Every finding on record at Cheney Golden Age Home

The facility reported a census of 36 residents. Based on interview and record review, the facility failed to electronically submit complete and accurate staffing information to the Federal regulatory agency through Payroll-Based Journal (PBJ) when the facility failed to accurately submit hourly staffing data for all nursing personnel. Findings included: - Review of the PBJ Staffing Data Report for Fiscal Year (FY) for Quarter 3- 2024 (April 1 - June 30), the data indicated the facility failed to have Licensed Nursing Coverage 24 hours/Day on the following dates: 05/04/24 Saturday (SA), 05/12/24 Sunday (SU), 05/18/24 (SU), 06/02/24 (SA), 06/15/24 (SA), 06/16/24 (SU), 06/23/24 (SU) and 06/29/24 (SA). Review of the Nursing Schedule and Payroll Data Sheets for the above dates revealed the facility had adequate 24-hour nursing coverage. On 11/18/24 at 08:00 AM, Administrative Staff A reported payroll data and scheduling data reflected the facility had 24 hour nursing coverage. Administrative Staff A stated nursing staff were directed to not clock out for lunch if they did not leave the building and stated they could only leave the building if the responsibilities were covered by another licensed nurse. Administrative Staff A reported the facility had been having problems getting their payroll contractor to accurately account for time where agency staff covered the shift. On 11/18/24 at 01:00 PM, Administrative Nurse B provided documentation to support adequate 24-hour nursing coverage for the listed dates. The facility's Payroll Based Journal Policy policy, dated 03/2024 documented the facility aimes to ensure complaince with Federal regulations to promote transparency and accountability for the workforce management. Additionally documented that the facility would report the hours worked from agency employees through the PBJ system. The facility failed to submit complete and accurate staffing information to the Federal regulatory agency through PBJ when the facility failed to accurately submit hourly staffing data for all nursing personnel.

The facility reported a census of 36 residents which included 12 sampled. Based on observation, interview, and record review, the facility failed to ensure a sanitary environment to prevent the potential spread of infectious organisms. The facility did not ensure sanitary storage of respiratory equipment to include nasal cannulas and oxygen tubing for Resident (R)26, R6, and R11. The facility did not ensure the appropriate use of personal protective equipment (PPE) related to enhanced barrier precautions for R2, who had a catheter. The staff wore PPE throughout one of three hallways of the facility. The facility failed to clean/sanitize the full body lift between use for multiple residents. Finding included: - Review of Resident (R)26's Physician Orders, dated 10/31/24, revealed diagnoses which included chronic obstructive pulmonary disease (COPD- progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), congestive heart failure, (CHF-a condition with low heart output and the body becomes congested with fluid), pain, altered mental status, and dementia (progressive mental disorder characterized by failing memory, confusion). The Admission Minimum Data Set (MDS) dated [DATE], documented the Brief Interview for Mental Status (BIMS) score of 13, which indicated no cognitive impairment. The MDS noted R26 received oxygen. The Quarterly MDS dated [DATE], documented the Brief Interview for Mental Status (BIMS) score of 13, which indicated no cognitive impairment. The MDS noted the resident received oxygen. The Care Plan dated 10/25/24, lacked directions to staff for storage of oxygen cannulas when not in use. The Physician's Orders dated 10/31/24, included Oxygen two liters (L), per nasal cannula, to keep oxygen saturations above 90 percent (%), every shift, ordered 07/11/2024. On 11/13/24 at 08:30 AM, R26 sat in her chair without her oxygen in use. The oxygen nasal cannula laid directly on top of the oxygen concentrator at the handle. The connective tubing laid directly on the floor beside the resident's chair. The oxygen concentrator lacked a storage bag to place the oxygen tubing when not in use to prevent cross contamination and infection. The resident reported she only used the oxygen at night and she had never had a storage bag to place her oxygen in, when not in use. During an observation on 11/13/24 at 04:20 PM the resident's oxygen nasal cannula laid under the handle of the concentrator in a rolled position. There was no storage bag available to store the nasal cannula when not in use to prevent cross contamination or infection. On 11/14/24 at 08:32 AM, Certified Nurse Aide (CNA) F stated the resident did use her oxygen. CNA F thought there should be a bag or something for the resident to store her oxygen tubing in when not in use to prevent the spread of infection. CNA F stated she did not know who was responsible for providing the bag but thought the Certified Medication Aides (CMA) took care of the oxygen cannulas, tubing, and supplies, such as storage bags. On 11/14/24 at 01:57 PM, Licensed Nurse (LN) O, report the resident's oxygen supplies were changed once a week on night shift. LN O stated R26 took her own oxygen off and placed it on the concentrator. She stated the cannula should be stored in some type of container when not in use to prevent cross contamination or infection. LN O could not recall seeing a storage bag available in the resident's room to store the oxygen cannula and tubing, when not in use. On 11/18/24 at 12:19 PM, Administrative Nurse B reported the respiratory equipment should have a bag available to store the oxygen tubing and cannula when not in use to prevent cross contamination and infection. Administrative Nurse B stated the facility provided bags for storage and thought they may be in the resident's closets. On 11/18/24 at 12:28 PM, Administrative Nurse B confirmed masks, cannulas, and tubing not stored in a bag when not in use was an infection control concern. The facility did not provide a policy to address available storage of oxygen, nasal cannulas, and tubing when not in use to prevent infection and/or cross contamination. The facility failed to provide a sanitary and safe environment to prevent cross contamination and infection related to available storage of nasal cannulas and oxygen tubing when not in use. 46960 - Review of the Electronic Health Record (EHR) for Resident (R) 11 included a diagnosis of obstructive sleep apnea (OSA - a sleep related breathing disorder that cause people to stop and start breathing while asleep). The Significant Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 11, which indicated moderately impaired cognition. The assessment documented R11 required substantial/maximum assistance for dressing, partial/moderate assistance for bathing, and supervision/setup for all other cares and used a CPAP device. The 09/26/24 Care Plan documented on R11 utilized a CPAP machine at night and while napping, initiated on 09/25/23, and revised on 01/22/24. The Physician's Orders documented CPAP at home settings at HS (hour of sleep or bedtime) and when napping, every shift, initiated on 10/05/23. During an observation on 11/12/24 at 01:05 PM, 11/14/24 at 07:50 AM, 11/18/24 at 08:30 AM, and 11/18/24 at 12:28 PM of R11's room revealed the CPAP equipment sat intact on R11's bedside cabinet and lacked a sanitary cover or bag. During an interview on 11/18/24 at 09:53 AM, Certified Nurse Aide (CNA) I stated cannulas and other oxygen delivery equipment including CPAP equipment should be stowed in a sanitary bag when not in use. During an interview on 11/18/24 at 10:04 AM, CNA J stated the CNA staff could assist residents in donning or doffing their cannulas and CPAP equipment and that all respiratory equipment should be stowed in the sanitary bags in their room when not in use. During an interview on 11/18/24 at 11:34 AM, Certified Medication Aide (CMA) C stated that CMA staff were responsible for changing out the CPAP and oxygen equipment and that oxygen equipment should be stowed in the sanitary bag when not in use. Further, stated that she was unsure of how CPAP mask/tubing should be stowed when not in use. During an interview on 11/28/24 at 12:28 PM, Administrative Nurse B confirmed that R11's CPAP mask was not stowed in a sanitary bag. Administrative Nurse B then retrieved a sanitary bag from the bottom drawer of R11's bedside cabinet that contained other un-bagged CPAP masks and placed R11's CPAP mask from the top of the bedside cabinet without cleaning it into the sanitary bag. Administrative Nurse B then educated R11 to place the CPAP mask in the sanitary bag when not in use. Administrative Nurse B confirmed R11's being stowed on top of the bedside cabinet was an infection control concern. The facility did not provide an infection control policy directly related to respiratory equipment. The facility failed to ensure R11's CPAP equipment was stowed appropriately to prevent the spread of illnesses. This deficient practice had the potential to lead to respiratory illnesses that would negatively impact R11's physical and psychosocial well-being. 51332 - Review of the Electronic Health Record (EHR) for Resident (R)2 included a diagnosis of urinary retention (lack of ability to urinate and empty the bladder) and multiple sclerosis (progressive disease of the nerve fibers of the brain and spinal cord hypertension). The Comprehensive Minimum Data Set (MDS) dated [DATE] documented R2 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The assessment documented R2 required extensive assistance for all Activities of Daily Living (ADL) such as walking, grooming, toileting, dressing, and eating. The MDS did not identify R2 had an indwelling urinary catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid). The Quarterly MDS dated [DATE] documented R2 had a BIMS score of 12, which indicated intact cognition. The assessment documented R2 had an indwelling urinary catheter. The Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA) dated 05/25/24 documented R2 was incontinent of bladder and bowel and staff would monitor and make interventions to prevent infections. The 08/22/24 Care Plan documented R2 required enhanced barrier precautions (EBP, apply to residents with wounds or indwelling medical devices, regardless of whether they are known to be infected) and staff should utilize EBP due to indwelling device regardless of Multi-Drug Resistant Organism (MDRO - a common bacteria that have developed resistance to multiple types of antibiotics) and for Healthcare Acquired Infections (HAI - infections acquired in a healthcare setting) colonization status including but not limited to the use of a urinary catheter and was last revised on 04/01/24. The 08/22/24 Care Plan documented EBP would be utilized per facility policy and procedures if criteria had been met, revised on 04/01/24. The 08/22/24 Care Plan documented if criteria were met, resident would be identified by signage placed on the outside of the bedroom door which indicated precautions, revised on 04/01/24. The Physician's Orders included a Foley (a brand of catheter) catheter change as needed (PRN) related to decreased urinary flow due to possible obstruction, initiated on 08/06/24. The Physician's Orders documented a Foley Catheter change monthly on the 21st of every month initiated on 08/21/24. During an observation on 11/12/24 at 11:41 AM, the door to R2's room lacked signage that indicated EBP was required. During and observation on 11/12/24 at 01:23 PM, the door to R2's room displayed a sign that indicated EBP was required. During an observation on 11/13/24 at 01:34 PM, Certified Nurse Aide (CNA) F and CNA J moved a mechanical lift from R2's room into different resident's room, without cleaning the mechanical lift. During an observation on 11/14/24 at 08:13 AM, CNA I preformed catheter care on R2 and used only gloves. CNA, I did not use EBP until 08:39 AM when another staff member entered the room and reminded CNA I that R2's catheter care required the use of EBP. During an interview on 11/13/24 at 02:16 PM, CNA J stated she knew that mechanical lifts used in a resident's room which required EBP, required cleaning and sanitizing with disinfectant wipes before it was used in another resident's room. During an interview on 11/14/24 at 08:24 AM, CNA I stated the sign on R2's door blended into the door which made it hard to see and did not stand out. CNA I stated she was not aware that R2 was on EBP because the sign was not highly visible, and a second person in the room with her helped her perform the correct level of PPE (personal protective equipment, such as gloves/gown/mask). CNA I stated if there would have been a red trash cans that would have prompted her to stop. In an interview on 11/13/24 at 02:29 PM Licensed Nurse (LN) O stated staff should wipe down mechanical lifts with antimicrobial wipes after using the lift in a resident's room that required EBP. During an interview on 11/28/24 at 12:28 PM, Administrative Staff A confirmed the staff were expected to disinfect the mechanical lift after use in residents' room that required EBP. The facility did not provide a policy to address EBP expectations to prevent infection and/or cross contamination. The facility failed to ensure staff donned appropriate PPE while providing catheter care for R2, who was on EBP precautions. This deficient practice had the potential to lead to cross contamination that would negatively impact R2's physical and psychosocial well-being. - Review of the Electronic Health Record (EHR) for Resident (R) 6 included a diagnosis of obstructive sleep apnea (OSA - a sleep related breathing disorder that cause people to stop and start breathing while asleep). The Significant Change Minimum Data Set (MDS) dated [DATE], documented R6 had a Brief Interview for Mental Status (BIMS) assessment score of 13, indicating intact cognition. The assessment documented R6 required substantial or maximum assistance from staff for transfers. R6 was dependent on staff to perform other cares. The assessment documented R6 required substantial/maximal assistance for dressing, partial/moderate assistance for bathing, and supervision/setup for all other cares and used a CPAP continuous positive airway pressure (CPAP- ventilation device that blows a gentle stream of air into the nose to keep airway open during sleep) device. The Care Plan initiated on 10/14/24 documented R6 utilized a CPAP machine at night, revised on 01/03/23. The Physician's Orders documented the resident required a CPAP at HS (hour of sleep or bedtime) with oxygen, check oxygen saturations every night, initiated on 02/05/22. During an observation on 11/12/24 at 11:48 AM, 11/13/24 at 12:42 PM, 11/14/24 at 08:19 AM, and 11/14/24 at 09:30 AM of R6's room revealed CPAP equipment sat intact on R6's bedside cabinet and lacked a sanitary cover or bag. During an interview on 11/18/24 at 09:53 AM, Certified Nurse Aide (CNA) I stated oxygen cannulas and other oxygen delivery equipment including CPAP equipment should be stowed in a sanitary bag when not in use. During an interview on 11/18/24 at 10:04 AM, CNA J stated CNA staff could assist residents in donning or doffing their oxygen cannulas and CPAP equipment and that all respiratory equipment should be stowed in the sanitary bags in their room when not in use. During an interview on 11/18/24 at 11:34 AM, Certified Medication Aide (CMA) C stated CMA staff were responsible for changing out the CPAP and oxygen equipment and that oxygen equipment should be stowed in the sanitary bag when not in use. CMA C stated that she was unsure of how CPAP mask/tubing should be stowed when not in use. During an interview on 11/28/24 at 12:28 PM, Administrative Nurse B confirmed R6's CPAP mask was not stowed in a sanitary bag. Administrative Nurse B then educated R6 to place the CPAP mask in the sanitary bag when not in use. Administrative Nurse B confirmed R6's being stowed on top of the bedside cabinet was an infection control concern. The facility did not provide a policy to address available storage of oxygen, nasal cannulas, and tubing, when not in use to prevent infection and/or cross contamination. The facility failed to ensure R6's CPAP equipment was stowed appropriately to prevent the spread of illnesses.

