Moweaqua Rehab & HCC

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow physician orders when administering medications including multiple doses of intravenous antibiotics for two (R7, R8) residents out of three residents reviewed for medication administration in a sample list of eight residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect residents' rights to be free from physical and verbal abuse by R1. These failures affected four residents (R1, R2, R3, R4,) of thirteen reviewed for abuse in the sample of thirteen and resulted in R1 punching R2 in the face with R2 receiving defensive hand wounds requiring medical evaluation at the hospital and prescriptions for oral and topical antibiotic treatments, R1 using verbal expletives towards R3, and R1 kicking R4 in the legs.

Inspectors wroteBased on interview and record review, the facility failed to revise residents' care plans following resident to resident physical and verbal abuse incidents. This failure affects four residents (R1, R2, R3, R4) of four reviewed for care plans in the sample of thirteen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a residents' dietary recommendations to the physician, notify the Registered Dietician and physician of continued weight loss, obtain weights as ordered, follow dietary orders, and failed to report a residents' peg tube (gastric tube) placement to the Registered Dietician upon readmission to the facility. These failures affect one (R3) of three residents reviewed for nutrition on a total sample list of eight residents. These failures resulted in R3 losing 13.5% of his body weight in three and a half months, resulting in malnutrition, dehydration, and peg tube placement due to nutritional insufficiency.

Inspectors wroteBased on interview and record review, the facility failed to monitor and document a residents' tube feeding administration amounts, gastric tube placement, residuals, feeding complications, and consultation to ensure adequate nutritional intake was being administered via the tube feeding. These failures affect one (R3) of one resident reviewed for tube feedings from a total sample list of eight residents reviewed. These failures resulted in R3 having nausea and vomiting with tube feeding administration, the tube feeding being shut off without a physician order/consultation, and R3 experiencing continued significant weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide bathing, oral care, and nail care to three (R1, R3, R4) of three dependent care residents reviewed for activities of daily living from a total sample list of eight residents reviewed.

Inspectors wroteBased on interview and record review, the facility failed to ensure the dignity of two (R4 and R5) of three residents reviewed for dignity from a total sample list of eight residents reviewed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to honor repeated requests of a resident's (R263) choice of living arrangements. This failure affects one (R263) of six residents reviewed for self-determination in a sample list of 34. This failure resulted in R263 becoming anxious, angry, refusing to eat, drink, and receive care from staff. Findings Include: R263's admission progress note, dated 11/15/24, documents, (R263) arrived from (hospital) at approximately 5pm. Nurse to nurse report indicates advanced Amyotrophic Lateral Sclerosis, with Benign Prostatic Hypertrophy, and Osteoporosis cited as the only comorbidities. Resident is non-verbal. Resident is a Do Not Resuscitate. Regular diet with a Gluten Intolerance; requires maximum assistance. Resident takes pills crushed in applesauce/pudding/yogurt. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide sufficient Registered Nursing (RN) hours on two of sixteen days reviewed for RN staffing. This failure has the potential to affect all 54 residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to employ a clinically qualified Director of Food and Nutrition Services, and failed to employ a person-in-charge (PIC) with the required Food Protection Manager Certification. These failures have the potential to affect all 54 residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to effectively sanitize dishes, failed to prevent direct cross-contamination of ice, failed to prevent the potential for biological cross-contamination of stored food, failed to prevent the potential for physical cross-contamination of food, failed to date and label TCS (time/temperature control for safety) food, failed to maintain sanitation test equipment supplies, and failed to maintain sanitary food service flooring areas. These failures have the potential to affect all 54 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to implement a comprehensive quality program. This failure has the potential to affect all 54 residents who reside in the facility.

Inspectors wroteBased on interview and record review, the facility failed to develop quality based performance improvement projects including collecting and measuring data. This failure has the potential to affect all 54 residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to hold quarterly quality improvement committee meetings, and failed to include the required members at these meetings. This failure has the potential to affect all 54 residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to resolve grievances for four (R31, R33, R48 and R49) of five residents reviewed for grievances from a total sample list of 34 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide fingernail care, bathing, and timely toileting/incontinence cares for three (R16, R21, R30) of 16 residents reviewed for Activities of Daily Living (ADLs) in the sample list of 34 residents.

