Every finding on record at Chapman Valley Manor

Based on record review and interview, the facility failed to ensure the Facility Assessment included the number of staff required for each unit and each shift, including weekends.Findings Included:- The Facility Assessment, dated 11/04/2025, did not identify the specific staffing levels required for each unit and did not identify the number of Registered Nurses (RN), Licensed Nurses (LPN/LVN), Certified Medication Aides (CMA), and Certified Nurse Aides (CNA) required for each unit, patient acuity, and census. The assessment lacked the staffing levels required for each daily shift and on weekends.On 08/12/2026 at 01:11 PM, Administrative Staff A stated she followed the facility's policy as to what was included in the Facility Assessment. Administrative Staff A stated she was not aware that the staffing plan had to be broken down per shift, to include weekends, by the number of required nursing staff based on the facility's census and staffing needs.The facility policy Facility Assessment, dated 06/26/2026, documented that the facility assessment will address the following: resident population, resident capacity, staffing levels, competency of staff, resources, recruitment and retention, and a contingency plan.

Based on observations, interviews and record review, the facility failed to ensure adequate infection control practice related to sanitary storage of nebulizer ((a device which changes liquid medication int a mist easily inhaled into the lungs)masks, continuous positive airway pressure (CPAP- ventilation device that blows a gentle stream of air into the nose to keep the airway open during sleep) masks, laundry services and wound care.Findings include:- On 08/10/2026 at 10:23 AM, observation revealed Laundry Aide U removed clothes from the covered cart, placed them in a resident's room without recovering the laundry cart. Laundry Aide U did not use hand sanitizer or perform hand hygiene between resident rooms.On 08/10/2026 at 11:08 AM, Resident (R) 16's CPAP mask hung on his bedside and was not placed in a bag.On 08/11/2026 at 08:21 AM, R16 was in his room sitting in his recliner eating breakfast. His CPAP mask hung on his bedside cabinet with no bag covering it.On 08/11/2026 at 02:25 PM, observation revealed Licensed Nurse (LN) H prepared to provide wound care for R1. LN H donned a gown and gloves prior to entering the room. LN H placed the gauze, normal saline, and betadine swabs on the over-the-bed table without a barrier. LN H then removed the soiled dressing from R1's right shin and then removed R1's bilateral heel protectors. LN H removed her gloves, then put on new gloves without sanitizing her hands. LN H proceeded to cleanse the shin and heel with normal saline using the gauze off the bedside table. After cleansing the areas, LN H reapplied a new foam dressing on the shin and then used betadine on the left heel.On 08/12/2026 at 10:10 AM, Certified Medication Aide (CMA) S entered R5's room with new equipment and nebulizer treatment. She removed the old equipment inside the chamber; the solution remained from the previous treatment the night before.On 08/12/2026 at 10:26 AM, LN G provided wound care for R6. After LN G washed her hands and placed new gloves on, she reached up to move her hair behind her ears; she also then reached into her pocket to obtain her pen to document the measurement. Wearing the same soiled gloves, she proceeded to clean the area on R6's coccyx, then placed a foam dressing over the area.On 08/10/2026 at 10:23 AM, Laundry Aide U said she does not use hand sanitizer between rooms because all she touched was the hangers and closet door.On 08/11/2026 at 01:35 PM, Administrative Nurse E said she expected the staff to rinse the nebulizer after each use and place it in a bag.On 08/11/2026 at 02:25 PM, LN H said she had not placed a barrier down for her supplies, and she should have washed her hands between the dirty and clean and changed gloves.On 08/12/2026 at 10:50 AM, LN G said she was not sure she touched her hair and went on to say she did break the infection control barrier when she pulled out her pen to measure using the same gloves.On 08/12/2026 at 01:35 PM, Administrative Nurse D said she will have to reeducate the staff on infection control issues.The facility's policy, Infection Prevention and Control Policy, updated 07/01/2026, states that the facility will facilitate safe care of all residents and staff with known or suspected communicable disease by establishing and maintaining an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infections.

Based on observation, record review, and interview, the facility failed to ensure Resident (R) 2's care plan addressed and put interventions in place to direct staff on the use of her antihypertensive medication (class of medication used to treat high blood pressure) metoprolol (a medication used to treat blood pressure, chest pain, and heart failure).Findings included:- R2's Electronic Medical Record (EMR) documented diagnoses of atrial fibrillation (rapid, irregular heartbeat), hypertension (HTN- elevated blood pressure), and type 2 diabetes mellitus (DM -a chronic condition where the body cannot use insulin properly and sugar builds up in the blood).R2's admission Minimum Data Set (MDS) dated 03/06/2026 documented a Brief Interview for Mental Status (BIMS) score of 13, which indicated intact cognition. R2 requires substantial assistance from staff for her activities of daily living (ADLs). R2 received an anticoagulant (a class of medications used to prevent the blood from clotting) and a diuretic (a class of medicines used to prevent the blood from clotting) on a regular basis.R2's Functional Abilities Care Area Assessment (CAA) dated 03/11/2026 documented that she recently admitted to the facility. R2 had a history of paraplegia and DM. She required partial/modified assistance for eating and oral hygiene; substantial assistance for bed mobility; dependent on staff for toileting hygiene, bathing, dressing, footwear, personal hygiene, transfers, and wheelchair mobility.R2's Care Plan dated 03/21/2026 directed staff to administer antidepressant (class of medications used to treat mood disorders) medications as ordered by the physician and to monitor and document side effects and effectiveness. R2's Care Plan directed staff on the Black Box Warning (BBW- the highest safety-related warning that medications can have assigned by the Food and Drug Administration) for losartan (a medication that treats blood pressure and lowers stroke risk) but lacked mention of her metoprolol. The Care Plan lacked staff direction on R2's antihypertensive medication metoprolol.R2's Orders tab of the EMR documented a physician's order dated 02/27/2026 for metoprolol (a beta blocker antihypertensive) 50 milligrams (mg) to give one table by mouth two times daily for HTN. The order lacked documentation of blood pressure or pulse readings prior to administration.On 08/11/2026 at 08:15 AM, R2 was still asleep in her bed.On 08/12/2026 at 12:50 PM, Licensed Nurse (LN) G stated she would expect R2's care plan to have direction for antihypertensive medications like metoprolol.On 08/12/2026 at 01:18 PM, Administrative Nurse D stated that R2's care plan should mention and have interventions for any blood pressure medication like metoprolol.The facility's Develop/Implement Comprehensive Care Plan policy dated 03/11/2026 documented that the MDS Coordinator would ensure that the resident care plan addresses the care and services that the resident needs in order to attain or maintain their highest practicable quality of life, including the resident's medical, nursing, physical, mental, and psychosocial needs and preferences. The MDS Coordinator would ensure that the care plans include person-specific, measurable objectives and timeframes in order to evaluate the resident's progress toward their goal(s). The MDS Coordinator will ensure that the care plan reflects person-centered goals for admission and desired outcomes, including what support the resident needs to make their own choices, how each resident is trying to communicate verbally and nonverbally, their preferences for daily activities, and an understanding of the resident's life prior to being admitted to the facility. The MDS Coordinator will ensure that the care plan reflects the interventions to enable each resident to meet their objectives. The MDS Coordinator will ensure that the resident's care plan stays updated to reflect current services, goals, and interventions.

