate. Each deficiency represents a violation of federal nursing home requirements.

What questions should families ask when visiting Guest House Nursing and Rehabilitation?

Families visiting Guest House Nursing and Rehabilitation should ask about staff retention and training programs. Also ask to speak with current residents or families, tour during mealtime, and request a copy of the most recent inspection report.

How does Guest House Nursing and Rehabilitation compare to other nursing homes?

Guest House Nursing and Rehabilitation 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.

Guest House Nursing and Rehabilitation | 35/100 (Grade F)

Jul 2025 9 deficiencies

CONCERN (D)

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

Deficiency F0602 (Tag F0602)

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 a resident was free from misappropriation of personal proper...

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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 a resident was free from misappropriation of personal property for 1 (#11) of 1 resident reviewed for personal funds. Findings:Review of the facility's undated Abuse and Neglect Prohibition policy revealed the following in part:Fundamental Information:Misappropriation of resident property means the deliberate misplacement, exploitation or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent.Review of Resident #11's record revealed an admission date of 02/27/2025 with diagnoses including chronic obstructive pulmonary disease, chronic cough, unsheltered homelessness, seizures, personal history of transient ischemic attack, cerebral infarction without residual deficits, chronic respiratory failure with hypoxia, pulmonary fibrosis, chronic kidney disease, other mixed anxiety disorders, and major depressive disorder.Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 15 indicating no cognitive impairment.Review of the Facility's Reported Incident revealed an allegation of misappropriation of funds/exploitation was reported to the facility on [DATE] by Resident #11 related to his Electronic Banking Transfer (EBT) card having an unauthorized charge on 07/07/2025. S7Certified Nursing Assistant (CNA) was identified as the staff member that had made unauthorized purchases with Resident #11's EBT card on 07/07/2025 and 07/11/2025. The investigation by the facility revealed the allegation was substantiated.Interview on 07/28/2025 at 3:30 p.m. with Resident #11 revealed he had allowed S7CNA to purchase items for him using her grocery store account using his EBT card a couple times in June 2025. Resident #11 further reported that someone had made purchases using his EBT card 2 times during July 2025 on 07/07/2025 and 07/11/2025 and he notified S8Social Services Director (SSD). Resident #11 reported S7CNA was terminated at the end of June 2025. Resident #11 reported he had 2 unauthorized charges of $225.32 and $88.35 in July 2025 on his EBT card. When Resident #11 reported this to the S8SSD, they were able to printout a list of his transaction history for his EBT card from 06/28/2025 through 07/10/2025, the charge for 07/07/2025 was made at a grocery store in the amount of $225.32. Resident #11 reported S8SSD helped him to deactivate his EBT card and setup online account information to help the resident track his purchases. Resident #11 had another unauthorized charge of $88.35 on 07/11/2025. Interview with S8SSD on 07/30/2025 at 8:00 a.m. revealed he was notified by Resident #11 on 07/08/2025 around 10:00 a.m. regarding a CNA from the facility making charges on his EBT card on 07/07/2025 for $225.32. S8SSD reported that Resident #11 had given his EBT card information to a CNA to purchase items for him to be delivered to the facility from a grocery store. S8SSD reported he notified S1Administrator on 07/08/2025 of the allegation of misappropriation of funds/exploitation made by Resident #11. S8SSD reported he and Resident #11 called the EBT program support on 07/09/2025. S8SSD was able to get a printout of Resident #11's transaction history on EBT card from 06/28/2025 through 07/10/2025 and identify the charge on 07/07/2025 in the amount of $225.32 was made at a grocery store. S8SSD reported Resident #11 confirmed he did not authorize this purchase. S8SSD reported they deactivated the resident's card at this time, but Resident #11 reported on 07/12/2025 he found another charge of $88.35 that was unauthorized on his EBT card again. S8SSD and Resident #11 called EBT program support back and cancelled the resident's EBT card, police were notified and a report was initiated by the police on 07/12/2025 after the second unauthorized purchase was made. S8SSD reported that the police only have a preliminary report and have not made any arrest at this time. S8SSD reported they were unable to print another history of transactions on this card due to it now being deactivatedAn interview with S1Administrator on 07/30/2025 at 8:30 a.m. revealed he was notified on 07/08/2025 by S8SSD of the allegation of misappropriation of funds/exploitation reported by Resident #11 by a CNA on his hall. S1Administrator reported he interviewed Resident #11, they were able to identify that the accused was S7CNA and she had obtained information from Resident #11's EBT card to purchase items for this resident from a grocery store.Review of Resident #11's Transaction History for his EBT card transactions from 06/28/2025 through 07/10/2025 revealed a purchase was made to a grocery store in the amount of $225.32. An interview on 07/30/2025 at 11:10 a.m. with S9CNA revealed she was working a few months ago and Resident #11 had a grocery store order delivered, but the driver from the store needed a pin number for the delivery. Resident #11 told her that S7CNA had the code for his order. S9CNA had to get the delivery code from S10Ward Clerk to give to the driver, but was unsure of the date this happened. An interview on 07/30/2025 at 11:30 a.m. with S11CNA confirmed he did have to get a code from S7CNA for a grocery store delivery order for Resident #11 while he was working with Resident #11 but unsure of the date.An interview on 07/30/2025 at 11:40 a.m. with S10Ward Clerk revealed S7CNA sent her a code to give to the staff for a grocery store delivery for Resident #11, but unsure of the exact date. An interview on 07/30/2025 at 2:30 p.m. with S1Administrator confirmed the facility failed to ensure Resident #11 was free from misappropriation of funds/exploitation by S7CNA. S1Administrator confirmed S7CNA made two unauthorized purchases on Resident #11's EBT card in July 2025.

CONCERN (D)

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

Deficiency F0604 (Tag F0604)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to ensure residents were free from physical restraint...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to ensure residents were free from physical restraints imposed for the purpose of discipline or convenience for 1 (#16) of 1 residents reviewed for restraints. The facility failed to have documented evidence of releasing the lap tray every two hours for range of motion. Findings:Use of Restraint Policy dated April 2017Policy Interpretation and ImplementationPhysical Restraints are defined as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body.The definition of restraint is based on the functional status of the resident and not the device. If the resident cannot remove a device in the same manner in which staff applied it given the resident's physical condition, and this restricts his/her typical ability to change position or place, that device is considered a restraint.Examples of devices that are/may be considered physical restraints include leg restraints, arm restraints, hand mitts, soft ties or vest, wheelchair safety bars, geri-chairs, and lap cushions and trays that the resident cannot remove.Practices that inappropriately utilize equipment to prevent resident mobility are considered restraints and are not permitted, including: c. placing a resident in a chair that prevents the resident from rising.Restraints may only be used if/when the resident has a specific medical symptom that cannot be addressed by another less restrictive intervention AND a restraint is required to: a. treat the medical symptom; b. protect the resident's safety; and c. help the resident attain the highest level of his/her physical or psychological well-being.11. The following safety guidelines shall be implemented and documented while the resident is in restraints:d. The opportunity for motion and exercise is provided for a period of not less than ten (10) minutes during each two (2) hours in which restraints are employed.e. Restrained residents must be repositioned at lease every two (2) hours on all shifts. Review of the medical record for Resident #16 revealed an admission date of 01/02/2025 with diagnoses including Parkinson's disease without dyskinesia, without mention of fluctuations; unspecified psychosis not due to a substance or known physiological condition; restlessness and agitation and generalized anxiety disorder.Review of the quarterly Minimal Data Set (MDS) assessment dated [DATE] revealed Resident #16 had severe cognitive impairment for daily decision making. The facility was unable to obtain a Brief Interview for Mental Status (BIMS) score. Further review also revealed Resident #16 was mobile via wheelchair and required partial/moderate assistance with transfers.Observations made on 07/28/2025 at 12:45 p.m., 07/29/2025 at 8:13 a.m., 07/29/2025 at 11:10 a.m., and 07/29/2025 at 3:00 p.m. revealed Resident #16 was sitting in a geri-chair with a lap tray in place.On 07/29/2025 at 12:00 p.m., a review of Resident #16's active July 2025 physician's orders revealed there was no order for the release of the geri-chair lap tray every two hours. Further review of Resident #16's records revealed there was no documentation of the release of the lap tray every two hours.On 07/29/2025 at 1:10 p.m., an interview with S6Certified Nursing Assistant (CNA) was conducted. S6CNA stated Resident #16 could not release the lap tray herself and she was also unaware that Resident #16's lap tray should be released every two hours.On 07/29/2025 at 1:15 p.m., an interview with S5Licensed Practical Nurse (LPN) was conducted. S5LPN stated there was no active order to release Resident #16's lap tray every two hours.On 07/29/2025 at 1:25 p.m., an interview was conducted with S2Director of Nursing (DON), S4 Corporate Consultant, and S3Registered Nurse (RN)-Admin confirmed that there was no order or documentation for releasing the geri-chair lap tray every two hours.

CONCERN (D)

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

Investigate Abuse (Tag F0610)