Inspectors wroteBased upon observation, interview, and record review, the facility failed to to ensure the resident's menus and/or the individual resident's food plan met her/his nutritional needs and preferences for four (R14, R16, R19, R43) of four residents reviewed from a total sample list of 34. 1.) R19's physician order, dated 2/5/24, documents diet order of regular diet mechanical soft texture with nectar thick fluids. On 11/17/24 at 1:10 PM, R19's plate of food includes carrots sliced, plain. [NAME] colored rice with brown orange cubes and green peas; fried breading piece mixed in; 1/2 cup red paste looking puree on side of plate. Side small plate has crumbled yellow cake substance with white frosting. Bowl contains plain macaroni noodles and brown lentil beans with clear liquid and thin red liquid as drink. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to serve timely and palatable meals to residents. These failures affect seven residents (R18, R19, R21, R25, R30, R31, R43) of 15 reviewed for meals in the sample list of 34.

Inspectors wroteBased on interview and record review, the facility failed to follow physicians orders for treatment of a nonpressure wound for one resident (R54) of two residents reviewed for nonpressure wounds in a sample list of 34. Findings Include: R54's Minimum Data Set (MDS), dated [DATE], documents R54 is cognitively intact. R54's Treatment Administration Record (TAR) for November documents a current physician's order to Change wound vac dressing day shift every day shift every Monday, Wednesday,and Friday. R54's Hospital discharge orders, dated 10/10/24, document, Left Medial Calf- Negative pressure therapy to be changed three times per week. Vac (vacuum) is continuous at 125mmHg. R54's TAR for November documents that treatment was not completed Monday 11/4/24, Friday 11/8/24, Monday 11/11/24, or Friday 11/15/24. [...]

Inspectors wroteBased on interview and record review, the facility failed to investigate, determine root cause, and implement resident centered fall interventions for one resident (R54) of one resident reviewed for falls in a sample list of 34. Findings Include: R54's Minimum Data Set (MDS), dated [DATE], documents R54 is cognitively intact. On 11/17/24 at 10:00AM, R54 stated, I fell here (at the facility) and my surgical incision busted open and I bled all over the floor. R54's hospital history and physical documents, (R54) presented to emergency room from Extended Care Facility where he had a mechanical fall in which his left lower extremity wound opened up and he was found to have bleeding. R54's progress Note, dated 10/1/24 at 2:45PM, documents, nurse was called to residents room due to resident falling. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer oxygen as ordered, failed to correctly apply a nasal cannula, failed to provide oxygen humidification, and failed to maintain clean, dated, and labeled oxygen tubing for one (R160) of five residents reviewed for respiratory care from a total sample list of 34 residents reviewed.

Inspectors wroteBased on interview and record review, the facility failed to regularly assess residents, obtain informed consent, identify or track specific managed behaviors, and provide therapy rationale. This failure affects for three residents (R262, R30, R41) taking psychotropic medication of five residents reviewed for medications in a sample list of 34. Findings Include: The facility's policy Psychotropic Medication Use ,dated 09/2022, states, Staff will complete Psychoactive Medication Review assessment on admission, when any new psychotropic medication is ordered, with a change in condition, and quarterly. This assessment will be completed for any medication prescribed to manage behaviors i.e. Depakote, Nudexa, etc. Prior to starting psychotropic medications, informed consent will be obtained from residents/representative per state guidelines. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide dental services for one (R16) of one residents reviewed for dental services from a total sample list of 34 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the the correct food consistency for three residents (R263,R16, R19) of five residents reviewed for dietary consistency in a sample of 34 residents. Findings Include: 1. R263's Hospital History and physical, dated 11/8/24, documents, (R263) liquid/?pureed diet. This same history and Physical documents (R263) has been diagnosed with Advanced Amyotropic Lateral Sclerosis (AMS) for the past eight years. On 11/17/24 at 9:00AM, R263 was observed lying in bed leaning to the right side. R263 had severe contractures to all extremities and was unable to speak. R263 had a communication board and was able to express himself by pointing to letters or responses on the board. R263's full breakfast (ground consistency) was on the over the bed tray, untouched. When asked if R263 can feed self, R263 pointed to no. [...]