Based on record review and interviews, the facility failed to update the plan of care for Resident (R) 5 to include nebulizer treatments (a device that changes liquid medication into a mist easily inhaled into the lungs).Findings included:- R5's electronic medical record (EMR) documented the diagnosis of chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing).R5's admission Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 14, which indicated intact cognition. The MDS had no documentation that R5 received nebulizer treatments.R5's Quarterly MDS, dated 07/17/2026, had no changes documented.R5's Care Plan, dated 05/27/2026, documented that R5 received two liters of oxygen at bedtime and had shortness of breath while laying down flat. The care plan lacked any interventions regarding the use of a nebulizer treatment or how often R5 received the treatment.R5's Medication Administration Record (MAR) documented the following nebulizer treatments: ipratropium albuterol inhalation solutions (inhaled medication used in a nebulizer), one application inhaled orally four times a day for COPD, and budesonide inhalation suspension 0.5 milligrams (mg)/2 milliliters (ml), one application inhaled orally four times a day for COPD.On 08/11/2026 at 01:35 PM, Administrative Nurse D said R5's nebulizer treatments should have been care planned.The facility policy Develop/Implement Comprehensive Care Plan, dated 03/11/2026, documented that the purpose of the policy is to ensure that each resident has a personal centered comprehensive care plan to develop his or her preferences and goals, and address any medical, physical, mental, psychosocial needs. The MDS coordinator will ensure that the resident's care plan stays updated to reflect current services, goals, and interventions.

Based on observation record review, and interview, the facility failed to ensure an environment free from accident hazards when staff failed to identify causative factors and implement adequate person-centered interventions to prevent future falls for Resident (R) 27, who had an unwitnessed fall from her bed.Findings included:- R27's Electronic Medical Record (EMR) documented diagnoses of post-polio syndrome (a condition that causes new muscle weakness, extreme tiredness, and pain) and osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain).R27's Annual Minimum Data Set (MDS) dated 06/26/2026 documented a Brief Interview for Mental Status (BIMS) score of 11, which indicated moderately impaired cognition. R27 had functional limitations in range of motion of both lower extremities. R27 utilized a wheelchair for mobility. R27 was dependent on staff for oral hygiene, toileting, bathing, dressing, putting on/taking off footwear, and personal hygiene. R27 had not had any falls since the prior assessment.R27's Falls Care Area Assessment (CAA) dated 07/01/2026 documented R27 was alert and generally able to make her needs known to staff. She was noted to have moderate cognitive impairment as evidenced by a BIMS score of 11, so staff must anticipate her needs. During the assessment period, R27 required staff assistance for activities of daily living (ADLs). R27 was encouraged to participate in ADLs as able. R27 was at risk of falls. R27 had not sustained any falls since prior assessment.R27's Care Plan last revised on 03/25/2026 directed staff that she was at risk for falls. The plan directed staff to place a fall mat next to her bed; ensure her call light was within reach; she needed a safe environment with an even floor that was free of spills and clutter, glare-free light, a working and reachable call light, handrails on walls, and personal items withing reach. R27's plan lacked a new person-centered intervention after she fell on [DATE].R27's Morse Fall Scale dated 06/12/2026 in the EMR documented a score of 75, which indicated she was a high risk for falls.R27's EMR documented an Incident Note dated 08/08/2026 at 06:50 AM. The note documented R27 had an unwitnessed fall on 08/08/2026 at approximately 05:50 AM. The resident was found on the floor in her room, lying on her left side. The resident was asking to be picked up and placed back into bed. Emergency Medical Services (EMS) was called for assistance and transport. R27 had blood on her arm and gown. The arm was cleansed and a bandage applied. R27 was alert and oriented. No injuries were noted to her head. EMS arrived at approximately 06:15 AM, and the resident was transported to the emergency department. R27's representative, physician, and director of nursing were notified, and neurological checks were initiated prior to transport.An Interdisciplinary Team (IDT) note dated 08/10/2026 documented the IDT met to discuss the resident's fall. The IDT discussed that the times did not add up with nurses' notes and witness statements. The IDT reviewed the cameras, and it happened at approximately at 05:48 AM. The IDT then reviewed the resident's care plan to ensure safety measures were followed at the time of the fall. No concerns were noted. The note documented staff would continue with the current safety interventions at that time. The note lacked indication that the IDT performed a root cause analysis to determine causative factors.On 08/11/2026 at 08:39 AM, staff propelled R27 in her wheelchair to the dining room for breakfast. R27 asked staff for coffee.On 08/12/2026 at 12:50 PM, Licensed Nurse (LN) G stated that new interventions would be put in place after a fall if it was warranted.On 08/12/2026 at 01:18 PM, Administrative Nurse D stated that after a fall, an investigation would be completed and the fall protocol would be followed. The IDT would discuss the fall after the investigation had been completed, and a new intervention would be put in place if one was needed. Administrative Nurse D stated that a new intervention was not put in place after every fall.The facility's Accidents and Supervision policy dated 10/16/2025 documented that the facility's Interdisciplinary Team will use assessments, resident medical history, resident interview, family interview, feedback from staff, and other members of the resident care team to determine the resident's risk for falls. The MDS Coordinator will ensure that the resident's care plan and tasks are updated. The Director of Nursing and/or designee will ensure that the floor staff are informed of the resident fall interventions. Fall interventions will be reviewed at admission, significant change, after a fall, quarterly, and as needed.

Based on record review, observation, and interview, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported that Resident (R) 18's blood pressure and/or pulse were not monitored prior to administration of her antihypertensive medication (class of medication used to treat high blood pressure). Findings included:- R18's Electronic Medical Record (EMR) documented diagnoses of Huntington's disease (a rare abnormal hereditary condition characterized by progressive mental deterioration, a disabling central nervous system movement disorder), bipolar disorder, anxiety, amyotrophic lateral sclerosis (ALS -also known as Lou Gehrigsdisease is a fatal nervous system disease that attacks motor neurons in the brain and spinal cord, leading to progressive muscle weakness, loss of voluntary movement), major depressive disorder (MDD), and hypertension (HTN).R18's admission Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 13, which indicated intact cognition. R18 was taking an antipsychotic, antianxiety, and an antidepressant medication.R18's Psychotropic Drug Use Care Area Assessment (CAA), dated 05/04/2026, documented that she had diagnoses of Huntington's disease, bipolar disorder, ALS, and HTN. R18 was alert and oriented and able to make her needs known to staff. During the assessment period, R18 required maximum to dependent staff assistance for most activities of daily living (ADLs). R18 was non-ambulatory and utilized a manual wheelchair for all locomotion. All medications were administered per physician orders, and the resident was monitored for signs and symptoms of adverse effects; none were noted at the time. R18 received antipsychotic medications for bipolar disorder and antidepressant medications for MDD. Psychotropic medication doses would be adjusted as indicated and ordered by the provider. Any moods or behaviors were to be documented by staff. No adverse effects of psychotropic medication use were noted. Medication management would comply with applicable requirements related to psychotropic medications and unnecessary drug use.R18's Care Plan, dated 05/07/2026, directed staff to assess for effects of psychotropic meds; dystonia (impairment in muscle tone), akathisia (movement disorder that causes an intense, uncomfortable feeling of inner restlessness and a strong, hard-to-control urge to move the body, especially the leg), akinesia (the loss or severe impairment of the ability to initiate voluntary muscle movement), rigidity, and tremors; discuss with resident/resident and family any concerns, fears, issues regarding diagnosis or treatments; give medications as ordered. Monitor/document for side effects and effectiveness; monitor intake to assure an adequate fluid intake to prevent dehydration; monitor, document, and report as needed signs and symptoms of tremors, rigidity, dizziness, changes in level of consciousness, and slurred speech.R18's Orders tab of the EMR documented a physician's order dated 05/22/2026 for losartan (a medication to treat HTN) 50 mg tablet by mouth daily related to HTN. Notify the physician if blood pressure was greater than 190/110 or less than 80/50 millimeters of mercury (mm/hg). R18's Medication Administration Record (MAR) reviewed from April 2026 to August 2026 revealed that blood pressure readings were not documented prior to administration of her losartan.Review of the CP's monthly regimen review (MRR) from April 2026 to July 2026 lacked identifying and reporting that R18's losartan had parameters, but the blood pressure was not monitored and documented before administering the medication.On 08/11/2026 at 08:15 AM R18 sat in her wheelchair at the dining table eating breakfast.On 08/12/2026 at 12:50 PM, LN G stated that the parameters were typically on the order and the blood pressure reading was entered into the MAR prior to administration. If the reading was out of parameters, it would flag to hold the medication. LN G stated she was not aware that R18's blood pressure reading was not monitored prior to administration of Losartan.On 08/12/2026 at 01:18 PM, Administrative Nurse D stated that the CP normally would identify and report if blood pressure monitoring was not documented prior to administration of an antihypertensive medication.The facility's Drug Regimen Review policy dated 10/20/2025 documented the pharmacist will identify and report any irregularities to the attending physician/practitioner and the facility's Director of Nursing (DON) or designee. The pharmacist will identify medication-related irregularities, including concerns involving: Medications without adequate clinical indication; excessive dose or duration; duplicate therapy; inadequate monitoring; adverse consequences; clinically significant interactions; contraindications; medication administration concerns; and other medication-related issues that may affect resident safety or outcomes. The attending physician/practitioner will review identified irregularities and pharmacist recommendations. The practitioner will: accept the recommendation and provide appropriate orders; or document the clinical rationale for declining the recommendation when required. The facility will ensure appropriate follow-up occurs and that new orders are implemented. When psychotropic medications are prescribed, the pharmacist's review will include evaluation of the medication's indication, effectiveness, adverse consequences, duration of therapy, appropriate monitoring, and opportunities for gradual dose reduction when applicable.