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 a thorough investigation was completed for an allegation 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 a thorough investigation was completed for an allegation of misappropriation of property/exploitation for 1 (#7) of 1 resident reviewed for personal funds.Findings:Review of the facility's undated Abuse and Neglect Prohibition revealed the following in part:Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion, and misappropriation of property. Fundamental Information:Misappropriation of resident property means the deliberate misplacement, exploitation or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent.Investigation:1. The facility will conduct an investigation of any alleged abuse/neglect or misappropriation of resident property in accordance with state law.Review of Resident #11's record revealed an admission date of 02/27/2025 with diagnoses including chronic obstructive pulmonary disease, chronic cough, unsheltered homelessness, other seizures, personal history of transient ischemic attach, cerebral infarction without residual deficits, chronic respiratory failure with hypoxia, pulmonary fibrosis, chronic kidney disease, other mixed anxiety disorders and major depressive disorder.Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 15 indicating no cognitive impairment.Review of the Facility's Reported Incident revealed an allegation of misappropriation of funds/exploitation was reported to the facility on [DATE] by Resident #11 related to his Electronic Banking Transfer (EBT) card having an unauthorized charge on 07/07/2025. S7Certified Nursing Aide (CNA) was identified as the staff member that had made unauthorized purchases with Resident #11's EBT card on 07/07/2025 and 07/11/2025. The investigation by the facility revealed the allegation was substantiated.Interview on 07/28/2025 at 3:30 p.m. with Resident #11 revealed he had allowed S7CNA to purchase items for him using her grocery store account using his EBT card a couple times in June 2025. Resident #11 further reported that someone had made purchases using his EBT card 2 times during July 2025 on 07/07/2025 and 07/11/2025 and he notified S8Social Services Director (SSD). Resident #11 reported S7CNA was terminated at the end of June 2025. Resident #11 reported he had 2 unauthorized charges of $225.32 and $88.35 in July 2025 on his EBT card. Resident #11 reported this to the S8SSD and they were able to printout a list of his transaction history for his EBT card from 06/28/2025 through 07/10/2025, the charge for 07/07/2025 was made at a grocery store in the amount of $225.32. Resident #11 reported S8SSD helped him to deactivate his EBT card and setup online account information to help the resident track his purchases. Resident #11 had another unauthorized charge of $88.35 on 07/11/2025. Interview with S8SSD on 07/30/2025 at 8:00 a.m. revealed he was notified by Resident #11 on 07/08/2025 around 10:00 a.m. regarding a CNA from the facility making charges on his EBT card on 07/07/2025 for $225.32. S8SSD reported that Resident #11 had given his EBT card information to a CNA to purchase items for him to be delivered to the facility from a grocery store. S8SSD reported he notified S1 Administrator on 07/08/2025 of the allegation of misappropriation of funds/exploitation made by Resident #11. S8SSD reported he and Resident #11 called the EBT program support on 07/09/2025. S8SSD was able to get a printout of Resident #11's transaction history on EBT card from 06/28/2025 through 07/10/2025 and identify the charge on 07/07/2025 in the amount of $225.32 was made at a grocery store. S8SSD reported Resident #11 confirmed he did not authorize this purchase. S8SSD reported they deactivated the resident's card at this time, but Resident #11 reported on 07/12/2025 resident found another charge of $88.35 that was unauthorized on his EBT card again. S8SSD and Resident #11 called EBT program support back and cancelled the resident's EBT card, police were notified and a report was initiated by the police on 07/12/2025 after the second unauthorized purchase was made. S8SSD reported that the police only have a preliminary report and have not made any arrest at this time. S8SSD reported they were unable to print another history of transaction on this card due to it now being deactivated. An interview with S1Administrator on 07/30/2025 at 8:30 a.m. revealed he was notified on 07/08/2025 by S8SSD of the allegation of misappropriation of funds/exploitation reported by Resident #11 by a CNA on his hall. S1Administrator reported he interviewed Resident #11, they were able to identify that the accused was S7CNA, and she had obtained information from Resident #11's EBT card to purchase items for this resident from a grocery store.Review of Resident #11's Transaction History for his EBT card transactions from 06/28/2025 through 07/10/2025 revealed a purchase was made to a grocery store in the amount of $225.32. An interview on 07/30/2025 at 2:30 p.m. with S1Administrator confirmed the facility failed to ensure a thorough investigation was completed for the allegation of misappropriation of funds/exploitation reported by Resident #11. S1Administrator confirmed the facility did not attempt to interview S7CNA after the allegation was reported, did not retrain staff on misappropriation of funds/property after the allegation was reported and failed to ensure residents were interviewed promptly with relevant questions related to misappropriation of funds/property.

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 reviews and interviews, the facility failed to notify the state-designated mental health disability authority pr...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to notify the state-designated mental health disability authority promptly for a review when a resident with Mental Disorders or Intellectual Disorders experienced a change in mental or physical status for 1 (#7) of 2 (#7 and #8) residents reviewed for Pre-admission Screening and Resident Review (PASARR).Findings: Review of Resident #7's record revealed an admission date of 06/24/2025 with diagnoses including unspecified dementia mild with mood disturbance, bipolar disorder current episode depressed mild or moderate severity unspecified, panic disorder, insomnia due to other mental disorder, post-traumatic stress disorder acute, hypertension, tachycardia, hypothyroidism, personal history of other mental and behavioral disorders. Further review of the record revealed Resident #7 was admitted to the facility from an inpatient psych facility.Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 15 indicating no cognitive impairment.Review of Resident #7's Form 142 (Louisiana Department of Health and Hospitals Medicaid Program Notice of Medical Certification) dated 06/18/2025 revealed resident was approved for Medicaid medical eligibility services for a temporary period effective 06/18/2025-09/26/2025 for skilled therapies. Review of Resident #7's record revealed he had combative and aggressive behaviors after he was admitted to the facility and he was transferred back to the inpatient psych facility on 06/27/2025 through 07/10/2025. An interview on 07/30/2025 at 8:00 a.m. with S8Social Service Director (SSD) revealed Resident #7 was admitted on [DATE] from an inpatient psych facility and the PASARR was done by the inpatient psych facility prior to the resident being admitted to the facility. S8SSD confirmed Resident #7 was transferred to an inpatient psych facility on 06/27/2025 due to aggressive and combative behaviors and did not return to the nursing home until 07/10/2025. S8SSD revealed he was not aware he was required to send in a PASARR review to the designated state authority following an inpatient psych stay for Resident #7. S8SSD confirmed he did not send in a PASARR review for Resident #7 after his inpatient psych stay from 06/27/2025 through 07/10/2025. Interview on 07/30/2025 at 8:30 a.m. with S1Administrator confirmed he was not aware that a PASARR review should have been submitted to the designated state authority after an inpatient psych stay for a resident.Review of the consult note from the psych admission dated 06/28/2025 for Resident #7 revealed the reason for admission was aggressive behavior, agitation and mood lability, and discharge diagnoses included aggressive behavior, bipolar, depression, antidepressive discontinuation syndrome and insomnia. Review of the record revealed no documentation of a PASARR review for Resident #7 after an inpatient psych stay from 06/27/2025 through 07/10/2025. Review of Resident #7's PASARR Level I Screen Outcome dated 06/17/2025 revealed PASARR Level I Determination: no level II required. Level I screen indicates - no evidence of a PASARR condition of intellectual/developmental disability or a serious behavioral health condition, if changes occur or new information refutes these findings, a new screen must be submitted. No medications listed and no diagnoses listed on PASARR form. An interview on 07/30/2025 at 2:30 p.m. with S1Administrator confirmed the facility failed to send in a PASARR review on Resident #7 to the designated state authority after he had an inpatient psych stay from 06/27/2025 through 07/10/2025 due to aggressive and combative behaviors.

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 reviews and interviews, the facility failed to develop and implement a comprehensive person-centered care plan f...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment for 1 (#89) of 2 (#63 & #89) sampled residents reviewed for mood/behavior. Findings: Review of the medical record for Resident #89 revealed an admission date of 10/21/2018 with diagnosis of Parkinson's disease, breast cancer, edema, transient ischemic attack, dementia, Post-Traumatic Stress Disorder (PTSD), major depressive disorder, and atrial fibrillation. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed the resident had a Brief Interview of Mental Status (BIMS) score of 15 which indicated the resident was cognitively aware and able to make daily decisions. Further review revealed Resident #89 needed maximal assistance with all activities of daily living. Review of section I revealed the resident had a Psychiatric/Mood disorder of Post-Traumatic Stress Disorder (PTSD). Review of Resident #89's current care plan dated 09/10/2024 revealed no documentation that included person-specific, measurable objectives and timeframes in order to evaluate the resident's progress toward his/her goals for the diagnosis of Post-Traumatic Stress Disorder. Interview on 07/30/2025 at 3:30 p.m. with S2Director of Nursing (DON) confirmed the diagnosis of PTSD was not care planned for Resident #89. S2DON further confirmed there should be a person centered care plan with interventions for PTSD in place for Resident #89.

CONCERN (D)

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

Accident Prevention (Tag F0689)

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 a resident was as free of accident hazards as is possible by...

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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 a resident was as free of accident hazards as is possible by failing to ensure an appropriate intervention was attempted for 1 (#71) of 8 (#2, #4, #9, #10, #18, #36, #71, #89) residents reviewed for accidents.Findings:Review of the medical record for Resident #71 revealed an admission date of 01/14/2025 with diagnoses that included vascular dementia, displaced fracture of middle phalanx of left middle finger, repeated falls, history of transient ischemic attack, and hypertension.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #71 had a Brief Interview of Mental Status (BIMS) score of 7 which indicated severe cognitive impairment with daily decision making. Resident #71 required substantial/maximal assistance with sit to lying, lying to sitting, and chair/bed-to-chair transfer. Additionally, the April MDS assessment documented the resident as always continent of bowel and bladder. Review of the in-service training report dated January 2025 revealed Certified Nursing Assistants (CNA) were to round on residents every 2 hours and as needed.Review of the incident report dated 04/27/2025 at 11:40 a.m. revealed that Resident #71 suffered an unwitnessed fall in her room. Resident #71 was found on the floor lying on her left side beside the bed. Resident #71 reported to staff that she rolled out of the bed to go to the bathroom. Resident #71 was assessed and no apparent injuries were found. Review of the active plan of care revealed that Resident #71 was at risk for falls. Further review of the care plan revealed the resident suffered a fall on 04/27/2025. The intervention added on 04/27/2025 for the fall was for the Certified Nursing Assistant (CNA) staff to offer toileting assist when rounding. On 07/30/2025 at 2:00 p.m., S2Director of Nursing (DON) was informed that the intervention to offer toileting assist when rounding was inappropriate because CNA staff had already received in-service training to round on residents and every 2 hours and as needed.

CONCERN (D)

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, record review and interview, the facility failed to ensure respiratory care was provided consistent with ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interview, the facility failed to ensure respiratory care was provided consistent with professional standards of practice for 1 (#61) of 1 (#61) residents reviewed for respiratory care. The facility failed to ensure there was signage indicating oxygen in use was posted outside the entrance of Resident #61's room. Findings:Review of the facilities Oxygen Administration policy, revised date of October 2010, revealed in-part: Place an Oxygen in Use sign on the outside of the room entrance door.On 07/29/2025 at 07:52 a.m. an observation of Resident #61 revealed she was receiving oxygen at 4 liters per minute (LPM) via nasal cannula (NC). Further observation revealed there was no signage posted outside Resident #61's room indicating no smoking oxygen in use. Record review revealed Resident #61 was admitted to the facility on [DATE] with diagnoses that included displaced intertrochanteric fracture of left femur, subsequent encounter for closed fracture with routine healing, encounters for orthopedic aftercare, chronic respiratory failure with hypoxia, other specified interstitial pulmonary diseases, chronic kidney disease stage 4, type 2 diabetes mellitus with hyperglycemia, and paroxysmal atrial fibrillation.Review of the July 2025 Physician orders revealed Oxygen 4 LPM/nasal cannula via concentrator continuously dated 07/02/2025 and bi-level positive airway pressure (BIPAP) to be worn every (q) hour of sleep (HS) with following settings: inspiratory pressure - 12; expiratory pressure - 5; fraction of inspired oxygen (FiO2) - 45.Review of the admission Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicates the resident was cognitively intact and able to make daily decisions. Further review revealed the resident has shortness of breath and wears oxygen.Review of the July 2025 electronic medication administration record revealed documentation Resident #61 received Oxygen at 4 LPM per nasal cannula and the BIPAP q HS as ordered by the physician. On 07/29/2025 at 09:45 a.m. an observation and interview conducted with S2Director of Nursing (DON) outside of Resident #61's room revealed there was no signage indicating no smoking oxygen in use posted outside Resident #61's room. S2DON confirmed Resident #61 receives continuous oxygen at 4 LPM via NC. S2DON further confirmed there should be signage posted outside Resident #61's room indicating no smoking oxygen in use.