Inspectors wroteBased on observation, interview, and record review, the facility repeatedly failed to maintain the dignity of four residents (R4, R7, R11, R3) out of four residents reviewed for dignity in a sample list of eleven residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a clean environment for four (R3, R4, R7, R9) residents out of five residents reviewed for cleanliness of environment in a sample of eleven residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide planned showers for five residents (R2, R3, R4, R5 R6) out of seven residents reviewed for showers in a sample list of eleven residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement fall interventions for one (R4) resident out of three residents reviewed for falls in a sample list of eleven residents.

Inspectors wroteBased on interview and record review, the facility failed to administer antibiotics as ordered by the physician for two of four residents (R2, R10) reviewed for antibiotic medication administration in the sample list of eleven.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident had adequate storage for personal belongings and space to accommodate a resident bed for one of three residents residents (R7) reviewed for environment on the sample list of seven. Findings Include: R7's Current Care Plan states R7 is dependent on staff for activities, cognitive stimulation, and social interaction related to impaired mobility, and R7 prefers to not be around others in social settings, with an initiated of 06/02/2024. On 9/30/24 at 11:50 AM, two boxes of R7's personal belongings were in the hallway outside R7's room, with R7's personal pillow laying on top of the boxes, exposed to anyone walking in and out the adjacent entry/exit door. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide bath/showers on a regular basis for three residents (R2,R5,R7) of three residents reviewed for hygiene in a sample list of seven residents. Findings Include: 1. R5's Progress notes document R5 was admitted to the facility 8/29/24. R5's Minimum Data Set (MDS), dated [DATE], documents R5 is cognitively intact and totally dependent for shower or bath. R5's Plan of Care (POC) History for bathing, dated 9/1/24 to 10/1/24, does not document a bath or shower was provided for R5 during that time period. On 10/2/24 at 11:00AM, R5 was observed in a Bariatric bed receiving care. R5 stated, I have not gotten a full bath since I got here. I've not been out of bed. I didn't get up at home for a while either. I'd like to have my feet washed. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide diabetic care for one resident (R1) of three residents reviewed for diabetic care in a sample list of seven residents. Findings Include: R1's face sheet documents R1 was admitted to the facility 8/14/24, with the diagnosis of Type II Diabetes Mellitus, Chronic Kidney Disease Stage III, Cardiomyopathy, and Cognitive Communication Deficit. R1's Progress note, dated 9/14/24 at 5:20PM, documents, (R1) noted diaphoretic, Altered Mental Status see current V/S (vital signs). Blood Glucose noted at 56. Nurse Practitioner on call for Patient Care Provider, gave new order Glucagon 1ml (milliliter), (IM) Intramuscular now. Recheck Blood sugar in 30 minutes. Resident noted [NAME] arms and legs. [...]