The facility reported a census of 36 residents. Based on interview and record review, the facility failed to conduct annual performance reviews for five of the five sampled Certified Nurse Aides, employed with the facility over a year. Findings included: - During review of employment records for the five Certified Medication Aide (CMA)/Certified Nurse Aides (CNA) staff, employed by the facility for over a year, revealed the facility failed to complete annual performance review for the following direct care staff: 1. CNA/CMA C, hired 01/22/04 2. CNA D, hired 08/24/23 3. CNA E, hired 06/07/23 4. CNA F, hired 09/18/06 5. CNA G, hired 1/26/23 On 11/18/24 at 03:03 PM, Administrative Staff A confirmed the above findings and said she could not locate the most recent performance evaluations. Administrative Staff A stated that all staff should have a performance evaluation annually. Administrative Staff A confirmed that direct care staff worked with all residents throughout the facility. The facility did not provide a policy to address the completion of annual performance evaluations. The facility failed to conduct annual performance reviews for five of the five sampled Certified Nurse Aides, employed with the facility for over a year, who provided care for all residents of the facility.

The facility identified a census of 36 residents, which included 12 residents sampled. Based on interviews, observations, and record review, the facility failed to review and revise care plans with appropriate interventions for two of the sampled residents; Resident (R) 6 related to development and implementation of appropriate interventions to prevent additional falls and R11 related to storage of continuous positive airway pressure (CPAP - a device that provides continuous air pressure to keep the upper airway open during sleep) equipment when not in use. These deficient practices resulted in uncommunicated care needs. Findings included: - Review of the Electronic Health Record (EHR) for Resident (R) 11 included the diagnosis of obstructive sleep apnea (OSA- a sleep related breathing disorder that cause people to stop and start breathing while asleep). The Significant Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 11, which indicated moderately impaired cognition. The assessment documented R11 required substantial/maximal assistance for dressing, partial/moderate assistance for bathing and supervision/setup for all other cares and used a CPAP device. The 09/26/24 Care Plan documented on 09/25/23 that R11 utilized a CPAP machine at night and while napping, initiated on 09/25/23 and revised on 01/22/24. The Physician's Orders documented CPAP at home settings at HS (hour of sleep or bedtime) and when napping, every shift, initiated on 10/05/23. During an observation on 11/12/24 at 01:05 PM, 11/14/24 at 07:50 AM, 11/18/24 at 08:30 AM and 11/18/24 at 12:28 PM of R11's room revealed CPAP equipment sat intact on R11's bedside cabinet and lacked sanitary cover or bag. During an interview on 11/18/24 at 09:53 AM, Certified Nurse Aide (CNA) I stated cannulas and other oxygen delivery equipment including CPAP equipment should be stowed in a sanitary bag when not in use. During an interview on 11/18/24 at 10:04 AM, CNA J stated that CNA staff could assist residents in donning or doffing their cannulas and CPAP equipment and that all respiratory equipment should be stowed in the sanitary bags in their room when not in use. During an interview on 11/18/24 at 11:34 AM, Certified Medication Aide (CMA) C stated that CMA staff were responsible for changing out the CPAP and oxygen equipment and that oxygen equipment should be stowed in the sanitary bag when not in use. Further, stated that she was unsure of how CPAP mask/tubing should be stowed when not in use. During an interview on 11/28/24 at 12:28 PM, Administrative Nurse B confirmed that R11's CPAP mask was not stowed in a sanitary bag. Administrative Nurse B then retrieved a sanitary bag from the bottom drawer of R11's bedside cabinet that contained other un-bagged CPAP masks and placed R11's CPAP mask from the top of the bedside cabinet without cleaning it into the sanitary bag. Administrative Nurse B then educated R11 to place the CPAP mask in the sanitary bag when not in use. Administrative Nurse B stated R11's care plan should include an intervention for staff to place the mask inside the bag if the mask was discovered not stowed appropriately and confirmed the lack of an intervention of R11's care plan for staff to stow R11's CPAP mask in the sanitary bag. The facility's Person Centered, Comprehensive Care Plans policy, dated 12/2023 documented the facility would provide an individualized and person-centered plan of care for all residents that was appropriate for the resident's needs. Additionally documented the facility would review and revise the care plan quarterly, or more frequently, to include interventions which direct and instruct staff to meet the goals of the resident. The facility failed to review and revise R11's comprehensive person-centered care plan to include interventions to place R11's CPAP mask in a sanitary bag when not in use. This deficient practice placed R11 at risk of uncommunicated care needs. 51332 - Review of the Electronic Health Record (EHR) for Resident (R) 6 included the following diagnoses: lack of coordination, morbid (severe) obesity (excessive body fat), hemiplegia (muscular weakness of one half of the body), hemiparesis (paralysis of one side of the body), cerebrovascular disease (conditions that affect the blood vessels in the brain and spinal cord can), hypertension (elevated blood pressure), and lymphedema (swelling caused by accumulation of lymph). The Significant Change Minimum Data Set (MDS) dated [DATE], documented R6 had a Brief Interview for Mental Status (BIMS) assessment score of 13, indicating intact cognition. The assessment documented R6 required substantial or maximum assistance from staff for transfers. R6 was dependent on staff to perform other cares. The MDS indicated R6 had no falls during the documented review period. The Quarterly MDS dated [DATE], documented a BIMS of 13, which indicated intact cognition. The MDS indicated R6 had no falls during the documented review period. The Falls Care Area Assessment (CAA) dated 07/07/24, documented R6 had a fall risk, but lacked documentation noting R6 had any falls. The resident's Care Plan lacked an intervention for the fall dated 06/25/24. The Progress Note dated 06/25/24 at 07:15 PM indicated that the nurse was requested to go to the shower room to perform a skin assessment. The nurse needed more treatment supplies and exited the shower room. Upon the nurse's reentry into the shower room, the staff successfully assisted R6 in standing for the second time. The resident could not maintain her standing position during the wound treatment and attempted to sit down without the wheelchair positioned behind her. Staff assisted R6 to the floor while waiting for more staff to assist with the transfer. (The facility failed to document this as a fall or initiate their fall policy related to this documentation.) Review of the facility Fall Investigation for R6 lacked documentation related to a fall on 06/25/24. The Progress Note dated 06/26/24 at 09:00 AM, revealed that R6 complained of right foot pain and difficulty bearing weight on it. The staff notified the resident's provider, who ordered an X-ray. The review of Physician Extender Summary dated 06/27/24 at 04:20 PM, revealed that during a transfer to the shower two days prior, it was believed that R6's right lower leg was caught in the chair. An X-ray was performed and revealed a non-displaced distal tibia fracture of the lower end of the right tibia. Observation on 11/14/24 at 09:00 AM, revealed R6 sitting in her wheelchair playing on her tablet alone in her room, with her right arm in a sling. The resident lacked a boot on her right foot. Observation on 11/14/24 at 08:19 AM, revealed Certified Medication Aide (CMA) S assisted R6 with a pivot transfer to the bathroom with one assist and resident was able to tolerate transfer comfortably without complaints of pain and able to bear own weight. On 11/18/24 at 08:30 AM, Certified Nurse Aide (CNA) P stated a fall would be defined as any time a resident's body contacts the floor. CNA P stated she did not think R6's care plan had undergone any change for the last seven months of her employment. CNA P knew of care plan changes either by the Point Click Care (POC) banner when logging in to chart or verbally when starting the shift during report from the previous shift. On 11/18/24 at 09:23 AM, Licensed Nurse (LN) M stated a fall would be defined as anytime a resident unintentionally went from a higher surface to a lower surface. LN M stated R6 had one fall that she knew, in October, which resulted in no injury. LN M stated immediately at that time she put the intervention in place for R6 to wait for help before transferring herself. On 11/18/24 at 10:34 AM, Administrative Staff A stated when any resident unintentionally went from a higher surface to a lower surface would be considered a fall. Administrative Staff A stated even when a resident had to be assisted to the floor by staff the facility classified that instance as an assisted fall. Administrative Staff A stated that the facility required any assisted fall to be recorded as a fall. Review of facility's Fall Follow-Up Protocol dated February 2024 documented: A fall refers to an incident where a resident, without intention, fails to maintain their balance and descends to a lower level. This definition encompasses situations where the resident would have fallen if not for the timely intervention of care partners. This definition stands regardless of whether the resident sustains an injury or not. The facility failed to revise the care plan for R6 after a fall to prevent further falls. This deficient practice had the potential to negatively affect R6's physical well-being related to the ongoing risk of falls.