Based on record review, observation, and interview, the facility failed to ensure Resident (R) 18's blood pressure was monitored prior to the administration of her antihypertensive medication (class of medication used to treat high blood pressure).Findings included:- R18's Electronic Medical Record (EMR) documented diagnoses of Huntington's disease (a rare abnormal hereditary condition characterized by progressive mental deterioration, a disabling central nervous system movement disorder), bipolar disorder, anxiety, amyotrophic lateral sclerosis (ALS -also known as Lou Gehrigsdisease is a fatal nervous system disease that attacks motor neurons in the brain and spinal cord, leading to progressive muscle weakness, loss of voluntary movement), major depressive disorder (MDD), and hypertension (HTN).R18's admission Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 13, which indicated intact cognition. R18 was taking an antipsychotic, antianxiety, and an antidepressant medication.R18's Psychotropic Drug Use Care Area Assessment (CAA), dated 05/04/2026, documented that she had diagnoses of Huntington's disease, bipolar disorder, ALS, and HTN. R18 was alert and oriented and able to make her needs known to staff. During the assessment period, R18 required maximum to dependent staff assistance for most activities of daily living (ADLs). R18 was non-ambulatory and utilized a manual wheelchair for all locomotion. All medications were administered per physician orders, and the resident was monitored for signs and symptoms of adverse effects; none were noted at the time. R18 received antipsychotic medications for bipolar disorder and antidepressant medications for MDD. Psychotropic medication doses would be adjusted as indicated and ordered by the provider. Any moods or behaviors were to be documented by staff. No adverse effects of psychotropic medication use were noted. Medication management would comply with applicable requirements related to psychotropic medications and unnecessary drug use.R18's Care Plan, dated 05/07/2026, directed staff to assess for effects of psychotropic meds; dystonia (impairment in muscle tone), akathisia (movement disorder that causes an intense, uncomfortable feeling of inner restlessness and a strong, hard-to-control urge to move the body, especially the leg), akinesia (the loss or severe impairment of the ability to initiate voluntary muscle movement), rigidity, and tremors; discuss with resident/resident and family any concerns, fears, issues regarding diagnosis or treatments; give medications as ordered. Monitor/document for side effects and effectiveness; monitor intake to assure an adequate fluid intake to prevent dehydration; monitor, document, and report as needed signs and symptoms of tremors, rigidity, dizziness, changes in level of consciousness, and slurred speech.R18's Orders tab of the EMR documented a physician's order dated 05/22/2026 for losartan (a medication to treat HTN) 50 mg tablet by mouth daily related to HTN. Notify the physician if blood pressure was greater than 190/110 or less than 80/50 millimeters of mercury (mm/hg). R18's Medication Administration Record (MAR) reviewed from April 2026 to August 2026 revealed that blood pressure readings were not documented prior to administration of her losartan.On 08/11/2026 at 08:15 AM, R18 sat in her wheelchair at the dining table eating breakfast.On 08/12/2026 at 12:50 PM, LN G stated that the parameters were typically on the order and the blood pressure reading was entered into the MAR prior to administration. If the reading was out of parameters, it would flag to hold the medication. LN G stated she was not aware that R18's blood pressure reading was not monitored prior to administration of Losartan.On 08/12/2026 at 01:18 PM, Administrative Nurse D stated that if a medication had physician-ordered parameters, then the blood pressure should be monitored and documented prior to administration of an antihypertensive medication.The facility's Unnecessary Medications policy dated 10/20/2025 documented that the facility will ensure that each resident's drug regimen is free from unnecessary medications in accordance with applicable federal and state regulations and accepted standards of clinical practice. A medication may be considered unnecessary when it is: used in excessive doses, including duplicate drug therapy; used for an excessive duration; used without adequate monitoring.

The facility had a census of 31 residents. The sample included 12 residents. Based on record review and interviews the facility failed to conduct a risk assessment to identify risks and implement a water management program to mitigate the risk of Legionella disease (Legionella is a bacterium spread through mist, such as from air-conditioning units for large buildings. Adults over the age of 50 and people with weak immune systems, chronic lung disease, or heavy tobacco use are most at risk of developing pneumonia caused by Legionella) and other waterborne pathogens. This placed the residents in the facility at risk for infectious disease. Findings Included: - On 09/17/24 at 03:00 PM, Maintenance Staff U verified he was not aware of any routine facility water management checks and verified the facility had some rooms presently unoccupied. Maintenance Staff U stated housekeeping staff flushed the water in the unoccupied rooms on occasion, but not routinely. On 09/18/24 at 08:00 AM, Administrative Nurse E verified the facility did not have a system to check for standing water in any unoccupied rooms or other potential areas to mitigate potential Legionella growth inside the facility. The facility's Water Management Procedure policy, dated 08/14/24, documented the facility would develop a program to reduce the risk of Legionella growth and spread. The policy documented the water management team would review the elements of the program at least once a year and revise the program as needed. The facility would identify building water systems for which Legionella control measures are needed; assess how much risk the hazardous conditions in those water systems pose; and apply control measures to reduce the hazardous conditions, whenever possible, to prevent Legionella growth and spread. The facility would make sure the program is running as designed and is effective. The facility failed to conduct a risk assessment to identify risks and implement a water management program to mitigate the risk of waterborne pathogens placing the residents who resided in the facility at risk of contracting Legionella disease.

The facility had a census of 31 residents with three reviewed for Center for Medicare and Medicaid Services (CMS) Beneficiary Liability notices. Based on record review and interview, the facility failed to provide the correct CMS Form 10055, Advanced Beneficiary Notice (ABN), to the resident or their representative for Resident (R) 28, and R137. This placed the residents at risk for uninformed decisions regarding skilled services. Findings included: - The Medicare ABN form informed the beneficiaries Medicare may not pay for future skilled therapy and did not provide an estimated cost to continue their services. The form included options for the beneficiary to (1) receive specified services listed, and bill Medicare for an official decision on payment. I understand that if Medicare does not pay, I will be responsible for the payment, but I can appeal to Medicare. (2) receive therapy listed, but do not bill Medicare, I am responsible for payment for payment of services. (3) I do not want the listed services. The facility's Medicare ABN form staff provided to R28 (or their representative) was CMS-R-131 when the resident's skilled services ended on 06/12/24. The facility's Medicare ABN form staff provided to R137 (or their representative) was form CMS-R-131 when the resident's skilled services ended on 04/01/24. On 08/17/24 at 09:00 AM, Social Services X stated she did not realize she had been providing the families with the incorrect CMS form. The facility's ABN Policy, revised 11/01/19, documented the facility would provide timely notices regarding Medicare eligibility and coverage. The policy documented for Part A items and services; the facility should use the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) form CMS 10055. The facility failed to provide R28 and R137 the correct ABN form CMS 10055 as required. This placed the residents at risk for uninformed decisions regarding skilled services.