Inspectors wroteBased on interview and record review, the facility failed to seek a prescription for an ordered controlled pain medication prior to depleting supply for one resident (R5) of three residents reviewed for pain in a sample list of seven residents. Findings Include: R5's current Physician's Orders include a Physician's Order, initiated 8/29/24, for Tramadol 50 Milligrams by mouth for moderate pain. R5's Medication Administration Record (MAR) documents R5 did not receive Tramadol 9/6/24, 9/7/24, 9/8/24, 9/9/24, 9/10/24, or 9/11/24. During that time, R1's pain on a scale of 1-10 ranged from a low of 0 to a high of 8. On 10/2/24 at 11:00AM, R5 stated, I have pain most of the time and they were out of my pain pill for about a week. I really hurt and it was so bad I had trouble sleeping. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide laboratory services for two of three residents (R2 and R5) reviewed for laboratory services on the sample list of seven. Findings Include: 1. R2's progress note, dated 9/9/24 at 11:00PM, written by V10, Nurse Practitioner, documents an order for a urinalysis. R2's progress note, dated 9/10/24 at 1:54PM, by V8, Licensed Practical Nurse, documents a physician order was received for a urinalysis. R2's clinical physician orders do not document an active order was entered for a urinalysis to be completed. On 9/30/24 at 11:50AM, R2 stated R2 has felt like R2 has a urinary tract infection and staff have not collected a urine sample. On 10/2/24 at 10:05AM, V4, Corporate Nurse, stated V10 did enter a progress note with an order for a urinalysis 9/9/24. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provided showers to dependent residents. This failure affects four of four residents (R1, R2, R4, and R5) reviewed for showers and hygiene care on the sample list of five. Findings Include: 1. R1's Comprehensive Assessment, dated 8/12/24, documents R1 is severely cognitively impaired with one sided lower limb impairment, and requires moderate assistance from staff with showers. R1's Care Plan (current) documents R1 requires assistance by staff with bathing. The Facility Resident Shower Schedule documents R1 is to receive showers on Monday and Thursday on day shift. R1's Point of Care (POC) Bathing Record for August and September 2024 documents R1 has only received two showers in the month of August and none in the month of September. This same record documents R1's last shower/bed bath was on 8/7/24. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure call lights were answered in a timely manner for three of three residents (R3, R5, R6) reviewed for call lights on the sample list of 6. Findings Include: 1. R3's admission Record, dated 02/17/2021, documents R3 is diagnosed with Muscle Weakness, Unsteadiness On Feet, and Limitation Of Activities Due To Disability. R3's care plan, dated 8/6/21, documents R3 is at risk for falls r/t (related to) impaired mobility. The care plan, dated 04/20/2022, documents R3 has bladder incontinence and R3 is able to utilize call light and let staff know when she has to use bedpan, which she uses for bowel and bladder. R3 has a Minimum Data Set (MDS) dated [DATE]. Section C of the MDS states a Brief Interview for Mental Status (BIMS) of 15, indicating R3 is cognitively intact. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff wear the required PPE (Personal Protective Equipment) when entering an isolation room, failed to don procedure/isolation face masks in resident care areas, and failed to correctly wear procedure/isolation face masks in resident care areas. These failures have the potential to affect all 53 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to notify a resident's representative of a new Physician's Order for a chest xray, and failed to notify the resident's representative of the results of that chest xray for one of three residents (R1) reviewed for notification in the sample list of eight.

Inspectors wroteBased on interview and record review, the facility failed to protect the confidential health information for one of one resident (R1) reviewed for confidentiality in the sample list of eight.

Inspectors wroteBased on interview and record review, the facility failed to follow up with the physician to ensure timely care for one of three residents (R1) reviewed for COVID 19 infection in the sample list of eight.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide timely incontinence care for two (R1, R8) of four residents reviewed for incontinence in the sample list of eight.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement fall interventions and thoroughly investigate falls for one (R1) of three residents reviewed for falls in the sample list of eight.

Inspectors wroteBased on observation, interview, and record review, the facility failed to allow the right to refuse a laboratory blood draw for one (R5) of two residents reviewed for abuse on the sample list of five. This failure resulted in R5 having a negative reaction to the situation, in which R5 sustained skin tears to the left hand and arm. This failure also resulted in R5 having psychosocial harm in which R5 was afraid to sleep at night.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide safe cares for one (R5) of two residents reviewed for abuse on the sample list of five. This failure resulted in R5 sustaining skin tears to the right hand, wrist, and elbow.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide behavioral health interventions to ensure the safety of one resident (R33) and other residents R33 has access to in the facility. This failure has the potential to affect all residents who reside at the facility. Finding Include: The Resident Census and Condition of Residents Report, dated 10/16/23, documents the census is 41 residents. R33's Diagnoses list reviewed on 10/18/23 includes the following diagnoses: Alcohol Abuse, Seizures, Wernicke's Encephalopathy, Anxiety Disorder, Unspecified Dementia, and Atherosclerotic Heart Disease. R33's Minimum Data Set (MDS),, dated 8/1/23 documents R33 exhibits Disorganized Thinking, Inattention, and wandering. This MDS also documents R33 is completely independent with all Activities of Daily Living (ADLs) and only requires supervision with eating. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent cross-contamination of ice and sherbet, and failed to maintain a sanitary ice scoop. These failures have the potential to affect all 41 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain psychotropic medication assessments for five (R1, R4, R12, R20, R21) of five residents reviewed for psychotropic medications in the sample list of 20.