The facility had a census of 36 residents. The sample included 12 residents with three reviewed for hospitalization . Based on observation, interview, and record review the facility failed to provide written notice for facility-initiated transfers for Residents (R) 11, R2, or R6 or their representative when they were transferred to the hospital. Findings included: - Review of the Electronic Health Record (EHR) census log for R11 revealed a discharge from the facility to a hospital on 05/15/24 and noted the resident readmitted to the facility on [DATE]. The census log also documented a discharge from the facility to a hospital on 09/09/24 and readmitted to the facility on [DATE]. The EHR lacked documentation related to written notification of the resident or resident's representative related to this discharge/transfer. Review of the EHR census log for R6 revealed a discharge from the facility to a hospital on 06/27/24 and readmitted to the facility on [DATE]. The EHR lacked documentation related to written notification of the resident or resident's representative related to these discharges/transfers. Review of the EHR census log for R2 revealed a discharge from the facility to a hospital on 07/21/24 and noted the resident was readmitted to the facility on [DATE]. The EHR lacked documentation related to written notification of the resident or resident's representative related to this discharge/transfer. During an interview on 11/18/24 at 09:35 AM with Administrative Nurse K revealed the charge nurse on duty at the time of a hospitalization was responsible for the paperwork which includes a bed hold. The nurse would call the resident's representative and obtain verbal consent for the bed hold then submit the paperwork to the Business Office Manager who would call the resident's representative either later that day or on the next business day to confirm the authorization for a bed hold. Administrative Nurse K stated she was unsure if a written notice was provided to the resident or resident's representative. During an interview on 11/18/24 at 10:20 AM with Administrative Staff T and Administrative Staff A confirmed the nurse on duty at the time of a hospitalization would fill out a bed hold form, call the resident's representative, and obtain verbal consent for the bed hold then send the paperwork to the business office for verification later that day or on the next business day. Administrative Staff A confirmed bed holds were not submitted to the resident or resident's representatives in writing. Administrative Staff A stated she was unaware of the regulatory requirement that a written notice be given to the resident or resident's representative upon transfer/discharge. The facility failed to provide a policy related to discharge notifications. The facility failed to provide written notification of facility-initiated discharges/transfers to the residents, the resident's representative.

The facility reported a census of 36 residents with 12 residents sampled. Based on interview, observation, and record review, the facility failed to protect the privacy and dignity of three residents; Resident (R) 35 when a medication was administered via percutaneous endoscope gastrostomy tube (PEG - a tube inserted through the wall of the abdomen directly into the stomach) with her left breast exposed and the door to the room stood open, failed to explain procedures to R31 when providing cares, and further failed to provide privacy to when staff transported R2 from the shower room to her room with her buttocks exposed. These practices had the potential to lead to negative psychosocial effects related to dignity. Findings included: - The Electronic Health Record (EHR) for R35 included the diagnoses of: nontraumatic intracerebral hemorrhage (bleeding in the brain not caused by trauma), need for assistance with personal cares, generalized muscle weakness and dysphagia (difficulty or inability to swallow). The Admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status score of nine which indicated moderately impaired cognition. The assessment documented R35 as dependent on staff for all cares and had a feeding tube (PEG tube). The Nutritional Status Care Area Assessment (CAA) dated 10/22/24 documented R35 required tube feedings and was dependent on staff. Observation on 11/14/24 at 08:11 AM of Administrative Nurse B administering medication via PEG and R35's left breast partially exposed during the procedure. Interview on 11/14/24 at 08:25 AM Administrative Nurse B stated that her expectation was for the door to resident's rooms to be closed during cares or procedures to provide dignity to the residents. Additionally, Administrative Nurse B confirmed that the door to R35's room was open during the administration of medications via PEG tube and R35's left breast was partially exposed. During an interview on 11/14/24 at 08:30 AM R35 stated she was bothered that the door to her room was open during the time when the PEG tube was exposed and her left breast was partially exposed. The facility's Right to Dignity policy, dated 02/2024 documented the facility would promote care for elders of the facility in a manner and environment that maintains and enhances the elder's dignity and respect. The facility failed to protect the dignity of R35 when the door to R35's room was left open when a medication was administered via PEG tube with the PEG tube exposed and R35's left breast partially exposed. This deficient practice had the potential to lead to negative psychosocial effects related to dignity. 51332 - The Electronic Health Record (EHR) for R2 included the diagnoses of dementia (a progressive mental disorder characterized by failing memory confusion), pain, major depressive disorder (major mood disorder which causes persistent feelings of sadness),weakness, multiple sclerosis (progressive disease of the nerve fibers of the brain and spinal cord hypertension), hypertension (HTN-elevated blood pressure), urinary retention (lack of ability to urinate and empty the bladder), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). The Admission Minimum Data Set (MDS) dated [DATE] documented that R2 had a Brief Interview for Mental Status (BIMS) assessment score of 15, indicating intact cognition. The assessment documented R2 required extensive assistance for all ADL (activities of daily living such as walking, grooming, toileting, dressing and eating) from staff and required mechanical full body lift. The Quarterly MDS dated [DATE] documented R2 had a Brief Interview for Mental Status (BIMS) assessment score of 12, indicating intact cognition. The assessment documented R2 required extensive assistance for all cares and required the use of a mechanical full body lift. The Cognitive Loss/Dementia Care Area Assessment (CAA) dated 05/25/24 documented that R2 was not ambulatory and depended entirely on staff for care. R2 was at risk for injuries due to inadequate safety awareness related to cognitive decline, confusion, and anxiety. Observation on 11/14/24 at 10:50 AM revealed Certified Nurse Aide (CNA) I transported R2 in a shower chair, from the shower room to her bedroom. During the transport down the hall, R2's buttock was exposed and visible to anyone in the area. During an interview on 11/13/24 at 11:52 AM, Certified Medication Aide (CMA) S stated residents were expected to be dressed in the shower room, after being showered, before being brought in the hall to go to their room. During an interview on 11/13/24 at 10:50 AM, CNA I stated it was facility policy to transfer residents who required mechanical lifts in their rooms not in the shower room. During an interview on 11/13/24 at 11:39 AM, Licensed Nurse (LN) O stated that residents were not to be transferred in the hall in the shower chair. LN O stated that staff were to take mechanical lifts into the shower room and transfer residents there. In an interview on 11/13/24 at 01:48 PM, Administrative Staff A stated she expected staff to make sure that residents were adequately covered after having a shower before taking them into the hall to provide dignity to the residents. Administrative Staff A confirmed she expected staff not to transfer residents in the hall with the shower chair. The facility's Right to Dignity policy, dated February 2024, documented that elders will be undressed and dressed inside the bathing room rather than being transported without full clothing. The facility failed to protect R2's dignity when staff transported R2 from the shower room to her room with her buttocks exposed. This deficient practice had the potential to lead to negative psychosocial effects related to dignity. - The Electronic Health Record (EHR) for R31 included the diagnoses of dementia (a progressive mental disorder characterized by failing memory confusion), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). The Significant Change Minimum Data Set (MDS) dated [DATE] documented R31 was unable to complete the Brief Interview for Mental Status (BIMS) assessment. The assessment documented R31 as dependent on staff for all cares. The Quarterly (MDS) dated [DATE] documented that R31 was unable to complete the Brief Interview for Mental Status (BIMS) assessment, The assessment documented R31 as dependent on staff for all cares. The Care Plan initiated on 08/28/24 directed staff to clearly explain all care activities prior to and as they occur during each contact. Observation on 11/12/24 at 11:48 AM revealed Certified Nurse Aide (CNA) F, assisted by CNA D, transferred R31 with a full body mechanical lift from the bed to the geri-chair. Both staff members did not identify themselves to the resident to R31 and/or, explain the care they would perform, during the interaction. R31 yelled out while staff performed cares. Once staff completed the transfer they attempted to de-escalate the resident. R31 was agitated, unable to sit still, and was yelling out. In an interview on 11/13/24 at 04:48 AM, Administrative Nurse A stated she expected staff to communicate with residents even if the resident could not effectively communicate with staff during cares being performed. The facility's Right to Dignity policy, dated 02/2024, documented that staff will refrain from failing to focus on the elder as an individual when talking with the elder or failing to address the elder as an individual during care and services. The facility failed to protect R31's dignity when staff provided care without explaining the procedure. This deficient practice had the potential to lead to negative psychosocial effects related to dignity.