The facility had a census of 31 residents. The sample included 12 residents. Based on observation, record review and interview the facility failed to ensure staff possessed the necessary knowledge and competency to respond immediately when a hospice Certified Nurse Aide (CNA) removed Resident (R) R29's fentanyl (narcotic pain medication with a high risk for abuse) patch and further failed to dispose of the patch per the standards of practice and manufactures instructions. This placed the residents at risk for inadequate care. Findings included- - On [DATE] at 02:25 PM, observation revealed R29 rested in bed on her back with oxygen on per nasal cannula. R29 reported the hospice CNA removed her fentanyl patch while providing R29 a bed bath today after stating that it was expired. On [DATE] at 02:28 PM, when asked about the removal of R29's fentanyl patch, Licensed Nurse (LN) H stated the hospice CNA told her the patch came off when providing R29 a bed bath. LN H stated she did not remember what the CNA said she did with the fentanyl patch. LN H stated she thought the CNA tossed it in R29's trash can but the aide had already left so she could not ask her. Observation revealed LN H and LN I went to R29's room, applied gloves, and searched the bathroom trash can and the bedside trash can but the fentanyl patch was not found. LN H then searched R29's chest and back area, and the bed but the fentanyl patch was not found. LN H went back to the nurse's station, phoned hospice services, and spoke to the hospice CNA. LN H said the hospice CNA had reported to her she had taken the trash from R29's room and placed it in the shower room across the hall. Further observation revealed LN H went to the shower room, applied gloves, and searched the trash can. LN H found the fentanyl patch, folded in half in the trash can; it was dated [DATE]. LN H discarded the fentanyl patch in Sharp's container (a specialized, puncture-resistant container used to safely dispose of sharp objects, such as needles and syringes) on the medication cart. LN H stated that R29 was scheduled to receive a new fentanyl patch at 04:00 PM. On [DATE] at 03:36 PM, LN G stated if a CNA reported to her that R29's fentanyl patch had come off and the CNA tossed it in the trash can, she would immediately go to R29's room and retrieve it. LN G stated a fentanyl path was an important medication, and a CNA should not be taking it off and discarding it. On [DATE] at 12:03 PM, Administrative Nurse D stated if a CNA reported to the nurse a resident's fentanyl patch came off and she tossed it in the trash can, the nurse should immediately go and retrieve it and discard it in Sharp's container. The Food and Drug Administration (FDA.Gov) instructs that fentanyl patches contain a powerful opioid medicine that can be dangerous to people it's not prescribed for. This adhesive patch delivers a strong pain medicine through the skin. Even after a patch is used, a lot of the medicine remains. Fentanyl comes with instructions to fold and flush used or leftover patches. The facility failed to ensure staff possessed the skill and competency required to safely monitor and dispose of R29's fentanyl patch. This placed the residents at risk for inadequate care.

The facility had a census of 31 residents. The sample included 12 residents, with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure the Consultant Pharmacist identified and reported Resident (R) 26's as needed (PRN) Haldol (antipsychotic medication that treats mental and neurological disorders) did not have a 14-day stop date. This placed the resident at risk for unnecessary psychotropic (alters mood or thought) medications. Findings included: - R26's Electronic Medical Record (EMR) revealed diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), cerebrovascular accident (CVA-stroke- sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), and major depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, and emptiness). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R26 had severely impaired cognition. R26 required minimal staff supervision for activities of daily living (ADLs). R26 had delusions, verbal and other behaviors directed towards others one to three days a week, and received antianxiety, antipsychotic, and antidepressant medication. R26's Care Plan, dated 04/02/24, directed the staff to monitor the resident for physical aggression, R26 had threatened and struck out at staff due to anger. R26 had poor impulse control due to frontal lobe dementia and was a new resident of the facility. The care plan directed staff to de-escalate the resident by calmly allowing him to talk, give him reassurance, and distract him once he calms down. The care plan directed staff to administer medications as ordered and document if effective. The Physician Order, dated 04/23/24 directed staff to administer Haldol (an antipsychotic), 1 milligram (mg), by mouth, every hour, PRN as needed for aggression. The order lacked a stop date. The Medication Administration Record for August 2024 documented R26 received the PRN medication on 08/01/24 and 08/12/24. The Medication Administration Record for September 2024 documented R26 received the PRN medication on 09/14/24. R26's Consultant Pharmacist monthly medication reviews completed on 05/26/24, 06/16/24, 07/22/24, and 08/20/24 lacked evidence the CP identified and reported the PRN Haldol with no stop date. On 09/17/24 at 09:40 AM, observation revealed Certified Medication Aide (CMA) R administered R26's morning medication without difficulty. On 09/18/24 at 02:40 PM, Administrative Nurse D verified R26's Haldol did not have a stop date and the consultant pharmacist did not notify her of the need for a stop date. The Consultant Pharmacist Services Provider-Requirements, policy dated 07/29/2023, documented the consulting pharmacist agrees to render the required services in accordance with local, state, and federal laws, regulations, guidelines, facility policies and procedures, and community standards of practice. The consulting pharmacist provides services, including but not limited to reviewing the medication regimen of each resident at least monthly, utilizing federally mandated standards of care in addition to other applicable standards, and documenting the review and findings in the resident's medical record. Reviewing medication administration records (MARs) and physician orders at least monthly to assure proper documentation of medication orders and administration of medications to residents. The consultant pharmacist would submit a written report of findings and recommendations resulting from the review of the medication regimen and nursing. The facility failed to ensure the CP identified and reported R26's PRN Haldol did not have a 14-day stop date. This placed the resident at risk for unnecessary psychotropic medications.

The facility has a census of 31 residents. The sample included 12 residents, with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure Resident (R)26's as-needed (PRN) antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) had a 14-day stop date. This placed the resident at risk for unnecessary psychotropic (alters mood or thought) medications and related complications. Findings included: - R26's Electronic Medical Record (EMR) revealed diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), cerebrovascular accident (CVA-stroke- sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), and major depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, and emptiness). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R26 had severely impaired cognition. R26 required minimal staff supervision for activities of daily living (ADLs). R26 had delusions, verbal and other behaviors directed towards others one to three days a week, and received antianxiety, antipsychotic, and antidepressant medication. R26's Care Plan, dated 04/02/24, directed the staff to monitor the resident for physical aggression, R26 had threatened and struck out at staff due to anger. R26 had poor impulse control due to frontal lobe dementia and was a new resident of the facility. The care plan directed staff to de-escalate the resident by calmly allowing him to talk, give him reassurance, and distract him once he calms down. The care plan directed staff to administer medications as ordered and document if effective. The Physician Order, dated 04/23/24 directed staff to administer Haldol (an antipsychotic), 1 milligrams (mg), by mouth, every hour, PRN as needed for aggression. The order lacked a stop date. The Medication Administration Record for August 2024 documented R26 received the PRN medication on 08/01/24 and 08/12/24. The Medication Administration Record for September 2024 documented R26 received the PRN medication on 09/14/24. On 09/17/24 at 09:40 AM, observation revealed Certified Medication Aide (CMA) R administered R26's morning medication without difficulty. On 09/17/23 at 10:30 PM, Administrative Nurse D verified R26's Haldol did not have a stop date. Administrative Nurse D stated the consultant pharmacist did not notify her that the Haldol did not have a stop date. The facility's Monitoring of Antipsychotics policy dated April 12, 2016, documented that residents would receive antipsychotic medications only when medically necessary. Every effort would be made to ensure that residents who use antipsychotics receive the intended benefit of the medication and that unwanted side effects are kept to a minimum. The facility failed to obtain the required 14-day stop date for R26's PRN antipsychotic medication. This placed the resident at risk for unnecessary medications and related complications.The Physician Order, dated 04/23/24 directed staff to administer Haldol (an antipsychotic), 1 milligrams (mg), by mouth, every hour, PRN as needed for aggression. The order lacked a stop date. The Medication Administration Record for August 2024 documented R26 received the PRN medication on 08/01/24 and 08/12/24. The Medication Administration Record for September 2024 documented R26 received the PRN medication on 09/14/24. On 09/17/24 at 09:40 AM, observation revealed Certified Medication Aide (CMA) R administered R26's morning medication without difficulty. On 09/17/23 at 10:30 PM, Administrative Nurse D verified R26's Haldol did not have a stop date. Administrative Nurse D stated the consultant pharmacist did not notify her that the Haldol did not have a stop date. The facility's Monitoring of Antipsychotics policy dated April 12, 2016, documented residents would receive antipsychotic medications only when medically necessary. Every effort would be made to ensure that residents who use antipsychotics receive the intended benefit of the medication and that unwanted side effects are kept to a minimum. The facility failed to obtain the required 14-day stop date for R26's PRN antipsychotic medication. This placed the resident at risk for unnecessary medications and related complications.