Inspectors wroteBased on interview and record review, the facility failed to prevent misappropriation of property for one (R12) of one residents reviewed for misappropriation of property from a total sample list of 20 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a nicotine transdermal patch as ordered for one (R19) of two residents reviewed for smoking from a total sample list of 20.

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain a wound care treatment order or complete a wound assessment for one of one resident (R30) reviewed for Moisture Associated Skin Damage (MASD) in a sample list of 20. Findings Include: On 10/16/23 at 10:10 AM, V6, Hospice Certified Nurse's Aide, stated (R30) developed excoriation as a result of moisture. (R30) has been experiencing diarrhea as a possible side effect from a recently completed antibiotic. V6 and V7, Certified Nurse's Aides (CNAs), were observed completing incontinence care for R30. R30 had an area approximately 1 inch in diameter on R30's left buttock which was beefy red, with a small amount of red drainage. V6 applied a white cream to the open area following cleaning. V6 stated V6 was applying zinc oxide because that is what hospice does for open areas caused by moisture. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to secure a resident's indwelling urinary catheter tubing to one (R4) of three residents reviewed for indwelling urinary catheters from a total sample list of 20 residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure all licensed nurses were competent in medication administration to ensure residents take medication as ordered. This failure affects one of 20 residents (R3) reviewed for medication safety in a sample list of 20.

Inspectors wroteBased on observation, interview, and record review, the facility failed to post notice of availability of survey results and failed to post the most up to date survey inspection results in an area accessible to residents and families. This failure has the potential to affect all 41 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent the development and worsening of pressure ulcers by failing to: ensure a residents brace was in proper position and monitored, monitor skin condition underneath a brace, implement turning and positioning programs, assess a pressure ulcer upon admission, provide pressure ulcer treatments and interventions, and routinely assess, monitor, and provide pressure relieving interventions for residents. These failures affect four (R33, R26, R246, R27) of five residents reviewed for pressure ulcer on the sample list of 37. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent falls by failing to provide supervision; failing to ensure a safe room environment; and failing to maintain wheelchair brakes in working condition for three (R197, R10, R20) of five residents reviewed for falls on the sample list of 37. This failure caused R197 to fall sustaining a laceration to his left eye brow which required medical intervention to close. Findings Include: 1. R197's admission record, printed 9/29/22, lists the following diagnoses: Dementia with Behavioral Disturbance, Type II Diabetes with Neuropathy, Cognitive Communication Deficit, Muscle Weakness, Unsteadiness on Feet, Chronic Kidney Disease, Altered Mental Status, and Parkinson's Disease. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a continued sufficient level of staff to care for resident's needs for seven (R20, R197, R198, R36, R38, R18, and R2) of 24 residents reviewed for sufficient staffing on the sample list of 37. This failure also has the potential to affect all 50 residents in the facility.

Inspectors wroteBased on observation, interview, and record, review the facility failed to employ sufficient dietary staff to serve resident meals on standard tableware. This failure has the potential to affect all 50 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to serve resident meals at a palatable temperature for three (R2, R7, and R37) of 24 residents reviewed for dining on the sample list of 37. This failure has the potential to affect all 50 residents in the facility.