The facility census totaled 36 residents, with 12 residents included in the sample. Based on observation, interview, and record review, the facility failed to identify a fall, investigate causal factors, and implement fall prevention interventions for Resident (R)6 to prevent further falls. Findings included: - Review of the Electronic Health Record (EHR) for Resident (R)6 included the following diagnoses: lack of coordination, morbid (severe) obesity (excessive body fat), hemiplegia (muscular weakness of one half of the body), hemiparesis (paralysis of one side of the body), cerebrovascular disease (conditions that affect the blood vessels in the brain and spinal cord can), hypertension (elevated blood pressure), and lymphedema (swelling caused by accumulation of lymph). The Significant Change Minimum Data Set (MDS) dated [DATE], documented R6 had a Brief Interview for Mental Status (BIMS) assessment score of 13, indicating intact cognition. The assessment documented R6 required substantial or maximum assistance from staff for transfers, and noted R6 was dependent on staff to perform other cares. The MDS indicated R6 had no falls during the documented review period. The Quarterly MDS dated [DATE], documented a BIMS of 13, which indicated intact cognition. The MDS indicated R6 had no falls during the documented review period. The Falls Care Area Assessment (CAA) dated 07/07/24, documented R6 had a fall risk, but lacked documentation noting R6 had any falls. The resident's Care Plan lacked an intervention for the fall dated 06/25/24. The Progress Note dated 06/25/24 at 07:15 PM indicated that the nurse was requested to go to the shower room to perform a skin assessment. The nurse needed more treatment supplies and exited the shower room. Upon the nurse's reentry into the shower room, the staff successfully assisted R6 in standing for the second time. The resident could not maintain her standing position during the wound treatment and attempted to sit down without the wheelchair positioned behind her. Staff assisted R6 to the floor while waiting for more staff to assist with the transfer. (The facility failed to document this as a fall or initiate their fall policy related to this documentation.) Review of the facility Fall Investigation for R6 lacked documentation related to a fall on 06/25/24. The Progress Note dated 06/26/24 at 09:00 AM revealed that R6 complained of right foot pain and difficulty bearing weight on it. The staff notified the resident's provider, who ordered an X-ray. The review of Physician Extender Summary dated 06/27/24 at 04:20 PM revealed that during a transfer to the shower two days prior, it was believed that R6's right lower leg was caught in the chair. An X-ray was performed and revealed a non-displaced distal tibia fracture of the lower end of the right tibia. Observation on 11/14/24 at 09:00 AM, revealed R6 sitting in her wheelchair playing on her tablet alone in her room, with her right arm in a sling. The resident lacked a boot on her right foot. Observation on 11/14/24 at 08:19 AM, revealed Certified Medication Aide (CMA) CMA S assisted R6 with a pivot transfer to the bathroom with one assist and resident was able to tolerate transfer comfortably without complaints of pain and able to bear own weight. On 11/18/24 at 08:30 AM, Certified Nurse Aide (CNA) P stated a fall would be defined as any time a resident's body contacts the floor. CNA P stated she did not think R6's care plan had undergone any change for the last seven months of her employment. CNA P knew of care plan changes either by the Point Click Care (POC) banner when logging in to chart or verbally when starting the shift during report from the previous shift. On 11/18/24 at 09:23 AM, Licensed Nurse (LN) M stated a fall would be defined as anytime a resident unintentionally went from a higher surface to a lower surface. LN M stated R6 had one fall that she knew, in October, which resulted in no injury. LN M stated immediately at that time she put the intervention in place for R6 to wait for help before transferring herself. On 11/18/24 at 10:34 AM, Administrative Staff A stated when any resident unintentionally went from a higher surface to a lower surface would be considered a fall. Administrative Staff A stated even when a resident had to be assisted to the floor by staff the facility classified that instance as an assisted fall. Administrative Staff A stated that the facility required any assisted fall to be recorded as a fall. Review of facility's Fall Follow-Up Protocol dated February 2024 documented: A fall refers to an incident where a resident, without intention, fails to maintain their balance and descends to a lower level. This definition encompasses situations where the resident would have fallen if not for the timely intervention of care partners. This definition stands regardless of whether the resident sustains an injury or not. The facility failed to identify a fall, investigate causal factors, and implement fall prevention interventions for R6 to prevent further falls. This deficient practice had the potential to negatively affect R6's physical well-being related to the ongoing risk of falls.

The facility reported a census of 38 residents. Based on observation, interview, and record review, the facility failed to provide sanitary food preparation, storage and serving to prevent the spread of food borne illness to the residents of the facility. Findings included: - Initial environmental tour of the kitchen, on 01/30/23 at 12:30 PM with Dietary Staff BB, revealed the following items/areas of concerns: 1. Five cutting boards identified, four cutting boards with deep cuts in the surface. One cutting board had flakes of the surface that came off during use. 2. A slotted dish cart next to the steam table was full of dishes all right-side-up, identified by Dietary Staff BB as clean and ready to use. The top dishes contained debris of unknown composition. Upon inspection and verification, dietary BB removed the dirty dishes. On 01/30/23 at 12:35 PM, a free-standing refrigerator inspection with Dietary Staff BB revealed the following concerns: 1. A large plastic bag of corned beef, unsealed. 2. A large plastic bag of shredded cheese, unsealed. 3. A large container of chopped lettuce lacked the date of preparation or the expiration date. 4. A large container of sweet & sour sauce with an open date of 07/09/22. Dietary Staff BB reported products stored in the manufacturer's packaging could be utilized for six months beyond the open date (01/09/23). 5. A large container of maraschino cherries, open and undated. 6. A large tub of sour cream, open and undated. 7. A large container of Honey Mustard salad dressing, open and undated. 8. A large container of mayonnaise, open and undated. On 01/30/23 at 12:40 PM, a free- standing freezer inspection with Dietary Staff BB revealed the following concerns: 1. A large bag of frozen churros, resealed and undated. 2. Two large boxes of frozen small chocolate [NAME] cakes, open and undated. 3. A large box of frozen breakfast sausage patties, open and undated. On 01/30/23 at 12:50 PM, a walk-in freezer inspection with Dietary Staff BB revealed the following concern: 1. A large bag of frozen corn, open and unsealed. In addition, observation of the main kitchen on 01/31/23 at 11:28 AM with Dietary Staff BB, revealed the following concerns: 1. Dietary Staff CC placed utensils utilized for food service on the counter of the steam table and lacked a barrier. 2. Dietary Staff BB identified several dishes in a slotted dish cart with dried food and unidentified debris on the eating surfaces. 3. Dietary Staff DD placed three bins of pureed food into the warmer without lids or coverings on the pans. 4. Dietary Staff BB identified two trays full of prepared food in the warmer that lacked a covering. On 01/31/23 at 03:55 PM, Dietary Staff CC observed to place utensils utilized for food service on the counter of a steam table and lacked any type of barrier. On 01/31/23 at 04:00 PM, Dietary Staff BB stated that all items in the warming cabinet should be covered. Further, utensils used for food service at steam table should be placed inside the pan with the food, or off to the side on a plate or tray. The undated facility's policy for Food Preparation and Handling revealed all opened food items would be labeled with expiration and use-by dates, and any items beyond the use-by date will be discarded. Further documented all foods served were to be handled with clean utensils. Additionally, cutting boards with broken areas will be discarded immediately. The facility failed to store, prepare, and serve food under sanitary conditions for the residents in the facility. This created the potential for the spread of food borne illnesses to the residents of the facility.

The facility reported a census of 38 residents with 12 sampled, including three reviewed for Medicare Services. Based on interview and record review, the facility failed to provide the appropriate Notice of Medicare Non-Coverage (NOMNC- informs the beneficiaries of the right to an expedited review by a Quality Improvement Organization), form Center for Medicare/Medicaid Services (CMS)-10123, to all Medicare beneficiaries at least two days before the end of the Medicare covered Part A stay or when all of Part B therapies were ending for the three Residents (R)10, R139, and R140 reviewed. Findings included: - Review of Resident (R)10's medical record, provided by the facility, revealed the resident's Medicare services were to end on 10/13/22. However, the facility failed to produce a signed NOMNC for R10. Review of R139's medical record, provided by the facility, revealed Medicare services were to end on 10/27/22. However, the facility failed to provide a signed NOMNC for R139. Review of R140's medical record, provided by the facility, revealed Medicare services were to end on 08/03/22. However, the facility failed to provide a signed NOMNC for R140. On 01/31/23 at 09:13 AM, Administrative Nurse E stated the CMS-10053 form, as she had been instructed, was the only form used by the facility. The facility's 07/2021 Medicare Denial Notices (Advance Benefit Notification-ABN) policy documented that staff were to issue a SNFABN from 10055 at least two days prior to the end of a Medicare covered Part A stay. The policy lacked mention of the NOMNC form 10123. The facility failed to provide appropriate Beneficiary Protection Notification forms for the three residents reviewed to ensure the residents' right to appeal upon discontinuation of services.