The facility had a census of 31 residents. The sample included 12 residents. Based on observation, record review, and interview the facility failed to ensure one of the five residents, Resident (R) 19, reviewed during the medication administration pass remained free of medication errors. This placed the resident at risk for adverse reactions from the medication. Findings included: - R19's Electronic Health Record (EHR) revealed diagnosis of neoplasm of the esophagus (cancer that forms in the lining of the esophagus or throat), gastroesophageal reflux (GERD-backflow of stomach contents to the esophagus), hypertension (HTN-elevated blood pressure), and diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin) R19's Quarterly Change Minimum Data Set (MDS), dated [DATE], recorded R19 had a Brief Interview for Mental Status score of 14 and was cognitively intact. The MDS recorded he required extensive assistance from two staff with bed mobility and transfers. The MDS documented the resident received hospice services. R19's Care Plan, dated 07/16/24, recorded that R19 required extensive assistance with most activities of daily living (ADL) care. R19's Care Plan documented the resident received hospice services due to a terminal prognosis and directed staff to adjust the provision of ADLs to compensate for R19's change in needs. The care plan directed the staff to observe the resident closely for signs of pain, administer pain medications as ordered, and notify the physician if there is breakthrough pain. The Physician Order, dated 08/13/24, directed the staff to administer Wellbutrin XL (medication used to treat depression) oral tablet extended release 24-hour 150 milligrams (mg,), give one tablet via the feeding tube in the morning for increased anxiety and depression. On 09/17/24 at 08:00 AM, observation revealed License Nurse (LN) G crushed R19's morning medications including the Wellbutrin 150 milligram (mg), XL extended-release pill, then placed the crushed medication in a plastic medication cup. LN G took a spoon, removed the Wellbutrin pill coating, and discarded it. Continued observation revealed LN G administered the crushed medication with water in the resident's gastrostomy tube (G-tube: tube surgically placed through an artificial opening into the stomach). On 09/17/24 at 08:30 AM, LN G stated R19 received his medications crushed due to administration through the G-tube. LN G stated she had voiced her concern about crushing the extended-release medication to hospice and the order had not been changed. On 09/17/24 at 09:30 AM, Administrative Nurse D verified the extended-release medication should not be crushed and said it should be administered whole due to the extended release of the medication. Administrative Nurse D said she would contact the physician to get the medication in another form that can be crushed and administered through the G-tube. Medlineplus.gov directed that sustained-release and extended-release tablets should be taken whole; do not split, chew, or crush them. The facility's Medication Administration policy, dated 01/04/24, documented that medications are administered as prescribed, in accordance with good nursing principles and practices and by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medications. The policy documented that if safe to do so, medication tablets may be crushed or capsules emptied out when a resident has difficulty swallowing or a tube-fed, using the following guidelines: Long-acting or enteric-coated dosage forms should generally not be crushed and require a physician-specific order to do so. The facility failed to ensure R19 remained free from medication errors when staff crushed an extended-release medication prior to administration. This placed the resident at risk for adverse reactions from the medication.

The facility had a census of 31 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to correctly prepare a pureed diet for three residents who required the modified textured food to retain both nutritive value and palatability. This placed the affected residents at risk for impaired nutrition and decreased quality of life. Findings included: - On 09/17/24 at 10:30 AM, observation revealed Dietary Staff (DS) BB prepared three pureed diets. DS BB placed three ounces of chicken fried steak in the Xtreme blender (a food processor) and added two teaspoons of beef base mixed with 1.5 cups of water, and 1.5 slices of bread. DS BB blended the meat to a thin consistency and emptied the blended chicken fried steak into a metal pan and placed the pan into the oven. Observation revealed DS BB then placed three cups of cabbage in the Xtreme blender, 1.5 slices of bread, and two teaspoons of vegetable base mixed in one-half of a cup of water and mixed the ingredients to a puree texture. DS BB emptied the pureed cabbage into a metal pan and placed the pan into the warming well. Continued observation revealed DS BB placed three pieces of chocolate and vanilla marble birthday cake in a bullet-style personal blender and was going to add 2.5 cups of milk. Upon questioning the amount of liquid, DS BB asked the Certified Dietary Manager who instructed DS BB to use one cup of milk and add more if needed. Continued observation revealed the consistency was a runny liquid after adding one cup of milk, so DS BB added four teaspoons of thickener to obtain the correct pureed texture. On 09/17/24 at 02:40 PM, DS BB verified he did not follow a pureed recipe. DS BB did locate a puree recipe book in the kitchen that had copies of the food he prepared for the lunch meal with the correct amounts to obtain the appropriate pureed texture for the residents. The facility's Texture and consistency-Modified Diets policy, dated 2017, documented that texture and consistency-modified diets would be individualized with modifications made by the speech-language pathologist (SLP) and physician with the registered dietician nutritionist (RD) or designee and director of food and nutrition services. The food and nutrition services department would be responsible for preparing and serving the diet texture and fluid consistency as ordered. Care would be taken to serve the food and fluids as ordered by the physician or designee using the diet order form or other facility communication. The facility failed to prepare three pureed diets using professional standards for food service to maintain both nutritive and palatability. This placed the affected residents at risk for impaired nutrition and decreased quality of life.