CONCERN (D)

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

Deficiency F0757 (Tag F0757)

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 each resident's medication regimen was free from unnecessary...

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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 each resident's medication regimen was free from unnecessary medications by failing to monitor for any active bleeding or bruising for a resident who received an anticoagulant for 1 (#1) 3 (#1, #61, #71) reviewed for general concerns.Findings:Review of the medical record for Resident #1 revealed an admission date of 06/25/2025 with diagnoses that included acute on chronic congestive heart failure, chronic pulmonary edema, atrial fibrillation and hypertension.Review of the Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 14 which indicated that Resident #1 was cognitively intact with daily decision making. The MDS indicated that the resident received an anticoagulant which is a high risk medication.Review of the current plan of care documented the resident's risk for abnormal bleeding related to anticoagulant therapy. The plan of care also indicated that Resident #71 should be monitored for signs and symptoms of bleeding: bleeding gums, bruises, petechiae, nosebleeds, tarry stools, and hematuria. Review of the July 2025 Physician's Orders documented that the resident had an active order for Eliquis 2.5 milligrams (mg) by mouth twice daily. There was not a physician's order in place to monitor for signs and symptoms of bleeding. Review of the July 2025 Medication Administration Record (MAR) documented that Resident #1 received the Eliquis. Additionally, there was no documentation in present to monitor for signs and symptoms of bleeding. On 07/30/2025 at 2:00 p.m., S2Director of Nursing was informed of the findings related to the absence of monitoring for signs and symptoms of bleeding as indicated per the plan of care.

CONCERN (E)

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

Safe Environment (Tag F0584)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to maintain a safe, clean, comfortable and homelike environment for 2 ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to maintain a safe, clean, comfortable and homelike environment for 2 (#38, #100,) of 2 (#38, #100) sampled residents reviewed for environmental concerns. The facility failed to ensure that residents' wheelchairs were maintained in good repair.Findings:Resident #38 Review of Resident #38's record revealed an admit date of 01/04/2023 with diagnoses including chronic diastolic (congestive) heart failure, left knee primary osteoarthritis and chronic kidney disease. Further review of records revealed a quarterly Minimal Data Set (MDS) assessment dated [DATE] documented Resident #38 utilized a wheelchair for mobility and required moderate assistance with transferring.On 07/28/2025 at 9:53 a.m. and 07/29/2025 at 8:50 a.m., observations of Resident #38's wheelchair revealed the wheelchair arm padding to be cracked and torn.On 07/29/2025 at 9:50 a.m., an observation conducted with S2Director of Nursing (DON) confirmed that Resident #38's wheelchair armrest padding was cracked and torn. Resident #100 Review of Resident #100's medical record revealed an admit date of 01/01/2025 with diagnoses including other Alzheimer's disease, arthritis, asthma and cardiac arrhythmia. Further review of Resident #100's medical record revealed a quarterly Minimal Data Set (MDS) assessment dated [DATE] documented Resident #100 was mobile per wheelchair and required moderate assistance with transfers.On 07/28/2025 at 9:56 a.m. and 07/29/2025 at 8:55 a.m., Resident #100 was observed sitting a wheelchair that had cracked and torn arm padding.An observation on 07/29/2025 at 9:50 a.m. with S2DON confirmed that Resident #100's wheelchair arm padding was cracked and torn.

Mar 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

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected multiple residents

Based on observation, review of the policy, and interviews, the facility failed to ensure that all drugs and biologicals are stored in locked compartments by having an unlocked, open medication room t...

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Based on observation, review of the policy, and interviews, the facility failed to ensure that all drugs and biologicals are stored in locked compartments by having an unlocked, open medication room that was not being monitored by licensed nursing staff. Findings: Review of facility's policy and procedure for Administering Medications (no date) revealed the following: Medications and biological are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing or medical personnel and pharmacy personnel. Observation on 03/18/2025 at 5:02 a.m. revealed the medication room (medication room a) door was unlocked and propped open by a wooden board. No nursing staff were present in the nurse's station or medication room at this time. Interview on 03/18/2025 at 5:05 a.m. with S4 Certified Nursing Assistant (CNA) confirmed that the medication room door was unlocked and propped open and that no nurses were in the room or in view of the medication room. Interview on 03/18/2025 at 5:10 a.m. with S3 Licensed Practical Nurse (LPN) confirmed that the door was unlocked and propped open and that it should have been locked. S3LPN confirmed that no nurses were in medication room and that only authorized nurses are to have access to the medication room. Interview on 03/18/2025 at 8:30 a.m. with S2 Director of Nursing confirmed that medication rooms are to be locked at all times if staff are not present and that the door is never to be propped open.

Dec 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

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to ensure the assessment accurately reflected the res...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to ensure the assessment accurately reflected the resident's status for 1 (#1) of 2 (#1 and #2) resident records reviewed, by assessing that bed rails were not indicated for a resident who was identified as having bed rails in use. Findings: Review of the medical record revealed a recent admission date of 12/18/2024. The resident's diagnoses included in part vascular dementia, moderate with behavioral disturbance and a history of falls. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed resident #1 had a brief interview for mental status score of 03 indicating the resident had severe cognitive impairment with his daily decision making skills. Observation on 12/23/2024 at 10:20 a.m. and 12/26/2024 at approximately 8:40 a.m. revealed resident #1 had ¼ bed rails, one intact to each side of the resident's bed frame. Both rails were upright and in a locked position. Review of the Bed Rail assessment dated [DATE] at 6:54 a.m. revealed a check mark next to Side Rails/Assist Bar not indicated at this time. The assessment was signed by S3Registered Nurse (RN). On 12/26/2024 at 12:03 p.m., during a telephone interview, S3RN was notified of the findings regarding a check mark being documented next to side rails/assist bar are not indicated at this time. S3RN confirmed that she had completed the Bed Rail assessment dated [DATE] at 6:54 a.m. for resident #1. She revealed that she had been informed by the facility's previous Director of Nursing (DON) that by marking the use of bed rails, the facility had shown a high indicator use for restraints. She revealed that she had done what she had been told to do by her DON, at that time. S3RN confirmed the assessment was inaccurate. On 12/26/2024 at approximately 11:55 a.m., S1Administrator and S2Regional Director of Operations were notified of the above findings regarding resident #1.

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 F0700 (Tag F0700)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to ensure residents were assessed for the risk of ent...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to ensure residents were assessed for the risk of entrapment from bed rails prior to installation for 2 (#1 and #2) of 2 (#1 and #2) residents reviewed for accident hazards. The facility failed to have documented evidence of an assessment for the risk of entrapment from bed rails for residents identified as having ¼ bed rails in use. Findings: Resident #1 Review of the medical record for resident #1 revealed a recent admission date of 12/18/2024. The resident's diagnoses included in part vascular dementia, moderate with behavioral disturbance and a history of falls. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed resident #1 had a Brief Interview for Mental Status (BIMS) score of 03 indicating the resident had severe cognitive impairment with his daily decision making skills. Observations on 12/23/2024 at 10:20 a.m. and 12/26/2024 at approximately 8:40 a.m. revealed resident ¼ bed rails, one intact to each side of the resident #1's bedframe. Both rails were upright and in a locked position. Review of the medical record revealed there was no documented evidence of resident #1 being assessed for risk of entrapment for bed rails of any kind. Review of the Bed Rail assessment dated [DATE] at 6:54 a.m. revealed a check mark next to Side Rails/Assist Bar not indicated at this time. The assessment was signed by S3Registered Nurse (RN). On 12/26/2024 at 12:03 p.m., during a telephone interview, S3RN was notified of the findings regarding a check mark being documented next to side rails/assist bar are not indicated at this time. S3RN confirmed that she had completed the Bed Rail assessment dated [DATE] at 6:54 a.m. for resident #1. She revealed that she had been informed by the previous Director of Nursing (DON) that by marking the use of bed rails, the facility had shown a high indicator use for restraints. S3RN further confirmed that she could not recall if resident #1 actually required the use of the bed rails at the time she had completed the assessment on 12/18/2024 nor if resident #1 required the use of bed rails at the present time. On 12/26/2024 at approximately 2:00 p.m., an interview with S4Maintenance Supervisor was notified of the findings regarding resident #1 having ¼ bed rails, one intact to each side of the bedframe. S4Maintenance Supervisor confirmed that he did not have any documentation to indicate that resident #1 was assessed for the risk of entrapment for bed rails of any kind. On 12/26/2024 at approximately 11:55 a.m., S1Administrator and S2Regional Director of Operations were notified of the above findings regarding resident #1. Resident #2 Review of the medical record revealed that resident #2 was admitted to the facility on [DATE] with diagnoses including, left femur fracture with joint replacement, major depressive disorder, and insomnia. Review of the admission MDS assessment dated [DATE] revealed resident #2 had a BIMS score of 08 indicating that resident #2 had moderate cognitive impairment with daily decision making skills. On 12/26/2024 at 8:25 a.m. and 12/30/2024 at 9:39 a.m., observations revealed resident #2 had ¼ bed rails, one intact to each side of the bedframe. Both bed rails were observed in an upright and locked position. Review of the medical record revealed there was no documented evidence of resident #2 being assessed for the risk of entrapment for bed rails of any kind. On 12/26/2024 at approximately 2:00 p.m., an interview with S4Maintenance Supervisor was notified of the findings regarding resident #2 having ¼ bed rails, one intact to each side of the bedframe. S4Maintenance Supervisor confirmed that he did not have any documentation to indicate that resident #2 was assessed for the risk of entrapment for bed rails of any kind. On 12/26/2024 at approximately 11:55 a.m., S1Administrator and S2Regional Director of Operations were notified of the above findings regarding resident #2.