The facility reported a census of 38 residents with 12 residents selected for review, that included six residents reviewed for unnecessary medications. Based on observation, interview and record review, the facility failed to ensure one of the six residents, Resident (R) 25, regarding monitoring for extrapyramidal (abnormal involuntary body movements caused by medications) symptoms and for R6, regarding as needed (PRN) psychotropic medication stop date and monitoring behaviors. Findings included: - The electronic clinical record for Resident (R) 6 documented diagnoses of hypertensive heart disease with heart failure (a chronic condition where high blood pressure has weakened the heart), cerebral infarction (a condition where part of the brain has died from lack of oxygen and/or blood flow), anxiety (a chronic feeling of tension and worried thoughts) and encephalopathy (damage or disease that affects brain function). Review of Resident (R)6's Significant Change Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) of five, indicating severely impaired cognition. Hallucinations (sensing things while awake that appear to be real, but the mind created) were present. Review of [DATE] Delirium Care Area Assessment (CAA), documented R6 had signs and symptoms of delirium (a mental state of anxiety, disorientation, hallucinations, delusions and incoherent speech). The pharmacist was to review R6's medications per facility protocol. Review of care plan dated [DATE] instructed staff to consult with the pharmacist and for physician to consider a dose reduction as needed and at least quarterly. The physician's orders dated [DATE], documented Ativan (lorazepam is a psychotropic medication that affects brain activities associated with mental processes and behavior)) 0.5milligrams (mg) to be given every four hours as needed (PRN) for anxiety/restlessness. The order lacked a 14 day stop date or an evaluation/ justification statement for long-term use. Review of the medication administration record (MAR) from [DATE] to [DATE], R6 received Ativan PRN on 59 occasions. Review of R6's Electronic Health Record (EHR) scanned documents or progress notes lacked documentation from the resident's physician regarding a stop date 14 days from initiation or a justification to continue the medication beyond the initial 14-day period. On [DATE] at 03:23 PM, Licensed Nurse (LN) I, reported she was unable to provide documentation related to the physician's evaluation/ justification for PRN medication order to extend over 14 days. On [DATE] at 12:02 PM, Administrative Nurse D stated that her understanding was an order for PRN psychotropic medications that came from hospice provider could be open-ended without a stop date. Furthermore, she was unaware of the requirement for a physician evaluation/justification to extend PRN medication order for longer than 14 days. The ,d+[DATE] facility policy Psychotropic Medication Use documented that antianxiety medications that have a PRN order must include a 14 day stop date .except if the physician believed it was appropriate to extend beyond the 14 days, however such rational must be documented in the resident's medical record. The facility failed to identify possible irregularities for this resident who received an anti-anxiety medication beyond 14 days after the physician ordered the medication without an evaluation/rationale by the resident's physician. The facility failed to monitor this resident's behavior. This placed the resident at risk for receiving unnecessary medications. 31078 - Resident (R) 25's signed physician orders, dated [DATE] revealed the following diagnoses that included anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), dementia (progressive mental disorder characterized by failing memory, confusion), with psychotic disturbance (any major mental disorder characterized by a gross impairment testing). The Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of five, indicating severe cognitive impairment. The resident required supervision and assist of one staff for his dressing and toileting. The resident received scheduled pain medication with pain controlled. The resident had no psychotropic drugs used. The Annual MDS dated [DATE], revealed a BIMS score of four indicating severe cognitive impairment. The resident had hallucinations (sensing things while awake that appear to be real, but the mind created) and delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue). The resident rejected care on ,d+[DATE] days. The resident received scheduled pain medication with pain controlled. The resident received antidepressant and diuretic medications taken daily during the 7-day observation period. The Cognitive loss/dementia Care Area Assessment (CAA) dated [DATE] revealed the resident had signs of cognitive decline. The Behavioral symptoms CAA revealed the resident had behaviors and was at risk for undiagnosed infections process that resulted in increased confusion, anxiety, falls, and injuries related to poor safety awareness. The pharmacist to review the resident's medications per facility protocol. The Psychotropic drug use CAA revealed the resident received Psychotropic (medication that affects behavior, mood, thoughts, or perception) medications. The resident had an increased risk for adverse reactions due to use of high-risk medications. Monitor him for effectiveness and side effects of the medication. The pharmacy consultant to review the resident's medication monthly. The Care Plan dated [DATE] revealed staff should monitor the resident's behavior related to his medications of Zoloft. Staff were to administer the medications as ordered and monitor/document for side effects and effectiveness. The resident had behaviors of hallucination and wandering. He believed bugs were in his ears and legs. The resident hoarded Kleenex tissues in his pants, would make maps out of objects and would urinate in his cups and in the sink. The Physician orders included the following: 1. Sertraline HCl (antidepressant medication), 100 milligrams (mg), daily in the morning, related to dementia with behavioral disturbances, ordered [DATE]. 2. Risperdal (antipsychotic medication) 0.5 mg, two times a day, for dementia with behavioral disturbances. The physician discontinued this medication on [DATE]. 3. Risperdal, 1.0 mg, twice a day, for dementia with behavioral disturbances, ordered [DATE]. Review of the [DATE] Medication Administration Record (MAR), revealed staff should monitor/document the resident's behavior for the Risperdal and Zoloft every shift, as ordered. Staff lacked behavior monitoring on 18 of 49 occasions. Review of the nursing note dated [DATE] revealed the physician visited with the resident. The resident continued to complain of bugs in his leg. The resident had behaviors of making inappropriate comments towards the female staff members as well as grabbing. On [DATE] at 11:45 AM, the resident sat in the dining room with another resident, visiting, without behaviors. On [DATE] at 12:04 PM, revealed the resident sat at a dining table and ate his lunch independently. He displayed no behaviors. On [DATE] at 2:20 PM, CNA N reported the resident did not have behaviors often. On [DATE] at 9:35 AM, LN H reported she was unaware why staff lacked behavior monitoring for the resident and verified there were multiple days and times staff lacked behavior monitoring. On [DATE] at 11:30 AM, Administrative Nurse D reported it was the responsibility of the nurse on duty to monitor the resident behaviors, and staff should monitor the resident's behavior daily. The facility's policy for Behavior Management in Dementia Care dated ,d+[DATE], revealed the purpose of dementia care in the facility was to provide a quality of life with respect, dignity and caring in a friendly, clean, and non-abusive atmosphere. The facility failed to ensure the resident was free of unnecessary medications by the failure to monitor behaviors every shift as ordered by the physician.

The facility reported a census of 38 residents with 12 residents selected for review, that included six residents reviewed for unnecessary medications and drug regimen review. Based on observation, interview and record review, the facility's consultant pharmacist failed to ensure one of the six residents, Resident (R)6, regarding as needed (PRN) psychotropic medication stop date. Findings included: - The electronic clinical record for Resident (R) 6 documented diagnoses of anxiety (a chronic feeling of tension and worried thoughts) and encephalopathy (damage or disease that affects brain function). The significant change Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) of five, indicating severely impaired cognition. Hallucinations (sensing things while awake that appear to be real, but the mind created) were present. Review of 10/04/22 Delirium Care Area Assessment (CAA), documented R6 had signs and symptoms of delirium (a mental state of anxiety, disorientation, hallucinations, delusions and incoherent speech). The physician's orders, dated 10/01/22, documented Ativan (lorazepam is a psychotropic medication that affects brain activities associated with mental processes and behavior)) 0.5milligrams (mg) to be given every four hours as needed (PRN) for anxiety/restlessness. The order lacked a 14 day stop date or an evaluation/ justification statement for long-term use. Review of the medication administration record (MAR) from 11/02/22 to 01/31/23, R6 received Ativan PRN on 59 occasions. Review of R6's Electronic Health Record (EHR) scanned documents or progress notes lacked documentation from the resident's physician regarding a stop date 14 days from initiation or a justification to continue the medication beyond the initial 14-day period. On 02/01/22 at 03:23 PM, Licensed Nurse (LN) I, reported she was unable to provide documentation related to the physician's evaluation/ justification for PRN medication order to extend over 14 days. On 02/02/23 at 12:02 PM, Administrative Nurse D stated that her understanding was an order for PRN psychotropic medications that came from hospice provider could be open-ended without a stop date. Furthermore, she was unaware of the requirement for a physician evaluation/justification to extend PRN medication order for longer than 14 days. On 02/02/23 at 12:05 PM, pharmacy consultant HH revealed it was an oversight on her part that she did not request a stop date for the medication or a physician certification statement to justify use longer than 14 days. The 06/2022 facility policy Psychotropic Medication Use documented that antianxiety medications that have a PRN order must include a 14 day stop date .except if the physician believed it was appropriate to extend beyond the 14 days, however such rational must be documented in the resident's medical record. The facility's consultant pharmacist failed to identify possible irregularities for this resident who received an anti-anxiety medication beyond 14 days after the physician ordered the medication without an evaluation/rationale by the resident's physician. This placed the resident at risk for receiving unnecessary medications.

The facility census totaled 38 residents with 12 residents sampled, that included six residents sampled for unnecessary medications. Based on observation, interview, and record review, the facility failed to follow physician orders in a timely manner for Resident (R) 8. This failure placed the resident at risk for adverse effects related to medication use. Findings included: - R8's diagnoses from the Electronic Health Record (EHR) included Alzheimer's Disease (progressive mental deterioration characterized by confusion and memory failure), anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, and emptiness). The 02/23/22 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of two, indicating severe cognitive impairment. R8 received an antidepressant (class of medications used to treat mood disorders and relieve symptoms of depression) and an opioid (class of medication used to treat pain) daily in the seven day look back period. The 11/22/22 Quarterly MDS documented a BIMS of three indicating severe cognitive impairment. R8 received an antidepressant daily in the seven day look back period. The 11/29/22 Care Plan documented staff were to administer R8's medications as ordered and listed specific behaviors to monitor for. Review of the Progress Notes dated 01/19/23, documented a visit from the resident's provider with new orders to change the supplement to mid-morning and mid-afternoon and not offer at mealtime, and to start Mirtazapine (an antidepressant medication) for depression and weight loss, and to discontinue Lexapro (an antidepressant medication). The Electronic Health Record (EHR) documented as of 01/31/23, an order for the Lexapro (discontinued on 01/19/23) remained on the medication administration record (MAR) and lacked an order for Mirtazapine (ordered on 01/19/23, a total of 12 days.) On 02/01/23 at 07:55 AM, R8 sat in her wheelchair in the common area. R8 was awake and watching the TV. On 02/02/23 at 11:04 AM, Certified Medication Aide (CMA) R reported R8 took her medications and CMA R followed the MAR. On 02/02/23 at 08:05 AM, Licensed Nurse (LN) I revealed a facility nurse would be with the physician in the family dining room, and that nurse would take notes and orders and was responsible to process the orders. On 02/02/23 at 08:40 AM, LN G revealed on physician visit days, the staff take the residents into the family dining room, where the physician is set up, for their visits. The LN, accompanies the physician, would take new physician orders and was responsible to process the new orders. LN G confirmed she would not be one of the nurses to complete this task. On 02/02/23 at 10:46 AM, Administrative Nurse D revealed she expected staff nurse to process all orders from a physician visit in a timely manner. The facilities 01/2023 Prescribing/Ordering-General Practices policy documented the nurse on duty at the time the physician order received would enter it on the electronic physician order sheet, the electronic medication order form, and note the order. The facility failed to ensure physician orders were followed for R8 for a total of 12 days. This failure placed the resident at risk for adverse effects related to medication use.