The facility had a census of 31 residents. The sample included 12 residents with two reviewed for hospice (a type of health care that focuses on the terminally ill patient's pain and symptoms and attending to their emotional and spiritual needs at the end of life) services. Based on observation, record review, and interview, the facility failed to ensure a coordinated plan of care, which coordinated care and services provided by the facility with the care and services provided by hospice, was developed and available for Resident (R)19 and R29. This placed the residents at risk for inappropriate end-of-life care. Findings included: - R19's Electronic Health Record (EHR) revealed diagnosis of neoplasm of the esophagus (cancer that forms in the lining of the esophagus or throat), gastroesophageal reflux (GERD-backflow of stomach contents to the esophagus), hypertension (HTN-elevated blood pressure), and diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin). R19's Quarterly Change Minimum Data Set (MDS), dated [DATE], recorded R19 had a Brief Interview for Mental Status score of 14 and was cognitively intact. The MDS recorded he required extensive assistance from two staff with bed mobility and transfers. The MDS documented the resident received hospice services. R19'sCare Plan, dated 07/16/24, recorded that R19 required extensive assistance with most activities of daily living (ADL) care. R19's Care Plan documented the resident received hospice services due to a terminal prognosis and directed staff to adjust the provision of ADLs to compensate for R19's change in needs. The care plan directed the staff to observe the resident closely for signs of pain, administer pain medications ordered, and notify the physician if there is breakthrough pain. The care plan lacked instruction on the services provided by hospice visits, supplies and medical equipment provided by hospice, medications covered by hospice, and the hospice provider including their address and phone number. A review of R19's medical records revealed the resident was admitted to hospice care on 04/09/24. The facility had a plan of care provided by hospice in a communication book but it did not list specifics on the care provided. On 09/16/24 at 02:40 PM, R19 sat in a recliner in his room. He had a musician playing the guitar at his bedside. On 09/17/24 at 11:30 AM, Administrative Nurse D verified the facility lacked specific information on the facility care plan that coordinated with the hospice care plan. The Coordination of Hospice Services policy, dated 02/01/20, documented the facility would maintain a written agreement with hospice providers that specifies the care and services to be provided and the process for hospice and nursing home communication of necessary information regarding resident's care. The facility and hospice provider would coordinate a plan of care would implement interventions in accordance with the resident's needs, and goals, and recognize standards of practice in consultation with the resident's attending physician/practitioner and resident's representative, to the extent possible. The plan of care would identify the care and services that each entity would provide to meet the needs of the resident and his/her expressed desire for hospice care. The facility would communicate with the hospice and identify, communicate, follow, and document all interventions put into place by the hospice and the facility. The facility would monitor and evaluate the residents to the hospice care plan. All residents receiving hospice would continue to receive the same facility services as the residents who have not elected hospice. The facility would immediately contact and communicate with the hospice staff, attending physician/practitioner, and the family resident representative regarding significant changes in the resident's status, clinical complications, or emergent situations. The facility failed to coordinate care between the facility and the hospice provider for R19, who received hospice services. This deficient practice placed him at risk for inappropriate end-of-life care 32358 - R29's Electronic Health Record (EHR) revealed diagnoses of chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing) and congestive heart failure (CHF-a condition with low heart output and body becomes congested with fluid). R29's Admission Minimum Data Set (MDS), dated [DATE], recorded R29 had a Brief Interview for Mental Status score of 12, which indicated mildly impaired cognition. The MDS documented R29 was dependent on staff for most activities of daily living (ADLs). The MDS documented the resident received hospice services. R29'sCare Plan, dated 08/20/24, documented R29's dependence on staff with most ADLs. The care plan documented that R29 had a mood problem retaining to her disease process of end-stage COPD and CHF and received hospice services. The care plan instructed staff to administer medications as the physician ordered, monitor and document for side effects and effectiveness of the medications, and report as needed (PRN) any verbalization of risk for harm to self or acute episodes of feeling or sadness to the physician. The plan lacked interventions related to the equipment, supplies, and medications provided or the frequency of hospice visits. The Hospice Agreement for the provision of hospice services to nursing home residents between R29's hospice provider and the facility dated 01/01/24 documented the hospice shall develop, at the time an eligible resident is admitted into the hospice program, a hospice care plan in cooperation with the interdisciplinary care team of the care home. On 09/16/24 at 02:25 PM, observation revealed R29 resting in bed on her back with oxygen on per nasal cannula. On 9/17/24 at 12:02 PM, Administrative Nurse D verified the facility lacked specific information on the facility's care plan that coordinated with the hospice care plan. The Coordination of Hospice Services policy, dated 02/01/20, documented the facility would maintain a written agreement with hospice providers that specifies the care and services to be provided and the process for hospice and nursing home communication of necessary information regarding resident's care. The facility and hospice provider would coordinate a plan of care would implement interventions in accordance with the resident's needs, and goals, and recognize standards of practice in consultation with the resident's attending physician/practitioner and resident's representative, to the extent possible. The plan of care would identify the care and services that each entity would provide to meet the needs of the resident and his/her expressed desire for hospice care. The facility would communicate with the hospice and identify, communicate, follow, and document all interventions put into place by the hospice and the facility. The facility would monitor and evaluate the residents to the hospice care plan. All residents receiving hospice would continue to receive the same facility services as the residents who have not elected hospice. The facility would immediately contact and communicate with the hospice staff, attending physician/practitioner, and the family resident representative regarding significant changes in the resident's status, clinical complications, or emergent situations. The facility failed to coordinate care between the facility and the hospice provider for R29. This placed the resident at risk for inadequate end-of-life care.

The facility identified a census of 28 residents with three residents reviewed for falls and accidents. Based on record review, observation, and interview, the facility failed to follow Resident (R) 1's fall interventions, which resulted in a fall from R1's bed and R1 sustained a broken nasal bone. On 01/07/23 at 04:15 PM, staff provided care to R1 but did not replace the fall mat next to R1's bed when they left the room. Certified Medication Aide (CMA) M later found R1 lying on the floor on her stomach with her face in a pool of blood and blood running out of her nose. R1 was transferred to the emergency room where she was diagnosed with a broken nasal bone. This deficient practice also placed R1 at risk for injury, pain, and bruising. Findings included: - R1's Electronic Medical Record (EMR) documented diagnoses of dementia (progressive mental disorder characterized by failing memory, and confusion) with behavioral disturbance, cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), and seizures (violent involuntary series of contractions of a group of muscles). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R1 had a Brief Interview for Mental Status (BIMS) score of two which indicated severely impaired cognition. The MDS documented R1 required substantial/maximum assistance from staff for eating, oral hygiene, upper body dressing, personal hygiene, and bed mobility. The MDS documented R1 was dependent on staff for lower body dressing, putting on and taking off shoes, transfer, bathing, and locomotion in a wheelchair. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 01/07/24, documented R1 had late-stage dementia, was unable to follow simple commands, and often answered questions inappropriately. The CAA documented R1 could not focus, a history of restlessness, and a history of lethargy. The Falls CAA, dated 01/07/24, documented R1 had to be transferred with a full body lift and had a suspected stroke with right-sided flaccidity. The CAA documented fall interventions including decreasing R1's time in bed, a slightly built-up mattress, and a memory foam fall mattress. R1's Care Plan initiated on 01/19/22 and revised on 01/08/24 documented R1 had an unwitnessed roll out of bed with a major injury dated 11/04/23. The care plan directed staff to get R1 up when she was awake (11/06/23), place a fall mat at her bed side (01/08/24), ensure bed was in lowest position (01/19/23), and ensure a sensor alarm was in place when R1 occupied her bed (01/08/24). The care plan directed staff to transfer R1 with two staff assist and a full body lift (12/29/23) and R1 was dependent on staff for locomotion in her wheelchair (10/11/23). R1's Fall Risk Assessment, dated 11/04/23, documented R1 was a high fall risk. The Incident Note, dated 01/07/24, documented CMA M reported R1 was lying face down on the floor by her bed. R1's bed was in the lowest position. Licensed Nurse (LN) G documented she and CMA M were in R1's room a few minutes before the fall attempting to help R1 keep her shirt on. LN G let R1 know a Certified Nurse's Aide (CNA) would be in shortly to get her up for supper. LN G documented she moved the fall mat with the sensor alarm from R1's bedside when she was putting R1's shirt back on and did not put it back because the CNA was going to be getting R1 up for supper soon. LN G placed a U-shaped pillow around R1 and gave her the call light. LN G documented after R1 fell , R1's nose was swollen and purple with a small cut on the bridge of R1's nose and a moderate amount of blood coming from both nostrils. LN G applied pressure to stop the bleeding. R1 had a 5 centimeter (cm) hematoma to the left side of her head and a 3.5 cm hematoma (abnormal pooling of blood in the body under the skin that results from a broken or ruptured blood vessel) to her left forehead. R1 was alert and oriented to herself only and had equal hand grips. R1 answered questions appropriately for her. Emergency Medical Staff (EMS) arrived and transferred R1 to the emergency room . The Incident Note, dated 01/07/24, documented LN G received a phone call from the emergency room nurse with a report regarding R1. R1 had extensive bruising to her face and had a right nasal bone fracture. R1 received a dose of blood pressure medication in the emergency room due to elevated blood pressure. The Incident Note, dated 01/07/24, documented R1 returned to the facility at 08:05 PM. R1 had dark purple discoloration on her left forehead, mouth, under her right eye, and across the bridge of her nose. The Incident Note, dated 01/08/24, documented R1 had extensive bruising to her face and swelling to her nose due to a nasal fracture. The fall mats and sensor alarms remained in place while R1 was in bed. The Facility Incident Report, dated 01/08/24, documented staff assisted R1 in putting her shirt back on correctly then placed a U-shaped pillow in the bed with R1 and covered R1. Staff left R1's room to assist another resident. R1's fall mat was moved by LN G and LN G did not put the fall mat back by the side of the bed. When staff went back to R1's room, R1 was face down on the floor. R1 had a bloody nose and a bump at the top of her nose that started to bruise and swell. The investigation recorded the corrective actions included the U-shaped pillow was removed from R1's room, staff continued R1's bed in the low position, and staff received education on replacing the fall mat before leaving the room and following R1's plan of care. Staff were to ensure the sensor pad was on R1's bed, and R1's fall mat was changed to a memory foam topper. On 01/17/24 at 10:00 AM, observation revealed R1 sat in her wheelchair in the dining room with her eyes closed. R1 continued to have extensive bruising under her eyes, across her nose, and up into her forehead. R1 did not respond to verbal stimuli. On 01/17/24 at 10:10 AM, observation revealed a memory foam fall mat on top of R1's bed. On 01/17/24 at 10:15 AM, CMA N stated R1's fall interventions in place before the last fall was for staff to ensure the sensor alarm was in her bed and ensure R1 had a fall mat at her bedside. CMA N stated the sensor alarm was to follow R1 wherever she went. On 01/17/24 at 10:30 AM, Administrative Nurse D stated she expected all of her staff to follow R1's care plan and ensure the fall mat was in place before leaving R1's room. The facility's Fall Prevention Policy, dated 01/06/23, documented each resident will be assessed for the risks of falling and will receive care and services in accordance with the level of risk to minimize the likelihood of falls. Primary interventions included: a low bed, fall mats, clear pathways, assistive devices, and monitoring for changes in the resident's cognition, gait, ability to rise/sit, and balance. The facility failed to ensure a safe environment for R1 when staff failed to place her fall mat at the bedside as directed by R1's care plan. This deficient practice resulted in a facial fracture due to a fall from the bed and placed R1 at risk for pain. On 01/10/24, the facility identified and completed all corrective actions including staff education on following residents' plan of care and fall prevention interventions. All actions were completed before the onsite survey therefore the deficient practice was deemed past noncompliance and remained at a G scope and severity.