Inspectors wroteBased on observation and interview, the facility failed to prevent the potential for cross-contamination of stored food. This failure has the potential to affect all 50 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, facility staff failed to follow the facility's infection control prevention protocols while the facility was in an outbreak status by failing to wear a surgical mask and eye protection. This failure has the potential to affect all 50 residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide shaving, incontinence care, and assistance with eating for residents. This failure affects seven (R44, R18, R246, R198, R36, R2, and R38) of 24 residents reviewed for assistance with activities of daily living on the sample list of 37.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess the ability to self administer medications for two of two residents (R43, R245) reviewed for self administration of medications on the sample list of 37.

Inspectors wroteBased on observation, interview, and record review, the facility failed to honor a resident's dining location preference. This failure affects one (R2) of 24 residents reviewed for dining choices in the sample of 37.

Inspectors wroteBased on interview and record review, the facility failed to prevent the physical abuse of one resident (R40) by another resident (R41) for two of two residents (R40, R41) reviewed for resident to resident altercations on the sample list of 37.

Inspectors wroteBased on observation, interview, and record review, the facility failed to secure urinary catheters and failed to prevent back flow of urine during cares for two of three residents (R26 and R42) reviewed for urinary catheters on the total sample list of 37.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop written resident care policy and procedures for aerosol drug delivery system storage in residents rooms, and failed to ensure personal aerosol drug delivery system equipment was stored properly to prevent cross-contamination for one of two residents (R245) reviewed for respiratory therapy on the total sample list of 37.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide timely pain control for one resident (R198) of two residents reviewed for pain in a sample list of 37.

Inspectors wroteBased on interview and record review, the facility failed to assess a dialysis site for one of one (R31) resident reviewed for dialysis in a sample list of 37. Findings Include: R31's admission Record, printed 9/28/22, includes the following diagnoses: End Stage Renal Disease and Dependence on Renal Dialysis. R31's Care Plan, dated 8/17/22, documents, (R31) needs dialysis hemodialysis related to renal failure · (R31) will have immediate intervention should signs/symptoms of complications from dialysis occur through the review date. (R31) will have no signs/symptoms of complications from dialysis through the review date. Do not draw blood or take B/P (Blood Pressure in arm with graft. (R31) receives dialysis at (local dialysis center) (R31) has a chair time at 11:45 am. Our facility to provide transportation to and from dialysis. (R31) is to eat lunch prior to dialysis. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess R21 for bed side rail use, including an evaluation of alternatives prior to bed rail use, risk of entrapment, and benefits of use. This failure affects one resident (R21) reviewed for side rail use in the sample list of 37.

Inspectors wroteBased on interview and record review, the facility failed to initiate resident centered Dementia care interventions for one of one resident (R197) reviewed for Unsafe wandering in a sample list of 37. Findings Include: R197's admission record, printed 9/29/22, lists the following diagnoses: Dementia with Behavioral Disturbance, Type II Diabetes with Neuropathy, Cognitive Communication Deficit, Muscle Weakness, Unsteadiness on Feet, Chronic Kidney Disease, Altered Mental Status, and Parkinson's Disease. R197's Minimum Data Set (MDS), dated [DATE], documents R197 is severely cognitively impaired, experiences hallucinations and Delusions, displays physical, verbal, and other behavioral symptoms directed at others, and wanders. [...]

Inspectors wroteBased on interview and record review ,the facility failed to justify the use of psychotropic medications by failing to complete quarterly psychotropic assessments and identifying targeted behaviors, failing to limit the use of an as needed antianxiety medication to 14 days for two (R36, R197) of five residents reviewed for psychotropic medications in a sample list of 37.

Inspectors wroteBased on observation and record review, the facility failed to administer eye drops per manufacturer's directions for one (R36) of five residents reviewed for medication administration on the sample list of 37. These failures resulted in two medication errors out of 25 opportunities resulting in a 8.0% error rate.

Inspectors wroteBased on observation and interview, the facility failed to maintain a resident bed side rail in a safe condition. This failure affects one resident (R21) reviewed for side rails in the sample list of 37.