The facility reported a census of 38 residents, with 12 residents included in the sample, including two residents sampled for respiratory services. Based on observation, interview, and record review, the facility failed to provide necessary respiratory care and services for one Resident (R) 5, who required physician ordered oxygen (O2) and nebulizer inhalation treatments. Findings included: - Resident (R) 5's signed physician orders, dated 12/27/22 revealed the following diagnoses that included acute respiratory failure (difficulty to breathe) and chronic obstructive pulmonary disease (COPD - progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). The Significant change in status Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 04, indicating severe cognitive impairment. The resident required extensive assist with daily care. The resident used oxygen (O2). The Cognitive loss/dementia Care Area Assessment (CAA) dated 12/29/22, revealed the resident had signs of cognitive decline. The resident planned to remain in the facility for hospice services due to heart failure and COPD, The Care Plan dated 06/09/20 revealed the resident had COPD and acute respiratory failure with hypoxia (inadequate supply of oxygen). Staff were to monitor for difficulty breathing (dyspnea) on exertion. Remind the resident not to push beyond his endurance. Monitor for signs of acute respiratory insufficiency such as anxiety, confusion, restlessness, shortness of breath at rest, and cyanosis (bluish tint to skin). Monitor/document/report any signs of respiratory infection such as fever, chills, increase in sputum (A mixture of saliva and mucus produced by the lungs because of viral or bacterial infections) and document the amount, color, and consistency, chest pain, increased difficulty breathing (dyspnea), increased coughing and wheezing. Oxygen setting was for the resident to use O2 via nasal cannula at 2liters/minute to keep 02 saturations above 90 percent (%). The Physician's order dated 05/28/20 revealed O2 via nasal cannula at 2 liters/minute to keep 02 saturations above 90%. The tubing and nasal cannula to be changed every two weeks. The date must be on the humidifier tubing and the cannula. The nebulizer to be in a dated plastic bag at the resident's bedside. Ipratropium- Albuterol 0.5- 2.5 mg 1 vial inhale three times a day for COPD. Observation on 01/31/23 at 11:06 AM, revealed the resident was in bed. The oxygen tubing or cannula along with the nebulizer tubing lacked a date when staff changed them. On 02/01/23 at 08:48 AM, Certified Nursing Assistant (CNA) N reported the resident always wore O2. On 02/02/22 at 09:40 AM, Licensed Nurse G reported she thought the O2 tubing, and nebulizer were to be changed on the night shift. She reported she had not changed it. On 02/02/23 at 11:30 AM, Administrative Nurse D reported the oxygen and nebulizer tubing's were scheduled to be changed on the night shift. The facility policy for Administration of Oxygen dated 11/22, revealed nursing was to change the tubing, nasal cannula, and nebulizer equipment bi-weekly. The nebulizer equipment was to be kept in a dated plastic bag at the bedside when not used. The facility failed to provide necessary respiratory care and services on one resident who required physician ordered oxygen and nebulizer treatments.

The facility census totaled 38 residents with 12 in the sample that included three residents for accident hazards. Based on observation, interview, and record review, the facility failed to ensure the fall prevention interventions implemented to prevent further falls for Resident (R) 8. Findings included: - R8's diagnoses from the Electronic Health Record (EHR) documented: Alzheimer's Disease (progressive mental deterioration characterized by confusion and memory failure), anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and chronic pain. The 02/23/22 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of two, indicating severe cognitive impairment. R8 had no falls since prior assessment. The 11/22/22 Quarterly MDS documented a BIMS of three indicating severe cognitive impairment. R8 had one non-injury fall since prior assessment. The 11/29/22 Care Plan documented R8 was at risk for injuries related to multiple falls and lacked an updated intervention related to the fall experienced by R8 on 12/06/22. Review of the Fall Investigations and Nurse Notes dated 12/06/22 documented R8 fell with no injuries noted. The immediate intervention was that R8's primary care physician would review her medications and they would move R8 to the family room for supervision. On 01/31/23 at 01:19 PM, R8 laid in bed with her eyes closed. The bed was in a low position and a fall mat next to the bed. On 02/02/23 at 11:04 AM, Certified Medication Aide (CMA) R reported the resident had falls but had not received any injuries. CMA R stated the low bed and fall mat were interventions from falls. On 02/01/23 at 02:28 PM, Administrative Nurse D revealed she expected staff to implement a new intervention following a fall. She confirmed that for R8's 12/06/22 fall, the intervention had not been followed up on and that there was no other intervention put in place. The facilities 12/2022 Fall Follow-Up Protocol policy documented staff were to document on the care plan with interventions to prevent further falls based on the determined causal factor at the time of the initial fall follow-up. The facility failed to implement interventions after this resident fell on [DATE], to prevent further possible falls.

The facility reported a census of 38 residents with 12 residents included in the sample. The sample included one resident sampled for Activity of daily living (ADL) cares for dependent residents. Based on observation, interview, and record review, the facility failed to change gloves to provide a sanitary environment while performing peri care to one Resident (R) 5, following his bowel movement. Findings included: - R5's signed physician orders dated 01/19/23 revealed the following diagnoses: chronic obstructive pulmonary disease ([COPD]a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), malignant neoplasm of bone (the tendency of a medical condition, especially tumors, to become progressively worse, most familiar as a characteristic of cancer), personal history of malignant neoplasm of prostate, personal history of malignant neoplasm of the thyroid, and vascular dementia (progressive mental disorder characterized by failing memory, confusion). The Significant change in status Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 04, indicating severe cognitive impairment. The resident required extensive assistance with his daily care including toileting and incontinent care. The Care Area Assessment (CAA) dated 12/29/22 revealed: No care issues triggered for further investigation. The Care Plan dated 06/09/2020, revealed the resident required assistance with his ADL's. The resident required total assist of two staff for toilet use. The resident was incontinent of bowel and bladder. The resident wore a brief for incontinence and clothing protection. Observation on 02/01/23 at 08:39 AM, revealed the resident remained in his bed for breakfast. Following the meal, certified nursing assistant (CNA) N donned gloves and removed the resident's bed covers to check the resident's incontinence brief. The resident's brief soiled with feces (BM) and urine. CNA N removed the soiled brief and cleansed the resident's perineal area with disposable wet wipes. CNA N applied a clean brief with the same gloves used to clean the BM. Staff failed to remove the dirty gloves. CNA N placed an incontinent pad under the resident, then placed a foot cradle under the resident's lower legs, and covered the resident up, all with the same soiled gloves. On 02/01/23 at 08:48 AM, CNA N verified she wore the same gloves during the incontinent care and aftercare and did not remove her gloves unless the gloves were visibly soiled. On 02/01/23 at 09:40 AM Licensed Nurse (LN) G reported staff should change their gloves whenever going from dirty to clean, to avoid cross contamination. On 02/02/22 at 11:30 AM, Administrative Nurse D reported she expected all staff to change their gloves during care when going from dirty to clean, even if the gloves were not visibly soiled. Review of the Facility's Policy Perineal Care Protocol dated 11/22 revealed perineal care will be provided every shift and as needed based on elders individualized needs. Wash hands and don gloves. Remove soiled brief and place in closable plastic bag. Do not touch anything with soiled gloves after procedure (curtain, bed rails, clean linen or call bell). The facility failed to change gloves to provide a sanitary environment while performing peri care to one resident following his bowel movement.

The facility census totaled 38 residents with 12 in the sample. Based on observation, interview, and record review, the facility failed to review and revise the care plans for two residents, Resident (R) 8 related to fall prevention interventions and R35, related to DNR (do not resuscitate- or no code, a written legal order to withhold cardiopulmonary resuscitation [CPR], in respect of the wishes of a person in case their heart stopped or they stopped breathing). Findings included: - R8's diagnoses from the Electronic Health Record (EHR) documented diagnoses that included Alzheimer's Disease (progressive mental deterioration characterized by confusion and memory failure), anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and chronic pain. The [DATE] Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of two, indicating severe cognitive impairment. R8 had no falls since prior assessment. The [DATE] Quarterly MDS documented a BIMS of three indicating severe cognitive impairment. R8 had one non-injury fall since prior assessment. The [DATE] Care Plan documented R8 was at risk for injuries related to multiple falls and lacked an updated intervention related to the fall experienced by R8 on [DATE]. Review of the Fall Investigations and Nurse Notes dated [DATE] documented R8 fell with no injuries noted. The immediate intervention was that R8's primary care physician would review her medications and they would move R8 to the family room for supervision. On [DATE] at 01:19 PM, R8 laid in bed with her eyes closed. The bed was in a low position and a fall mat next to the bed. On [DATE] at 11:04 AM, Certified Medication Aide (CMA) R reported the resident had falls but had not received any injuries. CMA R stated the care plan should guide staff how to care for the resident. On [DATE] at 02:28 PM, Administrative Nurse D revealed she expected the care plan to be updated whenever there was an incident and staff should follow the interventions on the care plan. She confirmed R8's fall on [DATE] lacked an intervention to prevent further falls. On [DATE] at 09:55 AM, Administrative Nurse E revealed that staff should change/revise the care plan after information obtained during the morning meetings. All the nurses, social services, and administration staff could change the resident's care plans. The facilities ,d+[DATE] Fall Follow-Up Protocol policy, documented staff were to document on the care plan with interventions to prevent further falls based on the determined causal factor at the time of the initial fall follow-up. The facility failed to revise the care plan with interventions after this resident fell on [DATE], to prevent further possible falls. 46960 - Review of Resident (R) 35's admission Minimum Data Set (MDS), dated [DATE], documented a brief interview for mental status (BIMS) of 12, indicating moderately impaired cognition. Review of the Care Area Assessment (CAA) dated [DATE], lacked documentation related to end of life cares. Review of the care plan dated [DATE], documented R35 to be Full code (CPR-a technique of basic life support for the purpose of oxygenating the brain and heart until appropriate medical treatment can restore normal heart and ventilation action.) This included interventions that instructed staff to initiate CPR, notify family, and call 911 if the resident's heartbeat and respirations ceased. The Physician's orders included an order for Do not Resuscitate ( (DNR or no code] a written legal order to withhold cardiopulmonary resuscitation in respect of the wishes of a person in case their heart stopped or they stopped breathing), dated [DATE]. Review of the resident's scanned documents revealed the physician and the resident signed the DNR order on [DATE]. On [DATE] at 02:50 PM, Licensed Nurse (LN) B stated that R35 was a DNR. On [DATE] at 09:55 AM, Administrative Nurse E verified the resident's care plan documented a full code status and reported the resident had an order for a DNR. She stated she failed to update the care plan to reflect the resident's current order of a DNR. On [DATE] at 11:46 AM, Administrative Nurse D revealed the expectation was for staff to revise the resident's care plan related to the code status. The ,d+[DATE] facility's policy for Coordination and Completion of RAI process documented that if conflicting information is recorded, the MDS coordinator is responsible for negotiating with the team to ensure accuracy of the information. Furthermore, care plans will be updated at the time of the conference or on the shift immediately following the conference. The facility failed to review and revise this resident's wishes on the resident's care plan regarding his code status. This placed the resident at risk for receiving medical procedures that he did not want.