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 F0729 (Tag F0729)

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 that before allowing an individual to serve as a nurse aid...

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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 before allowing an individual to serve as a nurse aide, a facility must receive receive registry verification that the individual has met competency evaluation requirements for 1 Certified Nursing Assistant (S5CNA) of 3 (S5CNA, S6CNA, and S7CNA) personnel files reviewed. The facility allowed an employee to work as a CNA with an expired and out of State certification. Findings: Review of S5CNA's personnel file revealed his date of hire was on [DATE]. Further review revealed that S5CNA received his nurse aide certification in a different state from which he was currently empoyed. Review further revealed the certification had expired on [DATE]. On [DATE] at 8:15 a.m., an interview with S1Administrator confirmed that S5CNA did not have a current nurse aide certification in the state he was currently employed. On [DATE] at 9:53 a.m., an interview with S8CNA Supervisor confirmed that S5CNA had provided services to residents after his nurse aide certification had expired on [DATE].

Aug 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 F0726 (Tag F0726)

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 nursing staff was competent in providing nursing and relat...

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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 nursing staff was competent in providing nursing and related services to assure resident safety and maintain resident's highest practicable physical, mental, and psychological well-being for each resident. The facility failed to ensure: 1) the Certified Nursing Assistants (CNAs) conducted a walk through round and provided a report on residents during shift change and 2) CNAs rounded on residents every 2 hours for 2 (#1, #2) of 3 (#1, #2, #3) sampled residents. Findings: Resident #1 Record review revealed resident #1 was admitted to the facility on [DATE] with diagnoses that included multiple myeloma not having achieved remission, personal history of Non-Hodgkin's lymphoma, adult failure to thrive, unspecified dementia unspecified severity without behavioral disturbance, depression, history of falling, and acute kidney failure unspecified. Review of Assessment Reference Date (ARD) Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated resident #1 was cognitively intact. Resident #1 had no range of motion impairment to upper or lower extremities and ambulated independently without any assisted devices. Resident #1 was independent with eating and oral hygiene. Resident #1 required setup or clean up assistance with personal hygiene and dressing upper body and required supervision or touching assistance with toileting hygiene and putting on/off footwear. Resident #1 required partial/moderate assistance with shower/bathe and dressing lower body. On 08/08/2024 at 9:40 a.m., an interview with S4CNA revealed she worked the day shift (7a.m to 3p.m.) on 08/03/2024 on hall A. S4CNA reported when she arrived to work S3CNA who worked the night shift, told her hi, but did not do a walk through or give her a report on the residents before she left. S4CNA reported she and S5CNA were both assigned to work hall A. S4CNA reported S5CNA was assigned to provide care for resident #1. S4CNA reported after she had finished making rounds on her residents, she started passing out ice water to residents. S4CNA reported around 7:40 a.m. she took ice water to resident #1's room. On 08/08/2024 at 10:42 a.m., a telephone interview with S3CNA reported she work the night shift (11p.m. to 7:00 a.m.) on hall A on 08/02/2024 and provided care for resident #1. S3CNA reported she checked on resident #1 at 11:00 p.m., 1:00 a.m., 3:00 a.m., and 5:00 a.m. S3CNA reported resident #1 was awake most of the night watching television. S3CNA reported resident #1 did not voice any needs or report any discomfort when she checked on him throughout the night. S3CNA reported she last checked on resident #1 around 5:00 a.m. and he was in his bed watching television. S3CNA revealed resident #1 reported he did not needing anything when she asked him. S3CNA reported she did not do a walk through or give report to the oncoming CNAs before she got off. On 08/08/2024 at 12:13 p.m., a telephone interview with S5CNA revealed he worked the day shift (7 a.m. to 3 p.m.) on 08/03/2024. S5CNA reported he did not receive a report from S3CNA who worked the night shift and they did not do a walk through at shift change. S5CNA reported he and S4CNA were assigned to work the day shift on hall A. S5CNA reported he started his rounds around 7:05 a.m. assisting residents. S5CNA reported he generally assist the residents who are not able to walk and require extensive assistance with their Activities of Daily Living (ADL) first. S5CNA reported he had not made it to resident #1's room until around 8:15 a.m. Resident #2 Record review revealed resident #2 was admitted to the facility on [DATE] with diagnoses that include bradycardia, presence of pacemaker, primary osteoarthritis right hand, idiopathic gout multiple sites, essential hypertension, atherosclerotic heart disease, unspecified atrial fibrillation, mixed hyperlipidemia, obstructive sleep apnea, solitary plasmacytoma not having achieved remission, anemia, type 2 diabetes mellitus without complications, morbid obesity, and multiple myeloma not having achieved remission. Review of the quarterly MDS assessment dated [DATE] revealed a BIMS score of 15 which indicated resident #2 was cognitively intact. Resident #2 required extensive one person assistance with bed mobility, transfers, and toilet use. Resident #2 required supervision one person assistance with eating. Resident #2 was always incontinent of bowel and bladder. Resident #2 was unable to walk and used a wheel chair for ambulation. On 08/08/2024 at 9:40 a.m., an interview with S4CNA revealed she worked the day shift (7a.m to 3p.m.) on 08/03/2024 on hall A. S4CNA reported when she arrived to work S3CNA who worked the night shift, told her hi, but did not do a walk through or give her a report on the residents before she left. S4CNA reported she and S5CNA were both assigned to work hall A. S4CNA reported S5CNA was assigned to provide care for resident #2. S4CNA reported after she had finished making rounds on her residents, she started passing out ice water to residents. S4CNA reported around 7:40 a.m. she took ice water to resident #2's room. On 08/08/2024 at 10:42 a.m., a telephone interview with S3CNA reported she worked the night shift (11p.m. to 7:00 a.m.) on hall A on 08/02/2024 and provided care for resident #2. S3CNA reported she checked on resident #2 at 11:00 p.m., 1:00 a.m., 3:00 a.m., and 5:00 a.m. S3CNA reported she provided incontinent care and brief change for resident #2 when she rounded on him throughout the night. S3CNA reported she last checked on resident #2 around 5:00 a.m. and she brought him 2 cups of coffee per his request. S3CNA reported she did not do a walk through or give report to the oncoming CNAs before she got off. On 08/08/2024 at 12:13 p.m., a telephone interview with S5CNA revealed he work the day shift (7 a.m. to 3 p.m.) on 08/03/2024. S5CNA reported he did not receive a report from S3CNA who worked the night shift and they did not do a walk through at shift change. S5CNA reported he and S4CNA were assigned to work the day shift on hall A. S5CNA reported he started his rounds around 7:05 a.m. assisting residents. S5CNA reported he generally assist the residents who are not able to walk and require extensive assistance with their Activities of Daily Living (ADL) first. S5CNA reported he had not made it to resident #2's room until around 8:15 a.m. On 08/12/2024 at 8:50 a.m., an interview with S2Director of Nursing (DON) revealed it is expected that the CNAs and nurses make rounds every 2 hours on residents they are assigned to provide care for. S2DON further revealed it is expected that the CNAs and LPNs give report and do a walk through round at the beginning and end of their shifts. On 08/08/2024 at 2:15 p.m., interview with S6CNA Supervisor confirmed she conducted a CNA in-service on 06/19/2024 about transferring, turning, rounding every 2 hours. S6CNA Supervisor revealed CNAs were also informed they were required to do a walk through and give a report with the oncoming CNAs before they get off. The off going CNA and the oncoming CNA are to physically go into the residents' rooms together for the walk through report at the beginning and ending of each shift. Review of the in-service sign in sheet with S6CNA Supervisor revealed S3CNA, S4CNA, and S5CNA's signatures were noted.

Jul 2024 5 deficiencies

CONCERN (E)

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

MDS Data Transmission (Tag F0640)

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 electronically transmit encoded, accurate and complete Minimum Data ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to electronically transmit encoded, accurate and complete Minimum Data Set (MDS) data to Centers for Medicare and Medicaid (CMS) in a timely manner for 3 (#43,#48, and #94) of 3 (#43,#48, and #94) residents reviewed for the completion of a fourteen day discharge assessment. Findings: Record review revealed resident #43 was admitted to the facility on [DATE] and discharged on 04/01/2024. The last transmitted MDS assessment in the electronic health record was an admission assessment completed on 03/19/2024. Record review revealed resident #48 was admitted to the facility on [DATE] and discharged on 04/27/2024. The last transmitted MDS assessment in the electronic health record was an admission assessment completed on 03/05/2024. Record review revealed resident # 94 was admitted to the facility on [DATE] and discharged on 04/05/2024. The last transmitted MDS assessment in the electronic health record was a quarterly assessment completed on 03/06/2024. On 07/24/2024 at 04:20 p.m., an interview with S2Licensed Practical Nurse (LPN)/Minimum Data Set (MDS) nurse confirmed a minimum data set assessment was not submitted within fourteen days of discharge for resident #43, resident #48, and resident #94.

CONCERN (E)

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected multiple residents

Based on observation, record review, and interview the facility failed to develop and implement a comprehensive person-centered care plan for 1 (#66) of 1 (#66) residents identified with a skin rash. ...

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Based on observation, record review, and interview the facility failed to develop and implement a comprehensive person-centered care plan for 1 (#66) of 1 (#66) residents identified with a skin rash. Findings: On 07/22/2024 at 10:48 a.m., observation of resident #66 revealed a dark patchy red rash to the face, back and arms. Interview at that time with resident #66 revealed she did not know the cause of the rash. On 07/24/2024 review of the record for resident #66 revealed diagnoses in part of dermatitis, arthritis, stage 3 chronic kidney disease, mild cognitive impairment and atrial fibrillation. Further review of the record revealed resident #66 had allergies to sulfonamide antibiotics. Review of the record also revealed the initial treatment for the rash began on 06/07/2024 with an order for hydrocortisone 1% ointment apply to areas on the face twice a day (BID) for 10 days- avoid the eyes and for Claritin 10 milligrams (mg) by mouth (po) one time a day for 10 days. Further review of the record revealed the following orders for resident #66's rash: 07/01/2024 Benadryl 25mg every 24 hours as needed for itching. 07/08/2024 Claritin 10mg 1 tab po every day for 30 days. Prednisone 10mg 1 tab po every day for 5 days in the morning. Consult dermatology for dermatitis to face/arms. 07/09/2024 Stop prednisone, start Diflucan 100mg po every other day for 4 doses (Fungal Rash). 07/09/2024 Claritin 10mg every day related to Dermatitis give until 08/09/2024. 07/20/2024 Hydralazine hydrochloric acid (HCL) 25mg every day and on 07/26/2024 give 1 po every day for 1 week then stop. On 07/24/2024 review of the current plan of care revealed there were no problems/needs related to the skin condition or rash for resident #66 implemented. On 07/24/2024 at 3:01 p.m., an interview with S1Director of Nursing (DON) confirmed the current plan of care did not address the problems/needs related to the skin condition/rash for resident #66.