The facility identified a census of 28 residents with three residents reviewed for medication errors. The facility failed to prevent a significant medication error when staff administered amlodipine (medication used to treat high blood pressure) instead of amiodarone (medication used to regulate heart rate) to Resident (R) 2. This deficient practice placed R2 at risk for health complications and medication-related adverse effects. Findings included: - R2's Electronic Medical Record (EMR) documented R2 had diagnoses of atrial fibrillation (fast, irregular heartbeat), hypertension (high blood pressure), and chronic pain. The Admission Minimum Data Set (MDS), dated [DATE], documented R2 had a Brief Interview for Mental Status (BIMS) score of nine which indicated moderate cognitive impairment. The MDS documented R2 required substantial/maximum staff assistance for bed mobility, transfer, and ambulation. R2 required partial/moderate staff assistance for eating, toileting hygiene, upper body dressing, and personal hygiene. The Cognitive Loss/Dementia Care Area Assessment, dated 10/27/23, documented R2 was forgetful, and her husband helped her at home to remember things and keep track of the days. R2 had depression (a mood disorder that causes a persistent feeling of sadness and loss of interest) due to chronic pain. R2's Care Plan directed staff to administer R2's medications as ordered and to monitor R2 for any adverse side effects. The Electronic Medication Administration Record (EMAR) dated 10/21/23, documented R1 was prescribed amiodarone 200 mg by mouth daily. The Health Status Note, dated 11/17/23, documented R2's primary care physician discontinued R2's amlodipine 10 milligrams (mg) daily. The Facility Incident Report, dated 11/27/23, documented R2 received the wrong medication, (amlodipine). R2 received amlodipine 10 mg from 11/18/23 through 11/24/23 due to the medication card not being removed from the medication cart. Staff administered amlodipine incorrectly instead of amiodarone. The investigation documented corrective action for the situation was a system in which the nurse who received the order to discontinue a medication would pull the discontinued medication immediately. The Facility Facsimile, dated 11/27/23, documented Administrative Nurse D notified R2's primary care physician R2 received amlodipine 10 mg daily from 11/18/23 through 11/24/23 after being discontinued and did not receive amiodarone 200 mg daily during the same time. Administrative Nurse D faxed R2's blood pressure and pulses and reported R2 continued to have swelling. On 01/17/24 at 10:00 AM, observation revealed R2 sat at a table with friends talking and drinking coffee. On 01/17/24 at 10:00 AM, R2 stated that she liked living in the facility and it felt just like home. R2 stated she received good care at the facility. On 01/27/23 at 11:00 AM, Administrative Nurse D stated that she expected staff to follow the rights of medication administration and ensure they were administering the correct medications to the residents. The facility's Medication Administration Policy, dated 01/04/24, documented medications are administered as prescribed, in accordance with good nursing principles and practices, and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medications. The facility failed to follow the standards rights of drug administration in checking for the right medication which resulted in a significant medication error for R2. This deficient practice placed R2 at risk for health complications and medication-related adverse effects.