The facility reported a census of 38 residents, with 12 sampled. Based on interview and record review, the facility failed to complete an accurate comprehensive assessment for one of the resident's sampled that included Resident (R) 35 regarding wounds present on admission to the facility. Findings included: - Review of the admissions Minimum Data Set (MDS), dated [DATE], documented R35 had zero venous and arterial ulcers (a condition in which wounds develop on the lower legs because of problems with blood circulation) present at admission to the facility. Review of 12/26/22 Pressure Ulcer/Injury Care Area Assessment (CAA), documented contributing physician diagnoses which included the resident's chronic leg venous stasis wounds. Review of the care plan dated 01/02/03 documented interventions for staff to perform wound care for chronic venous stasis wounds. The Physician's orders, dated 01/25/23, included instructions for the wound care for the resident's venous stasis ulcers. Review of Electronic Health Record (EHR) Progress Notes and assessments revealed entries that documented wounds to R35's lower legs. On 01/31/23 at 04:45 PM, a family member revealed R35 admitted to the facility with venous stasis ulcers on both lower legs. On 02/01/23 at 01:29 PM, Certified Nurse Aide (CNA) M revealed that the resident had wounds on the resident's legs were present on admission. On 02/01/23 at 02:00 PM, LN H revealed the resident had wounds on R35's legs present on admission. On 02/02/23 at 09:55 AM, Administrative Nurse E revealed information from MDS assessments obtained from staff assessments documented in the EHR. She verified she was aware of R35's wounds, and the wounds should be reflected in the MDS. On 02/02/23 at 11:46 AM, Administrative Nurse D revealed staff should accurately document information into the MDS. The facility used the Resident Assessment Instrument (RAI) manual for guidance in completing the MDS's. The facility failed to accurately code the MDS for this resident related to wounds.

The facility reported a census of 38 residents with 29 residents in the designated COVID-19 unit. Based on observation, interview, and record review the facility failed to protect all residents residing in the facility by having Licensed Nurse (LN) C with a positive COVID-19 test and symptoms of the illness work on the COVID-19 unit against the recommendation the County Health Department. The COVID-19 positive, symptomatic, LN who was in the commons area to perform documentation exposed other staff who were negative for COVID-19 to [MEDICAL CONDITION] in a commons area. All facility staff (including the COVID -19 LN) were screened for signs and symptoms of COVID-19 at the same designated area. The facility failed to ensure LN C remained in full personal protective equipment (PPE) during her shift.These failures allowed all facility staff to potentially come into contact with the symptomatic LN C, who was positive for COVID-19 . This placed all residents in the facility in immediate jeopardy. Findings included: - Review of the employee testing for COVID-19 completed on 10/08/20 revealed LN C had a positive COVID-19 test. Review of the e-mail sent to the facility from the Sedgwick County Health Department (SCHD) on 10/08/20 revealed: Because the facility was short-staffed, staff who have tested positive may work, however, we need to make sure that several provisions are made to protect the rest of your facility and the community. Positive staff who are working must be well enough to work; this means that they must not be symptomatic. Positive staff must always wear full PPE (Personal Protective Equipment); I sent you a link to apply for assistance with this if needed. Positive staff must remain isolated from staff who are not positive. They must remain in a separate area of the facility, caring for separate residents, using separate bathrooms and breakrooms, etc. Positive staff must care only for residents who have tested positive. Positive staff remain under isolation; they cannot go anywhere but work and home. I hope these provisions will allow your facility to maintain safe staffing levels and to protect those who are not ill. Review of the screening sheets utilized by the facility for all employees, families, visitors, and government officials titled Screening Checklist - COVID-19 revealed question #3 asked Do you have any of the following: and then listed the following signs and symptoms of COVID-19: fever, chills, malaise/fatigue, myalgia (muscle pain), headache, sore throat, diarrhea, new olfactory and taste disorders(loss of taste or smell), muscle and body aches, congestion or runny nose, nausea or vomiting, lower respiratory illness (cough, shortness of breath or difficulty breathing), and an area to mark YES or NO. The form then read IF YES CALL to Supervisor - DO NOT ENTER and a small paragraph: They may or may not have COVID-19, and the potential consequences to COVID-19 entering the building is serious enough to ask them to not enter even though they may not have it. Many populations outside of the elderly do not show any symptoms but are able to transmit [MEDICAL CONDITION] to others. Review of the screening sheets completed for all employees on duty for 10/13/20 revealed LN C documented having symptoms of a sore throat, myalgia, and a headache. Review of the screening sheets completed for all employees on duty for 10/14/20 revealed LN C documented having diarrhea, malaise, myalgia, and a headache. Review of the screening sheets completed for all employees on duty for 10/15/20 revealed LN C documented having diarrhea and myalgia. Review of the Nursing Schedule indicated LN C worked an eight-hour shift on all three days (10/13/20, 10/14/20, 10/15/20). The facility assigned LN C to care for residents on the designated COVID-19 unit. Observation on 10/15/20 at 01:00 PM revealed LN C sat at the nurses' station in the commons area between all three hallways (two closed hallways labeled as COVID-19 units and a third hall was closed and labeled for Non-COVID-19 residents). The dietary department, dining room, all the main offices, and therapy room also opened to the commons area. LN C had an N-95 rated mask on (particulate-filtering facepiece respirator that meets the U.S. National Institute for Occupational Safety and Health N95 classification of air filtration, meaning that it filters at least 95% of airborne particles) and no other PPE (gown, gloves, faceshield) as she worked on the computer at the nurses station. LN C had a plus sign on the side of her mask, which indicated she was COVID-19 positive. During an interview on 10/15/20 at 12:00 PM LN C reported she had tested positive on 10/08/20 which was why she had a plus sign drawn on her mask. She reported she was at the nurse's station in the common area because that was where her computer was, and she needed to do her charting. She stated she felt a little better today but was still sick. She said she had been having nausea, vomiting, diarrhea, and was very exhausted, but was not running a fever so the DON and administrator wanted her to work. LN C reported she worked the last 3 days. All staff used the same entrance in the front except the staff working the non-COVID-19 unit (which had a separate entrance, breakroom, and bathroom). During an interview on 10/15/20 at 02:29 PM Certified Nursing Assistant (CNA) D stated when she arrived at the facility for work she rang the doorbell; all staff were screened to include temperature and oxygen (O2) saturation. She put on a new mask, gown, goggles, and sanitized her hands. CNA D said she had been tested multiple times, had COVID-19, and was at home for 10 days in quarantine. CNA D stated she now only works on the COVID-19 positive unit and has not been on the non-positive unit. CNA D reported that before going into a resident's room staff must put on a surgical mask over their N95 mask and wear gloves. She stated there was hand sanitizer in each resident room and the staff use it before coming out of the resident room and washed their hands in a bathroom on the unit. She stated she was not aware of any other staff working at the facility who have symptoms of COVID-19. During an interview on 10/15/20 at 02:59 PM Housekeeping (HS) staff E stated when she arrived to the main entrance of the facility, she used hand sanitizer and would self-screen for COVID-19 signs or symptoms and take her temperature, O2 level, and put on an N95 mask. HS E said she only worked in the COVID-19 positive units and did not go to the non-positive unit. Before going into the positive unit hallway, she put on a gown and made sure she had her face shield on. HS E stated she had been tested about 20 times and had been negative. During an interview on 10/15/20 at 03:18 PM, LN F stated she came through the front entrance and filled out a screening form, checked her temperature and oxygen saturation. She then put on the N95 mask and a LN or certified medication aide (CMA) verified her form. Currently employees were tested on ce a week, but were tested twice a week, prior. LN F stated she had not tested positive for COVID-19. She stated that she worked only the COVID-19-positive units and the non-positive units had their own designated staff. She stated she worked at the same nurses' station as LN C, approximately 3 feet apart on separate computers. Before going to the unit, she will put on a gown. LN F stated that it used to be that if you tested positive you had to self-quarantine for 14 days, but since the outbreak if you are asymptomatic but positive you can work, but these staff still follow social distancing guidelines. During an interview on 10/15/20 at 1:30 PM Administrative Staff A reported LN C was allowed to work because she talked to the SCHD and was advised if LN C's symptoms were better, she could work because they had no other LN to take her shifts. She reported the staff member was sent home now. During an interview on 10/15/20 at 02:55 PM Administrative Nurse B reported she had talked to Consultant H at the SCHD about staffing and he had told her if LN C could work with COVID-19 positive residents. The SCHD called the nurse daily for updates and knew LN C was at work. During an interview on 10/15/20 at 03:08 PM Consultant H revealed that he had spoken to the facility and he had advised them that asymptomatic COVID-19 staff could return early, but they had to be asymptomatic. He reported the facility had said they were severely short staffed and that is why staff could return when they were asymptomatic. He reported that LN C should not have been the LN on duty due to her symptoms. During an interview on 10/15/20 at 04:30 PM Administrative Nurse G stated she came into the back entrance and took temperatures, O2, and filled out the screening tool. She then put on an N95 and used hand sanitizer prior to entering the main facility. Administrative Nurse G statedshe has been tested multiple times for COVID-19 and has been negative. There are designated staff available to work the non-COVID-19 unit that must test negative or have already completed their 10-day quarantine and do not currently have symptoms. She stated that SCHD said any staff who are positive, if the staff felt like they were feeling better, were able to work, and did not have any fever for 24 hours they could come back to work on all units. Review of the 10/20 (Facility) Guidance On When Staff Can Return to Work policy revealed this policy was pertinent to staff with confirmed COVID-19 (including symptoms of respiratory infection cough, sore throat, shortness of breath, fever). Staff must call the Infection Control Nurse (ICN) and/or Director of Nursing (DON) to see if they qualify to return to work. The ICN/DON screened the staff member for any signs/symptoms of respiratory illness and return to work criteria for staff with confirmed COVID-19. Staff would be excluded from work until the resolution of fever without the use of fever-reducing medications and improvement in respiratory symptoms (e.g., cough, shortness of breath) and for staff who tested positive, asymptomatic and without fever, may return to work, if needed, on a COVID-19 dedicated hall to care for elders who have also tested positive. In the event of severe staffing shortages COVID-19 positive staff may be allowed to work if shortages continued despite other mitigation strategies, implementing criteria to allow staff with suspected or confirmed COVID-19 who are well enough and willing to work but have not met all return to work criteria to work. If staff can work before meeting all criteria, they should be restricted from contact with severely immunocompromised patients (e.g., transplant, hematology-oncology) and facilities should consider prioritizing their duties. The facility allowed staff with suspected or confirmed COVID-19 to perform job duties where they do not interact with others (e.g., patients or other staff), such as in telemedicine services. Allow staff with confirmed COVID-19 to provide direct care only for patients with confirmed COVID-19, preferably in a cohort setting. As a last resort, allow staff with confirmed COVID-19 to provide direct care for patients without suspected or confirmed COVID-19. The facility failed to protect all residents residing in the facility by having a LN with a positive COVID-19 test and symptoms of the illness to work on the COVID-19 unit and perform other duties in the common area shared with other staff members without full PPE as directed by the local health department. The facility presented an acceptable plan of removal of the immediate jeopardy on 10/16/20 at 12:16 PM which included staff members entering each distinct unit using different doors. The screening forms would be reviewed by the LN staff prior to allowing staff to enter the facility and document any findings on the back of the form. LN staff were advised if there were questions or concerns regarding an answer, they were to contact the infection preventionist. However, LN staff were instructed to send any staff member home that indicated signs or symptoms of COVID-19. The deficient practice remained at a scope and severity of an F