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** Based on observations, interviews, and record reviews, the facility failed to provide respiratory care consistent with professio...

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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 provide respiratory care consistent with professional standards of practice for 2 (#25, #71) of 2 (#25, #71) sampled residents reviewed for respiratory care. The facility failed to ensure: 1) a resident's oxygen (O2) was administered as ordered, the O2 tubing was dated, and the nebulizer was dated/stored properly (#25); and 2) a resident's O2 concentrator was clean (#71). Findings: Review of the facility Oxygen Administration (Concentrator or Tank) Policy (no date noted) revealed in part: Humidifier bottles, cannulas and O2 tubing will be changed at least once weekly and dated. Concentrator filter should be cleaned weekly or as needed as well. Resident #25 On 07/23/2024 at 2:11 p.m., review of the record for resident #25 revealed diagnoses in part of hypothyroidism, vascular dementia, atrial fibrillation, major depressive disorder, chronic obstructive pulmonary disease, chronic viral hepatitis C, and sleep apnea. Review of the quarterly Minimum Data Set (MDS) assessment revealed resident #25 was unable to be scored for the Brief Interview Mental Status (BIMS) review due to cognitive impairment. On 07/23/2024 at 9:34 a.m. review of the record revealed physician orders in part with start date noted: 06/29/2024 admit to hospice due to dementia. 07/01/2024 oxygen at 3 liters per minute continuous per nasal cannula for shortness of breath or wheezing and to keep the pulse oximeter greater than or equal to 92% and for albuterol sulfate nebulization solution (2.5milligrams/3milliliters) every 4 hours as needed for shortness of breath related to chronic obstructive pulmonary disease (COPD). On 07/22/2024 at 3:35 p.m., an observation of resident #25 revealed oxygen was being administered at 5 liters per minute (lpm) per nasal cannula with no humidification noted and there was no date on the oxygen tubing. Further observation revealed the nebulizer mask was not covered or dated. On 07/23/2024 at 9:45 a.m., an observation again of resident #25 revealed the oxygen continued again at 5 lpm per nasal cannula with no humidification noted and there was no date on the oxygen tubing. Further observation revealed the nebulizer mask was not covered or dated. On 07/24/2024 review of the July 2024 medication administration record (MAR) revealed resident #25 received albuterol sulfate nebulizer on 07/09/2024, 07/10/2024 and 07/11/2024. Further review of the July 2024 MAR revealed record of resident #25 receiving oxygen at 3 liters per minute and keep pulse oximeter greater than or equal to 92%. Review of the documentation on 07/22/2024, 07/23/2024, and 07/24/2024 revealed the nurse documented the oxygen as being delivered at 3 lpm. On 07/23/2024 at 2:50 p.m., observation again of resident #25 oxygen revealed it was being administered again at 5 lpm with no humidification per nasal cannula and no date on the oxygen tubing. Further observation of the room revealed the nebulizer mask was not covered and not dated. 07/23/24 at 3:17 p.m., an observation and interview with S1Director of Nursing (DON) confirmed the oxygen was flowing at 5 lpm per nasal cannula and should not have been flowing at 5 lpm per nasal cannula. S1DON further confirmed the oxygen tubing was not dated and the nebulizer tubing was not covered or dated and should have been. Resident #71 Review of the medical record for resident #71 revealed the resident was admitted on [DATE] with diagnoses including: chronic systolic congestive heart failure, hypertension, and atherosclerotic heart disease. Review of the admission MDS assessment dated [DATE] revealed resident #71 scored a 10 on the BIMS which indicated he had moderately impaired cognition for daily decision making skills. Observations on 07/22/2024 at 9:10 a.m., 07/23/2024 at 10:30 a.m., and 07/24/2024 at 8:25 a.m., revealed resident #71 was receiving O2 via nasal cannula. Further observation revealed his O2 concentrator had a dirty buildup on both the front panel and the filter on the back of the concentrator. Review of resident #71's July 2024 physician orders revealed an order dated 07/12/2024 for O2 3 lpm continuous via nasal cannula. Review of the record revealed the following care plan for resident #71: administer oxygen therapy as ordered by the physician and to monitor for signs and symptoms of respiratory distress. During an observation of resident #71's O2 concentrator on 07/24/2024 at 2:10 p.m. with the surveyor, S3Licensed Practical Nurse (LPN) confirmed the resident's O2 concentrator had a dirty buildup on both the front panel and the filter on the back of the concentrator. On 07/24/2024 at 4:40 p.m., during an interview with S1DON, she was informed of resident #71's concentrator having a dirty buildup on both the front panel and the filter on the back of the concentrator. S1DON was informed the concentrator was in need of cleaning.

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** Based on record review and interviews the facility failed to ensure that the pharmacist reported any irregularities to the physi...

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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 that the pharmacist reported any irregularities to the physician and director of nursing for 1 (#15) of 5 (#15, #23, #37, #51, #59) residents reviewed for unnecessary medications. The pharmacist failed to identify that resident #15 was receiving as needed (prn) doses of the psychotropic medication clonazepam beyond 14 days without a documented rationale and duration date for administration. Findings: Record review revealed resident #15 was admitted to the facility 02/09/2019 with diagnoses that included Alzheimer's disease, unspecified dementia, major depressive disorder, essential hypertension, insomnia, anxiety disorder, psychiatric disorder with delusions due to known physiological condition, and Tourette's disorder. Review of the active July 2024 physician orders revealed an order dated 05/23/2024 for clonazepam 0.5 milligram (mg) tablet give one tablet by mouth every day prn for agitation. Further review revealed there was no evidence of a stop date. Review of the quarterly minimum data set assessment dated [DATE] revealed a brief interview mental status score of 3 which indicated severe cognitive impairment. Review of the narcotic log revealed resident #15 received prn clonazepam 0.5 mg on multiple days in May, June, and July 2024. Review of the resident's medical record revealed no recorded reasoning by the physician for the continuation of clonazepam 0.5 mg by mouth every day prn for agitation order. Review of the monthly drug regimen by the consultant pharmacist dated 06/19/2024 revealed no documentation by the consultant pharmacist to address the prn medication clonazepam. On 07/24/2024 at 8:35 a.m., an interview with S4Licensed Practical Nurse (LPN) revealed resident #15 occasionally needed the prn dose of clonazepam 0.5 mg due to behaviors such as hollering out for her momma, crying, and making repetitive noises. On 07/24/2024 at 11:35 a.m., an interview with S1Director of Nursing (DON) confirmed resident #15 had an order for clonazepam 0.5 mg by mouth every day prn for agitation that was ordered on 05/23/2024 with no stop date. S1DON confirmed there was no documented evidence from the physician regarding a documented rationale for extended use of the prn medication clonazepam. S1DON further confirmed there was no documented evidence of the consultant pharmacist identifying and notifying the physician or the director of nursing of the ongoing need for the prn medication clonazepam.

CONCERN (E)

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

Medication Errors (Tag F0758)

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 ensure that each resident was free from unnecessary medication use...

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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 that each resident was free from unnecessary medication use for 1 (#15) of 5 (#15, #23, #37, #51, #59) residents reviewed for unnecessary medications. The facility failed to have a documented rationale in the resident's medical record to indicate the duration of an as needed (prn) psychotropic medication to be extended beyond 14 days of use for resident #15 who received the prn medication clonazepam. Findings: Record review revealed resident #15 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, unspecified dementia, major depressive disorder, essential hypertension, insomnia, anxiety disorder, psychiatric disorder with delusions due to known physiological condition, and Tourette's disorder. Review of the active July 2024 physician orders revealed an order dated 05/23/2024 for clonazepam 0.5 milligram(mg) tablet give one tablet by mouth every day prn for agitation. Further review revealed there was no evidence of a stop date. Review of the quarterly minimum data set assessment dated [DATE] revealed a brief interview mental status score of 3 which indicated severe cognitive impairment. Review of the narcotic log revealed resident #15 received prn clonazepam 0.5 mg on multiple days in May, June, and July 2024. Review of the resident #15 medical record revealed no recorded reasoning by the physician for the continuation of clonazepam 0.5 mg by mouth every day prn for agitation order. On 07/24/2024 at 8:35 a.m., an interview with S4Licensed Practical Nurse (LPN) revealed resident #15 occasionally needed the prn dose of clonazepam 0.5 mg due to behaviors such as hollering out for her momma, crying, and making repetitive noises. On 07/24/2024 at 11:35 a.m., an interview with S1Director of Nursing (DON) confirmed resident #15 had an order for clonazepam 0.5 mg by mouth every day prn for agitation that was ordered on 05/23/2024 with no stop date. S1DON confirmed there was no documented evidence from the physician regarding a documented rationale for extended use of the prn medication clonazepam.

May 2024 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

Report Alleged Abuse (Tag F0609)

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 all alleged violations involving abuse, neglect, exploitatio...