The facility had a census of 27 residents. The sample included 12 residents. Based on observation, record review and interview the facility failed to provide adequate hand hygiene when caring for Resident (R) 9 and R 22 during incontinence cares, placing the affected residents at risk for infection. Findings included: - R9's Electronic Medical Record (EMR) documented diagnosis of dementia (a group of thinking and social symptoms that interferes with daily functioning), and osteoarthritis (flexible tissue at the ends of bones wears down). The Quarterly Minimum Data Set, dated dated dated [DATE], documented the resident had severely impaired cognition and required total assistance from staff for transfers, bed mobility. R9 was incontinent of bowel and bladder. The Activities of Daily Living [ADL] Care Plan dated 11/11/22, directed the staff to provide incontinent care for the resident and apply clean incontinent brief as needed. On 03/02/23 at 11:45 AM, observation revealed R9 laid on her bed; Certified Nurse Aide (CNA) M pushed a total body lift into the room with CNA N. CNA M shut the resident's door, closed the curtains, and then CNA M and CNA N applied clean gloves. Each CNA stood on opposite sides of R9's bed, uncovered the resident and rolled her over to her right side. CNA N removed the incontinent brief revealing R9 was incontinent of stool. CNA N used incontinent wet wipes and cleansed R9's buttocks, removing the stool, and then placed a clean incontinent brief on the resident without changign gloves. CNA M and CNA N then placed the full lift sling under the resident, CNA M attached the lift to the sling then lifted R9 up from the bed while CNA N pushed the wheelchair closer. The CNAs then lowered R9 into her wheelchair. CNA N picked up the clear plastic bag with the soiled brief while CNA M pushed the resident in her wheelchair to the dining room. CNA M and CNA N then removed their soiled gloves and placed them in the trash container on the side of the medication cart. CNA M and CNA N walked up to the kitchen door and started passing lunch trays out to residents seated in the dining room. Continued observation revealed no handwashing by CNA M or CNA N after removing their soiled gloves and before passing lunch trays to the residents in the dining room. On 03/07/23 at 01:00PM, Administrative Nurse E verified staff were to change soiled gloves after providing incontinent care and were to apply clean gloves to put on a clean incontinent brief; gloves were to be removed before leaving a resident's room and hand hygiene was to be done by the staff. On 03/07/23 at 01:20PM, Administrative Nurse D statedshe expected staff to change gloves and complete hand hygiene when providing incontinent care. The Incontinence Care policy, dated 01/11/21, states all residents will receive incontinent care as needed, gloves will be changed when soiled. Staff will cleanse hands when care is completed. The Hand Hygiene policy dated 09/21/22, states hand hygiene should be done after removal of gloves, and gloves are to be changed if soiled. The facility failed to provide appropriate glove changing and hand hygiene when providing care for R9, then proceeded to pass lunch trays in the dining room. This deficient practice placed the affected residents at risk for infection. 32358 - R22's Electronic Medical Record (EMR) documented the resident had diagnoses dementia (progressive mental disorder characterized by failing memory, confusion) with behavioral disturbance and anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). R22's Annual Minimum Data Set, dated dated [DATE], documented R22's had a Brief Interview of Mental Status score of one, which indicated severe cognitive impairment. The MDS documented the resident required extensive staff assistance with activities of daily living (ADLs) except supervision with eating. The MDS documented R22 was frequently incontinent of urine and occasionally incontinent of bowel. R22's Incontinence Care Area Assessment (CAA), dated 01/06/23, documented R22 incontinence fluctuated (comes and goes) with her cognition and behaviors. R22's ADL Care Plan, revised 02/15/23, documented R22 required limited staff assistance with cueing with personal hygiene and staff supervision to limited assistance with toileting. On 03/02/23 at 01:43 PM, observation revealed Certified Nurse Aide (CNA) O propelled R22 in a wheelchair to her room and CNA N came into the room, both applied gloves. The CNAs used a gait belt, and assisted R22 to transfer from a wheelchair to her bed which revealed the back of R22's gray pants were wet across the buttocks area. CNA O removed the resident's pants and incontinent brief, and then CNA N left the room. CNA O provided perineal (genital area) care. Then, with the same soiled gloves, placed a new incontinent brief under R22, assisted the resident in turning to her left side touching R22's clothing, fastened the new incontinent brief, placed a pillow underneath the resident's head, and placed a blanket on R22. CNA O then removed and discarded her gloves in a trash bag. Continued observation revealed CNA O tied the bag, failed to wash her hands, left the room with the bag and carried to the dirty utility where CNA O still did not wash her hands. On 03/07/23 at 07:45 AM, observation revealed R22 sat in a wheelchair at the dining room table with shoes on. She visited and laughed with staff. On 03/07/23 at 01:22 PM, Administrative Nurse D stated she expected staff to remove gloves and wash hands after providing perineal care for R22. The facility's Incontinence Care Policy revised 01/11/21, documented after staff complete perineal care, they should remove their gloves and apply a clean brief on a resident. The facility's Hand Washing Policy, revised 09/21/22, documented recommendations for hand hygiene before moving from work on a soiled body site to a clean body site on same resident. The facility staff failed to change gloves and wash hands when providing R22 incontinent cares and continued to provide care with the same soiled gloves. This placed the resident at risk for infection.

The facility had a census of 27 residents, with three reviewed for Center for Medicare and Medicaid Services (CMS) Beneficiary Liability notices. Based on record review and interview, the facility failed to provide on the CMS form 10055, the estimated cost to continue services for skilled services to the resident or their representative for two of three reviewed residents, Resident (R)7 and R24 placing the residents at risk for uninformed decisions regarding skilled services Findings included: - The Medicare Advance Beneficiary Notice (ABN) form 10055 informed the beneficiaries that Medicare may not pay for future skilled therapy and did not provide an estimated cost to continue their services. The form included an option for the beneficiary to (1) receive specified services listed, and bill Medicare for an official decision on payment. I understand if Medicare does not pay, I will be responsible for payment, but can appeal to Medicare. (2) receive therapy listed, but do not bill Medicare, I am responsible for payment of services. (3) I do not want the listed services. The facility lacked documentation staff provided R7 (or their representative) the estimated daily cost on CMS form 10055 when the resident's skilled services ended 10/17/22. The facility lacked documentation staff provided R24 (or their representative) the estimated cost on CMS form 10055 when the resident's skilled services ended 09/28/22. On 02/02/23 at 03:00 PM, Administrative Nurse D stated she was responsible for providing CMS form 10055. Administrative Nurse D verified R7 and R24's CMS form 10055 lacked documentation they (or their representative) were provided with the estimated cost. Upon request the facility failed to provide a policy regarding beneficiary notification. The facility failed to provide R7 and R24 with the cost estimate for further services, placing the residents at risk for uninformed decisions regarding skilled services.

The facility had a census of 27 residents. The sample included 12 residents of which one was reviewed for tube feeding (gastrostomy tube, directly into the stomach, used to provide liquid nourishment, fluids, and medications by bypassing oral intake), Resident (R)16. Based on observation, record review, and interview, the facility failed to develop a comprehensive care plan for the use of the gastrostomy tube placing R16 at risk for inappropriate care. Findings included: - R16's Electronic Health Record (EHR) documented diagnoses of gastrostomy tube, edema (swelling, caused by excess fluid in body's tissues), and dementia (a group of thinking and social symptoms that interferes with daily functioning). The Significant Change Minimum Data Set (MDS) dated [DATE], documented the resident had a Brief Interview for Mental Status score of four, indicating severely impaired cognition. The MDS documented the resident required extensive assistance with transfers, and had a gastrostomy feeding tube that supplied all nutrition and fluids. The Care Area Assessment Summary (CAA), dated 12/08/22, documented R16 had cellulitis (a bacterial skin infection) in her face and neck causing difficulty with swallowing. A gastrostomy tube was placed to receive the nutrition and fluids needed. R16's EMR lacked a care plan for use of the gastrostomy tube. R16's EMR documented R16 discharged and admitted to the hospital with diagnosis of cellulitis on 11/23/22. R16 readmitted to the facility on [DATE] with a gastrostomy tube. The Physician Order dated 12/05/22 recorded an enteral feeding order for gastrostomy tube and directed staff to administer Jevity (high calorie, high protein, liquid nutrition) four times a day (QID), 350 milliliters (ml) at 05:30AM, 350 ml at 11:30AM, 500 ml at 06:00PM and 500 ml at 10:30PM. The Registered Dietician documentation dated 12/11/22, stated R16 was to receive a total of 1700 ml of nutritional supplement and 480 ml of water flushes through the gastrostomy tube daily. The Treatment Administration Record (TAR) dated 12/05/22, directed the staff to document intake through the gastrostomy tube every shift. Review of the TAR revealed the following: No documentation for 12/05/22 to 12/31/22. No documentation for 01/01/23 to 01/31/23. Minimal documentation for 02/01/23 to 02/28/23. Documentation for 03/01/23 to 03/06/23, each shift with amounts lacking the 1700ml of nutritional feeding and lacked the total amount of water flushes R16 was to receive through the gastrostomy tube. On 03/02/23 at 11:35 AM, observation revealed R16 sat on a chair in her room. Licensed Nurse (LN) G administered Jevity 350 ml through the gastrostomy tube and administered 120 ml of water before and after the Jevity. On 03/07/23 at 10:10 AM, LN G verified she was to document the amount of Jevity and water administered through the gastrostomy tube every shift. LN G also verified she was unsure of how much water to administer and stated she just administered the amount of water she thought R16 needed. LN G verified there was no care plan for the use of the gastrostomy tube. On 03/07/23 at 10:30AM, Administrative Nurse D verified the lack of documentation for what was administered through the gastrostomy tube. Administrative Nurse D also verified her expectation of the licensed nurses to document the amount of Jevity and water administered. Administrative Nurse D stated she was unsure of the amount to be administered and said there was no comprehensive care plan completed for the use of the gastrostomy tube. The Overall Care Plan, policy dated 11/29/22, states each resident will receive care based on their individual needs, and personalized with long and short term goals. A comprehensive care plan is to be developed for staff direction for care of each resident. The facility failed to develop a comprehensive care plan for R16's feeding tube, placing R16 at risk for inappropriate care of the gastrostomy tube.