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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 all alleged violations involving abuse, neglect, exploitation or mistreatment witnessed by staff are reported immediately to their supervisor or the Director of Nursing for 1 (#1) of 3 (#1, #2, #3) residents reviewed for abuse. Findings: Review of the facility's policy and procedure for Recognizing Signs and Symptoms of Abuse/Neglect with a revised date of January 2011 revealed: Our facility will not condone any form of resident abuse or neglect. To aid in abuse prevention, all personnel are to report any signs and symptoms of abuse/neglect to their supervisor or to the Director of Nursing (DON) Services immediately. Review of the medical record for resident #1 revealed diagnoses of Alzheimer's disease, depression, Tourette's, lumbago with sciatica, osteoporosis, dementia, reflux, anxiety, and psychotic disorder. Review of the current care plan for resident #1 revealed impaired cognitive short and long term memory loss related to the diagnosis of Alzheimer's disease. Further review of the care plan revealed interventions included for the staff to introduce self to resident when entering room, reorient resident as needed, encourage resident to be out of the room and to administer medications as ordered. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed resident #1 had severe cognitive impairment for daily decision making. Review of the facility's Investigative Report revealed on 04/29/2024 S2Director of Nursing (DON) informed S1Administrator that S5Certified Nursing Assistant (CNA) received word that S3CNA, the CNA that worked with resident #1 on 04/27/2024, raised her voice at resident #1 after she fell on the floor and used improper verbiage with resident #1. On 05/14/2024 at 10:30 a.m., an interview with S5CNA revealed on Monday 04/29/2024 S4Ward Clerk called S5CNA, and informed S5CNA that resident #1 fell on [DATE]. S4 [NAME] Clerk went to help and she saw S3CNA standing over resident #1 with her arm under the resident's arm saying stand up, get up, you aren't hurt, I am not having this today. S4Ward Clerk told S5CNA that she did not report what she saw and heard S3CNA say to resident #1 on 04/27/2024. Further interview with S5CNA revealed she immediately informed S2DON on 04/29/2024 of the conversation she had with S4Ward Clerk on 04/29/2024. On 05/14/2024 at 11:40 a.m., a phone interview with S4Ward Clerk revealed she was at the nurses' station with S6Licensed Practical Nurse (LPN). On 04/27/2024, S4Ward Clerk and S6LPN heard resident #1 yell out. S4Ward Clerk walked to the doorway and saw resident #1 was on the floor and S3CNA was trying to get resident #1 under her arm saying I don't know why you are down there. S4Ward Clerk revealed S3CNA started dragging resident #1 on the floor trying to get her up off of the floor. S4Ward Clerk revealed S3CNA was raising her voice and being mean to resident #1. S4Ward Clerk revealed she did not report the incident that happened on 04/27/2024 between resident #1 and S3CNA until Monday 04/29/2024. On 05/14/2024 at 3:30 p.m., an interview with S2DON revealed S4Ward Clerk should have reported the alleged abuse regarding resident #1 and S3CNA immediately. On 05/15/2024 at 4:10 p.m., an interview with S1Administrator confirmed S4Ward Clerk should have reported the alleged abuse regarding resident #1 and S3CNA immediately.

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews the facility failed to have documented evidence that allegations of verbal abuse were thor...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews the facility failed to have documented evidence that allegations of verbal abuse were thoroughly investigated for 1 (#1) of 3 (#1, #2, and #3) sampled residents reviewed for abuse. Findings: Review of the facility's Abuse Investigations policy dated April 2014 revealed: All reports of resident abuse, neglect, and injuries of unknown source shall be thoroughly and promptly investigation by facility management; 3. The individual conducting the investigation will, at a minimum: c. Interview the person (s) reporting the incident; d. Interview any witnesses to the incident; 5. Witness reports will be obtained in writing. Either the staff member will write his/her statement and sign and date it, or the investigator may obtain the staff statement, read it back to the member and have him/her sign and date it. Review of the medical record for resident #1 revealed diagnoses of Alzheimer's disease, depression, Tourette's, lumbago with sciatica, osteoporosis, dementia, reflux, anxiety, and psychotic disorder. Review of the current care plan for resident #1 revealed impaired cognitive short and long term memory loss related to the diagnosis of Alzheimer's disease. Further review of the care plan revealed interventions included for the staff to introduce self to resident when entering room, reorient resident as needed, encourage resident to be out of the room and to administer medications as ordered. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed resident #1 had severe cognitive impairment for daily decision making. Review of the facility's Investigative Report revealed on 04/29/2024 S2Director of Nursing (DON) informed S1Administrator that S5Certified Nursing Assistant (CNA) received word that S3CNA, the CNA that worked with resident #1 on 04/27/2024, raised her voice at resident #1 after she fell on the floor and used improper verbiage with resident #1. On 05/14/2024 at 10:30 a.m., an interview with S5CNA revealed on Monday 04/29/2024 S4Ward Clerk called S5CNA, and informed S5CNA that resident #1 fell on [DATE]. S4 [NAME] Clerk went to help and she saw S3CNA standing over resident #1 with her arm under the resident's arm saying stand up, get up, you aren't hurt, I am not having this today. S4Ward Clerk told S5CNA that she did not report what she saw and heard S3CNA say to resident #1 on 04/27/2024. Further interview with S5CNA revealed she immediately informed S2DON on 04/29/2024 of the conversation she had with S4Ward Clerk on 04/29/2024. On 05/14/2024 at 11:40 a.m., a phone interview with S4Ward Clerk revealed she was at the nurses' station with S6Licensed Practical Nurse (LPN). On 04/27/2024, S4Ward Clerk and S6LPN heard resident #1 yell out. S4Ward Clerk walked to the doorway and saw resident #1 was on the floor and S3CNA was trying to get resident #1 under her arm saying I don't know why you are down there. S4Ward Clerk revealed S3CNA started dragging resident #1 on the floor trying to get her up off of the floor. S4Ward Clerk revealed S3CNA was raising her voice and being mean to resident #1. S4Ward Clerk revealed that neither S1Administrator nor S2DON asked her to give a statement or interview about the incident that occurred on 04/27/2024. On 05/14/2024 at 4:20 p.m., review of the video footage with S1Administrator revealed S7CNA was seen in the video assisting resident #1 during the incident on 04/27/2024. There was no audio to the video footage and the incident in question took place out of the line of site for the camera. On 05/15/2024 at 3:30 p.m., a phone interview with S7CNA revealed on 04/27/2024 she heard resident #1 holler and she went to help. S7CNA revealed resident #1 was on the floor and S3CNA was trying to assist her. S7CNA revealed she did not witness any staff member being abusive to resident #1. S7CNA revealed that neither S1Administrator nor S2DON asked her to give a statement or interview about the incident that occurred on 04/27/2024. Review of the facility's investigative report revealed no documented evidence of a statement or an interview obtained from S4Ward Clerk or S7CNA regarding the incident with resident #1 and S3CNA that occurred on 04/27/2024. On 05/14/2024 at 3:30 p.m., an interview with S2DON revealed she did not interview or get a statement from S4Ward Clerk or from S7CNA regarding the alleged abuse to resident #1 by S3CNA. On 05/15/2024 at 11:30 a.m., an interview with S1Administrator revealed he did not interview or get a statement from S4Ward Clerk or S7CNA regarding the alleged abuse to resident #1 by S3CNA.

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 F0729 (Tag F0729)

Could have caused harm · This affected multiple residents

Based on record reviews and interview, the facility failed to ensure the State Adverse Actions Website checks were completed for Certified Nursing Assistants (CNA) monthly for 4 (S3CNA, S8CNA, S10CNA,...

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Based on record reviews and interview, the facility failed to ensure the State Adverse Actions Website checks were completed for Certified Nursing Assistants (CNA) monthly for 4 (S3CNA, S8CNA, S10CNA, and S11CNA) of 5 (S3CNA, S8CNA, S10CNA, S11CNA and S12CNA) personnel files reviewed. Findings: Review of S3CNA's personnel file revealed a hire date of 03/20/2024. Further review of S3CNA's personnel file revealed there was a State Adverse Action check upon hire. Further review of the personnel file revealed there was no documented evidence of State Adverse Action checks obtained monthly. Review of S8CNA's personnel file revealed a hire date of 05/15/2023. Further review of S8CNA's personnel file revealed there was a State Adverse Action check upon hire. Further review of the personnel file revealed there was no documented evidence of State Adverse Action checks obtained monthly. Review of S10CNA's personnel file revealed a hire date of 02/28/2024. Further review of S10CNA's personnel file revealed there was a State Adverse Action check upon hire. Further review of the personnel file revealed there was no documented evidence of State Adverse Action checks obtained monthly. Review of S11CNA's personnel file revealed a hire date of 02/23/2024. Further review of S11CNA's personnel file revealed there was a State Adverse Action check upon hire. Further review of the personnel file revealed there was no documented evidence of State Adverse Action checks obtained monthly. On 05/15/2024 at 3:20 p.m., an interview with S9Clerical confirmed State Adverse Action checks were not obtained monthly.

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 F0836 (Tag F0836)

Could have caused harm · This affected multiple residents

Based on record review and interview, the facility failed to ensure it was in compliance with state laws by failing to obtain criminal history checks upon hire for 1 (S8Certified Nursing Assistant) (C...

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Based on record review and interview, the facility failed to ensure it was in compliance with state laws by failing to obtain criminal history checks upon hire for 1 (S8Certified Nursing Assistant) (CNA) of 5 (S3CNA, S8CNA, S10CNA, S11CNA and S12CNA) personnel files reviewed. Findings: The current Long Term Minimum Licensing Standards, statute 9759 A. states the nursing facility shall have statewide criminal history checks performed on non-licensed personnel to include CNAs. Review of the personnel file for S8CNA revealed a hire date of 05/15/2023. Further review of S8CNA's personnel file revealed no documented evidence of a criminal history check obtained upon hire. On 05/15/2024 at 3:20 p.m., an interview with S9Clerical confirmed there was no documented evidence of a criminal history background check obtained upon hire for S8CNA.

Aug 2023 2 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

Deficiency F0658 (Tag F0658)

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 ensure services were provided by the facility to meet quality profe...

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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 services were provided by the facility to meet quality professional standards for 1 (#3) of 5 (#1, 2, 3, 4, 5) residents reviewed. The facility failed to ensure resident #3's Calcium-D3 was administered as ordered. Findings: Review of the record for resident #3 revealed diagnoses including type 2 diabetes mellitus, congestive heart failure, vascular dementia, chronic kidney disease stage 5, renal dialysis, paroxysmal atrial fibrillation, and hyperparathyroidism. Review of resident #3's Quarterly Minimal Data Set (MDS) dated [DATE] revealed she had a Brief Interview for Mental Status (BIMS) score of 99, which indicated the resident was unable to compete the interview. Further review revealed she required extensive to total dependence on staff for all activities of daily living. Review of resident #3's June 2023 physician orders revealed an order dated 06/02/2023 for Calcium (Ca) 600 milligrams (mg) -D3 10 micrograms (mcg) 1 by mouth twice daily with meals. Review of resident #3's June 2023 and July 2023 Medication Administration Records (MARs) revealed documentation staff administered the resident's Calcium 600mg-D3mcg daily instead of twice daily as ordered. On 08/02/2023 at 12:15 p.m., S1Administrator was informed resident #3's Ca-D3 was administered daily instead of twice daily as ordered for June 2023 and July 2023. On 08/02/2023 at 12:35 p.m., an interview with S2Director of Nursing (DON) confirmed the resident's above Ca-D3 was not given as ordered for June 2023 and July 2023. She confirmed there appeared to be a computer system issue and the Ca-D3 order did not populate correctly to the resident's June 2023 and July 2023 MARs.

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

Drug Regimen Review (Tag F0756)

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 ensure the pharmacist must report any irregularities to the attend...

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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 the pharmacist must report any irregularities to the attending physician, the facility's medical director, and the director of nursing and these reports must be acted upon for 1 (#3) of 5 (#1, 2, 3, 4, 5) residents reviewed. The pharmacist failed to identify that resident #3's Calcium-D3 was not administered as ordered. Findings: Review of the record for resident #3 revealed diagnoses including type 2 diabetes mellitus, congestive heart failure, vascular dementia, chronic kidney disease stage 5, renal dialysis, paroxysmal atrial fibrillation, and hyperparathyroidism. Review of resident #3's Quarterly Minimal Data Set (MDS) dated [DATE] revealed she had a Brief Interview for Mental Status (BIMS) score of 99, which indicated the resident was unable to compete the interview. Further review revealed she required extensive to total dependence on staff for all activities of daily living. Review of resident #3's June 2023 physician orders revealed an order dated 06/02/2023 for Calcium (Ca) 600 milligrams (mg) -D3 10 micrograms (mcg) 1 by mouth twice daily (BID) with meals. Review of resdient #3's June 2023 and July 2023 Medication Administration Records (MARs) revealed documentation staff administered the resident's Calcium 600mg-D3mcg daily instead of twice daily as ordered. Review of the Pharmaceutical Consultant Report dated 06/21/2023 revealed there was no documentation that the pharmacist identified resident #3 received the Ca 600mg-D3 10mcg daily instead of BID as ordered. On 08/02/2023 at 12:15 p.m., S1Administrator was informed resident #3's Ca-D3 was administered daily instead of twice daily as ordered for June 2023 and July 2023. Also informed S1Administrator that the pharmacy consultant failed to identify that resident #3's Ca-D3 was administered incorrectly for June 2023 and July 2023. On 08/02/2023 at 12:35 p.m., an interview with S2Director of Nursing (DON) confirmed the resident's above Ca-D3 was not given as ordered for June 2023 and July 2023. S2DON also confirmed the pharmacy consultant failed to identify that resident #3's Ca-D3 was administered incorrectly for June 2023 and July 2023.

Jun 2023 2 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 21 Review of the medical record for resident #21 revealed an admission of 07/22/2020 with diagnoses including unspecifi...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident 21 Review of the medical record for resident #21 revealed an admission of 07/22/2020 with diagnoses including unspecified atrial fibrillation, chronic obstructive pulmonary disease, bacterial infection, encephalopathy, paroxysmal atrial fibrillation, gram negative sepsis, hypertension, hypothyroidism, gastro-esophageal reflux, overactive bladder, chronic viral hepatitis C, tremor, and chronic pain. An observation on 06/20/2023 at 9:30 a.m. of resident #21 revealed the resident was lying in bed, and the resident did not have geri sleeves in place to arms. Review of the physician's orders for resident #21 revealed an order dated 06/20/2023 for a skin tear to right elbow: cleanse with dermal wound cleanser, pat dry, apply triple antibiotic ointment, cover with border dressing, change every 3 days and as needed for soilage/dislodgement. Review of the care plan dated 07/10/2017 revealed resident #21 was at risk for skin tears/bruising related to having fragile skin. Further review of the care plan revealed an intervention dated 12/23/2017 to place geri sleeves on resident. An observation of resident #21 on 06/21/2023 at 8:43 a.m. revealed the resident had a dressing to right elbow, and resident reported it happened when staff were transferring her. Resident did not have geri sleeves in place to her arms. An interview on 06/22/2023 at 8:55 a.m. with S9LPN (Licensed Practical Nurse) revealed resident #21 has a skin tear to right elbow that was found on 06/20/2023. Review of the incident report for resident #21 dated 06/20/2023 revealed S2DON (Director of Nursing) observed a skin tear to right elbow, but the resident was unable to tell her how it happened. Review of the yearly MDS (Minimum Data Set) for resident #21 dated 04/18/2023 revealed a BIMS (Brief Interview of Mental Status) score of 4 indicating severe cognitive impairment. Further review of the MDS revealed the resident required extensive assist with ADLs (Activities of Daily Living). An observation on 06/22/2023 at 8:55 a.m. of resident #21 revealed the resident did not have geri sleeves in place to arms. An interview on 06/22/2023 at 3:00 p.m. with S2DON confirmed resident #21 should have had geri sleeves in place. Based on observations, record reviews, and interviews the facility failed to implement the comprehensive person-centered careplan by not providing the diet as ordered for 1 (#43) of 5 (21, 43, 61, 74 and 136) residents reviewed for nutrition. The facility also failed to provide geri sleeves as stated in the care plan for 1 (#21) of 1 (#21) residents reviewed for skin conditions. Findings: Resident 43 Review of the medical record for resident #43 revealed admission date of 05/19/2023 with diagnoses including Alzheimer's disease, seizures, anemia, depression, arthritis, and dysphagia. Review of the physician orders dated 05/19/2023 revealed an order for a regular pureed diet, give juice at breakfast, and double portions at all meals. Further review of the order revealed give ice cream with lunch and supper, and provide two glasses of tea with lunch and supper. Review of the care plan revealed resident #43 required assistance with activities of daily living and had alteration in nutrition related to the resident required a mechanically altered diet. Review of the Minimum Data Set, dated [DATE] revealed the resident had severe impaired cognition for daily decision making. The resident required extensive assistance with activities of daily living. Review of the Registered Dietician notes dated 05/26/2023 revealed the resident was on a pureed diet with double portions, ice cream at lunch and supper every day, and fed all meals by her husband and/or staff. On 06/20/2023 at 11:45 a.m. observation of resident #43's lunch revealed the resident did not receive ice cream on the lunch tray as ordered. On 06/21/2023 at 12:06 p.m. observation of resident #43 revealed she was in the dining room being fed and review of the diet card revealed the resident was on a regular pureed diet. Observation of the lunch meal revealed the resident received a pureed diet with no ice cream on the tray. On 06/21/2023 at 12:20 p.m. S10Dietary Manager was informed of the ice cream not on the tray or diet card as ordered on 05/19/2023. On 06/22/2023 at 9:40 a.m., S2DON (Director of Nursing) was informed resident #43 did not receive ice cream with lunch as ordered and it was not on her diet card for her to receive ice cream at lunch and supper as ordered on 05/19/2023.

CONCERN (E)

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

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected multiple residents

Based on observation and interviews the facility failed to ensure expired medications were not available for use and administered to residents as evidenced by expired medications being stored in the f...

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Based on observation and interviews the facility failed to ensure expired medications were not available for use and administered to residents as evidenced by expired medications being stored in the facility's 2 of 2 medication rooms. This deficient practice had the potential to affect any of the facility's 92 residents as listed on the Resident Census and Condition of Residents Report. Findings: Review of the facility's policy titled, Medication Storage in the Facility revealed the following, in part: Policy: Medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing or medical personnel and pharmacy personnel. Procedure: 13. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication destruction, and reordered from the pharmacy, if a current order exists. On 06/22/2023 08:40 a.m. S8RN (Registered Nurse)/Infection Preventionist and surveyors observed Medication Room (Room B). The following medications were expired with the following expiration dates noted: 1 Normal Saline IV flush syringe - 07/2021 9 Normal Saline IV flush syringes - 03/05/2023 2 Normal Saline IV flush syringes - 03/2023 1 Aspirin 325mg (milligrams) 100 count bottle - 09/2022 On 06/22/2023 at 8:50 a.m. S8RN(Registered Nurse)/Infection Preventionist confirmed the above medications were expired. On 06/22/2023 at 9:05 a.m. S2DON (Director of Nursing) and surveyors observed Medication Room (Room A) and there was 1 bottle of Mineral Oil that had an expiration date of 06/2022. S2 DON confirmed that the Mineral Oil had expired.

May 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

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 reviews and interviews, the facility failed to provide notice of discharge in a facility initiated discharge for...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to provide notice of discharge in a facility initiated discharge for 1 (Resident #1) of 2 (#1, and #5) resident's records reviewed for discharge. The facility failed to notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing, and record the reasons for the transfer or discharge in the resident's medical record. Findings: Review of the Facility's Involuntary Transfer and Discharge Policy revealed in part: It is the policy of this facility to permit each resident to remain in the facility, and not be transferred or discharged from the facility unless a situation falls into one of the following six (6) categories: 1. The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility; When a transfer or discharge of a resident for any one of the six reasons listed above, the facility must document the reason for discharge in the resident's clinical record. 1. The resident and, if known, a family member or legal representative of the resident must be notified of the reasons for the move in writing and in a language they understand; 2. The notice must also include the effective date of transfer/discharge and the location to which the resident is transferred or discharged ; 3. The notice must include an explanation of the right to appeal the transfer to the State as well as the name, address, and phone number of the State long term care ombudsman. In the case of a developmentally disabled individual, the notice must include the name, address and phone number of the agency responsible for advocating for the developmentally disabled. In the case of a mentally ill individual, the name, address and phone number of the agency responsible for advocating for the mentally ill individuals shall be included in the written notice. Generally this notice must be provided at least 30 days prior to the transfer of the resident. (If a resident is sent out to a psychiatric hospital or acute hospital notices must still be sent to the resident in the hospital.) Review of the medical record for sampled resident #1 revealed diagnoses of bipolar disorder with psych features, unspecified moderate dementia with psychotic disturbances, abnormal gait, diabetes mellitus, anxiety disorder, osteoarthritis, hypertension, and psychosis. Review of the MDS (Minimum Data Set, dated [DATE] revealed resident #1 had independent cognition for daily decision making and required assistance with activities of daily living. Review of the nurses' notes dated 02/28/2023 at 2:21 p.m. revealed the resident was transported to a local emergency department via ambulance for evaluation. Review of the medical record revealed no documented evidence the resident or responsible party was notified of the discharge, and there was no documented evidence of the reason for the discharge located in the resident's medical record. Further review of the medical record revealed no documented evidence that the facility implemented the facility's Involuntary Transfer and Discharge Policy. On 05/30/2023 at 1:30 p.m., interview with S2 DON (Director of Nursing) revealed resident #1 was sent to a behavioral unit on 02/28/2023 and did not return to the nursing facility. S2 DON further confirmed resident #1 was discharged to another facility when she was discharged from the behavioral unit. On 05/31/2023 at 10:50 a.m., interview with S1 Administrator revealed resident #1 was involuntarily discharged from the nursing facility. S1 Administrator revealed there was no documented evidence in the medical record of the reason resident #1 was discharged from the facility. S1 Administrator confirmed he did not follow the Involuntary Transfer and Discharge Policy. S1 Administrator revealed he did not have documentation of the following: a family member and resident being notified of the reasons for the move in writing, the notice must include an explanation of the right to appeal, and the discharge notice was not sent to the resident or responsible party at least 30 days prior to the transfer of the resident.

Feb 2023 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 reviews and interview, the facility failed to immediately inform the resident's representative(s) of a resident'...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interview, the facility failed to immediately inform the resident's representative(s) of a resident's fall for 1 (#1) of 4 (#1, #3, #4, #5) residents reviewed for falls. Findings: Review of the medical record for resident #1 revealed the resident was admitted on [DATE] with diagnoses of dementia with behavioral disorder, Alzheimer's with late onset, hypertension, osteoarthritis of both hips, and long term use of anticoagulants. Review of the Minimum Data Set, dated [DATE] revealed the resident had severely impaired cognitive skills for daily decision making. The resident required one person extensive assistance with bed mobility, transfers, and toilet use. The resident was continent of bowel and bladder. Review of the care plan revealed the resident was at risk for falls. The interventions were as follows: keep call light in reach at all times, observe arrangement of resident's room for hazards, alert resident to changes, keep room, hallways clean and uncluttered, encourage resident to wear firm, non rigid shoes with nonskid soles, keep necessary items within easy reach, bedside commode placed, place sign in room to call for assist, staff to make hourly rounds as needed and when necessary, wing mattress - discontinued 12/12/2022, place bolster, move closer to nurses station and move bed against wall. Review of the Resident Incident Report dated 10/28/2022 at 7:40 a.m. revealed: this nurse was called into resident's room by aide. Upon arrival, this nurse observed resident lying in the floor beside bed with wheelchair beside her. This nurse asked resident what happened. Resident stated, I was getting out of bed and my legs just got weak. This nurse asked resident if she hit her head when she fell and resident stated, No. This nurse observed resident. No apparent bruising, skin tears or bleeding, performed active range of motion and passive range of motion, this nurse and aide assisted resident into wheelchair. Vital signs: temperature 97.3, pulse 62, respirations 20, and blood pressure 136/77, no pain noted. physician notified on 10/28/2022 at 8:00 a.m. and resident's representative notified on 10/28/2022 at 1:50 p.m. Review of the facility's Notification of Changes policy revealed: a facility must immediately inform the resident; consult with the resident's physician; and if known, notify the resident's legal representative or interested family member when there is - (A) An accident involving the resident which results in injury and has the potential for requiring physician intervention. An interview with S2Director of Nursing on 02/15/2023 at 3:20 p.m. confirmed the nurse did not notify resident #1's representative of her fall in a timely manner.

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 F0745 (Tag F0745)

Could have caused harm · This affected 1 resident

Based on record reviews and interviews, the facility failed to provide medically-related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being for ...

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Based on record reviews and interviews, the facility failed to provide medically-related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being for 2 (#1 and #8) of 8 (#1 - #8) sampled residents. The facility failed to arrange transportation services to medical appointments for resident #1 and resident #8. Findings: Review of the facility's statement of services revealed the following: Facility will provide transportation for ambulatory or wheelchair residents to and from doctor visits or other medical services as needed within a 50 mile radius of the facility. Resident #1 Review of the facility's appointment calendar revealed a medical appointment was scheduled for resident #1 on 01/17/2023. Further review of the calendar revealed the appointment was canceled and written on the calendar was daughter will not meet. An interview with S3Ward Clerk on 02/13/2023 at 2:50 p.m. revealed she doesn't remember why the appointment was canceled. She reported there were 3 other appointments scheduled in a row that day or there was no one to accompany the resident. An interview with S2Director of Nursing on 02/15/2023 at 3:20 p.m. confirmed the facility did not provide transportation to resident #1's appointment on 01/17/2023. Resident #8 Review of the facility's appointment calendar revealed an eye appointment was scheduled for resident #8 on 01/25/2023. Further review of the calendar revealed the appointment was canceled and rescheduled for 03/22/2023. An interview with S3Ward Clerk on 02/13/2023 at 8:17 a.m. reported the appointment was canceled because there was another long distance appointment that day. Review of the eye appointment progress notes from 09/23/2022 revealed the resident has normal tension glaucoma and received 3 different eye drops and an eye health vitamin. Further review revealed the resident was to follow up in 4 months. An interview on 02/15/2023 at 3:20 p.m. with S1Administrator confirmed the facility did not provide transportation to resident #8's eye appointment on 01/25/2023.

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 record reviews and interviews, the facility failed to implement a comprehensive person-centered care plan for 3 (#1, #3...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to implement a comprehensive person-centered care plan for 3 (#1, #3, #6) of 8 (#1 - #8) sampled residents. The facility had incomplete documentation of the residents' meal intake percentages for residents #1, #3 and #6. The facility failed to have resident #1 up and out of bed and in wheelchair in common area for all meals. The facility failed to have bolsters to resident #1's bed and have resident #1's bed against the wall. Findings: Resident #1 Review of the medical record for resident #1 revealed the resident was admitted on [DATE] with diagnoses of dementia with behavioral disorder, Alzheimer's with late onset, hypertension, osteoarthritis of both hips, and long term use of anticoagulants. Review of the Minimum Data Set, dated [DATE] revealed the resident had severely impaired cognitive skills for daily decision making. The resident required one person limited assistance with eating. The resident required one person extensive assistance with bed mobility, transfers, and toilet use. Review of the physician orders for February 2023 revealed the following orders: diet -mechanical soft with ground meats, resident to have 1:1 assistance with meals, resident to be up for all meals, out of bed and in wheelchair in common area, and offer resident a supplement/snack if consumption is less than 75%. Review of the care plan revealed the resident was at risk for alteration in nutrition. Review of the interventions revealed to monitor intake every shift. Further review of the care plan revealed the resident was at risk for falls. Review of the interventions revealed to place bolster and move bed against wall. Review of the Meal intake percentage form printed on 02/14/2023 from 01/01/2023 - 02/13/2023 revealed there was no documented evidence of the meal intake percentage for 37 meals. Observation on 02/12/2023 at 6:10 p.m. revealed the resident was in her bed with the head of the bed elevated and her meal tray within reach on the bedside table. There were no bolsters on the bed and the bed was not against the wall. An interview with S5CNA (Certified Nursing Assistant) on 02/13/2023 at 8:30 a.m. revealed she should document the resident's meal intake. Observation on 02/13/2023 at 5:05 p.m. revealed the resident was in her bed with S4CNA feeding her supper. There were no bolsters on the bed and the bed was not against the wall. An interview with S6LPN (Licensed Practical Nurse) on 02/14/2023 at 1:30 p.m. confirmed resident #1 should be up in her wheelchair and in the common area for all meals. S6LPN confirmed the resident did not have bolsters on her bed and her bed was not against the wall. S6LPN confirmed the staff should document meal intake every shift. An interview with S4CNA on 02/14/2023 at 4:50 p.m revealed she was unaware that resident #1 should be up in her wheelchair and in the common area for all meals. An interview with S2DON (Director of Nursing) on 02/14/2023 at 2:15 p.m. confirmed there were not bolsters on resident #1's bed and the resident's bed was not against the wall. An interview with S2DON on 02/15/2023 at 4:45 p.m. confirmed resident #1 should be up in her wheelchair and in the common area for all meals and the resident's meal intake percentages should be documented as per the plan of care. Resident #3 Review of the medical record for resident #3 revealed an admission date of 06/13/2022 with diagnoses of hypertension, Alzheimer's disease, depressive disorder, iron deficiency anemia, cognitive communication deficit, hypokalemia, dementia, and muscle wasting. Review of the quarterly Minimum Data Set, dated [DATE] revealed the resident had intact cognitive skills for daily decision making. The resident required limited assistance with bed mobility, transfers, hygiene and bathing and required supervision with setup help only for eating. Review of the February 2023 physician orders revealed an order dated 06/13/2022 for a regular diet and on 01/04/2023 offer resident a supplement/snack if meal consumption is less than 75%. Review of the care plan dated 06/13/2022 revealed the resident was at risk for alteration in nutrition related to vitamin deficiency. Review of the interventions revealed to monitor meal consumption and compliance with diet. Review of the Meal intake percentage form printed on 02/14/2023 from 01/01/2023 - 02/13/2023 revealed there was no documented evidence of the meal intake percentage for 47 meals. An interview with S7CNA on 02/14/2023 at 2:35 p.m. revealed the CNAs are supposed to document on the computer the meal percentages eaten for each resident. An interview with S8LPN on 02/14/2023 at 2:40 p.m. revealed the CNAs are to document the percentage of meals eaten for each resident. An interview with S2DON on 02/15/2023 at 4:45 p.m. confirmed the resident's meal intake percentages should be documented as per the plan of care. Resident 6 Review of the medical record revealed resident #6 was admitted on [DATE] with diagnoses of atrial fibrillation, hypertension, hyperlipidemia, dementia, reflux, dysphagia, cognitive communication deficit, vitamin deficiency, depression and fluid overload. Review of the annual Minimum Data Set, dated [DATE] revealed the resident had moderate cognitive skills for daily decision making. The resident required limited assistance with bed mobility, transfers, hygiene and bathing and required supervision with setup help only for eating. Review of the February 2023 physician orders revealed an order dated 01/04/2023 to offer resident a supplement/snack if meal consumption is less than 75%, and on 03/08/2022 regular diet, no added salt with thin liquids. Review of the care plan dated 03/08/2022 revealed at risk for alteration in nutrition. Review of the interventions revealed monitor meal consumption and compliance with diet. Review of the Meal intake percentage form printed on 02/14/2023 from 01/02/2023 - 02/13/2023 revealed there was no documented evidence of the meal intake percentage for 61 meals. An interview with S9CNA on 02/14/2023 at 2:15 p.m. revealed the CNAs are to document meal percentages eaten for each resident. An interview with S10LPN on 02/14/2023 at 2:25 p.m. revealed the CNAs are to document the percentage of each meal consumed on every resident. An interview with S2DON on 02/15/2023 at 4:45 p.m. confirmed the resident's meal intake percentages should be documented as per the plan of care.

Guest House Nursing and Rehabilitation

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