The facility had a census of 44 residents with 12 included in the sample. Based on observation, interview, and record review the facility failed to ensure the sanitary use of an indwelling urinary catheter by allowing a resident's catheter drainage bag to lay on the floor with nothing underneath to prevent contamination of the bag. This affected one Resident (R) 25 reviewed for the use of an indwelling catheter. Findings included: - Review of R25's signed physician orders dated 09/11/19 revealed a [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14 indicating intact cognition. The resident had an indwelling urinary catheter in place. Review of the Urinary Catheter Care Area Assessment (CAA) dated 03/19/19 revealed the resident required extensive assistance with toilet use. Review of the Care Plan dated 09/19/18 revealed the following interventions: The resident had an indwelling suprapubic catheter related to [MEDICAL CONDITION] bladder. The resident's catheter bag would always be covered and off of the floor. Staff would maintain the catheter bag below the level of the bladder. An observation of R25 on 11/14/19 at 01:22 PM revealed the resident in bed with the indwelling catheter drainage bag laying on the bare floor. An observation on 11/14/19 at 02:40 PM revealed the resident in bed with the indwelling catheter drainage bag in a privacy bag and laying on the bare floor. An observation on 11/18/19 at 08:27 AM revealed the resident in bed with the indwelling catheter drainage bag in a privacy bag and laying on the bare floor. An observation on 11/18/19 at 02:01 PM revealed the resident in bed with the indwelling catheter drainage bag in a privacy bag and laying on the bare floor. During an interview on 11/18/19 at 02:45 PM Certified Nurse Aide (CNA) C reported R25 liked to put himself to bed and did not wait on staff to assist him so the catheter bag lay on the floor, but staff would put the catheter bag on the bed when they checked on him. During an interview on 11/18/19 at 02:58 PM Licensed Nurse (LN) D reported the resident's catheter should be off the floor. LN D stated she would talk to Administrative Nurse B and figure out the facility could make sure the resident's catheter bag did not sit on the floor and still flowed below his bladder with his bed in the lowest position. During an interview on 11/18/19 at 03:13 PM Administrative Nurse B reported she would re-educate facility staff regarding catheter care, the resident's urinary catheter bag being attached to the bed frame, and for staff to keep the resident's privacy bag and catheter bag off the floor. The facility Communication Book and Kardex (CNA care plan) would be updated with current information. Review of the facility policy Catheter Care - Routine dated 02/2017 revealed the Foley drainage bag would be covered with a catheter drainage bag dignity cover and the cover would be changed daily or when soiled. Staff would maintain the position of the drainage bag below the level of the resident's bladder. The facility failed to ensure the sanitary use of an indwelling urinary catheter by allowing R25's catheter drainage bag to lay on the floor with nothing underneath to prevent contamination of the bag.

The facility census totaled 44 residents with 12 included in the sample. Based on observation, interview, and record review the facility failed to remove two expired pain medications from a refrigerator in one medication room reviewed for expired medications. Findings included: - Observation of the facility medication storage room on 11/18/19 at 07:59 AM revealed two packages of pain medication suppositories with an expiration date of 04/06/19. An interview on 11/19/19 at 08:35 AM with Licensed Nurse (LN) A revealed the director of nursing checked for expired medication on a monthly basis. An interview on 11/19/19 at 09:30 AM with Administration Nurse B revealed one person checked the medication room monthly for expired medications and placed any expired medications in a box for the pharmacy to destroy. Review of the Medication Storage policy dated 10/2014 revealed refrigerated medications were kept in closed and labeled containers. Outdated, contaminated, or deteriorated medications and those in containers that were cracked, soiled, or without secure closures were immediately removed from stock, and disposed of according to procedures for medication disposal. Medication storage conditions were monitored on a monthly basis The facility failed to remove two expired pain medications from a refrigerator in one medication room reviewed for expired medications.

The facility reported a census of 42 residents with 18 in the sample. Based on observations, interviews, and record review the facility failed to thoroughly assess a resident with known decline in urinary incontinence resulting in the failure to maintain or improve continence status for resident #27. The facility also failed to ensure medical justification for an indwelling urinary catheter which resulted in complications from the catheter for resident #55, a closed record. Findings included: - Review of resident #55's signed physician orders dated 7/7/14 revealed he/she had the following Diagnoses: [REDACTED]. of the body), and a UTI (urinary tract infection). Review of the admission MDS (minimum data set) dated 5/13/14 revealed a BIMS (brief interview for mental status) score of 14, indicating no cognitive impairment. The resident required extensive assistance of 2 or more staff for transfers and toileting. The resident had an indwelling urinary catheter (insertion of a catheter into the bladder to drain the urine into a collection bag). The resident admitted on [DATE]. Review of resident #55 ' s Urinary Incontinence/Indwelling Catheter CAA (care area assessment) dated 5/19/14 revealed the resident had a Foley catheter (the most common type of indwelling urinary catheter) in place for efficient elimination of urine. He/she had a Foley catheter in place while in the hospital, but the physician discontinued the Foley catheter on the day he/she was transferred to the facility. Resident #55 had an inability to void efficient quantities, but had the urge to void frequently. He/she had a large amount of [MEDICAL CONDITION] to his/her abdominal cavity. A staff member placed a Foley catheter on 5/9/14 per physician ' s order. Review of the significant change MDS dated [DATE] revealed a BIMS score of 13, indicating no cognitive impairment. The resident required extensive assistance of two or more staff for toileting and transfers. Review of the Urinary Incontinence/Indwelling Catheter CAA dated 7/2/14 revealed resident #55 had a history of [REDACTED]. Staff removed the resident's Foley catheter on 6/10/14. Review of resident #55's Indwelling Catheter care plan dated 5/26/14 directed the staff not to allow the tubing or any part of the drainage system to touch the floor, irrigate the catheter only if staff suspected an obstruction, position the bag below the level of the bladder, provide catheter care every shift using alcohol swabs to clean the drain port after emptying and genital care with morning and bedtime dressing, replace the catheter every month and PRN (as needed) accidental removal, report any unusual odor/color of urine to the charge nurse, store the collection bag inside a protective dignity pouch, use a catheter leg strap and assure enough slack left in the catheter between the meatus (the body opening on the genitals that allows the passage of urine) and strap, and use a 16 French/5 ml (milliliter) balloon (a size of a urinary catheter) catheter per physician order. Review of the resident's admission assessment dated [DATE] revealed the resident had a catheter removed prior to his/her hospital discharge. The resident dribbled urine and utilized commode and a urinal. Review of a physician order dated 5/6/14 revealed an order to monitor resident #55 for urination and [MEDICAL CONDITION] through the night and if he/she continued to void only small amounts of urine and was uncomfortable/distended, then replace the Foley catheter to dependent drainage. The order revealed a [DIAGNOSES REDACTED]. Review of a physician order dated 5/9/14 revealed an order to place a 16 French/5 ml balloon Foley catheter to dependent drainage with no indication for use. Review of a skilled nursing assessment dated [DATE] revealed resident #55 had a patent Foley catheter. Review of a fax to the physician dated 5/18/14 revealed resident #55 had a lot of pain in his/her genital area and very little output over the last few shifts. The resident ' s urine was dark amber and cloudy. He/she had some dark colored discharge out of his/her genital area. The resident started to routinely take his/her [MEDICATION NAME] (a medication for pain), but the [MEDICATION NAME] did not seem to help with his/her pain. The staff flushed resident #55 ' s Foley catheter to be sure it was patent and the only fluid that returned to the collection bag was the flush. A physician response revealed an order to culture the urine (a lab test ordered when symptoms suggest the possibility of a UTI) and start Keflex (an antibiotic medication). Review of a physician order dated 5/18/14 revealed an order to flush resident #55's Foley catheter as needed due to low urine output to check for an occlusion of the Foley catheter. Review of a nurse ' s note dated 5/19/14 revealed the resident had cloudy urine with sediment. Review of a nurse ' s note dated 6/5/14 at 10:10 a.m. revealed resident #55 had dark, reddish urine present in his/her Foley catheter collection bag. Review of a doctor ' s progress note dated 6/5/14 revealed resident #55 had genital pain and his/her family questioned whether the resident had a UTI. Review of the June 2014 MAR (medication administration record) from 6/5/14-6/9/14 revealed resident #55 received pain medication for genital pain 7 times in 4 days. Review of a nurse's note dated 6/6/14 at 1:51 p.m. revealed resident #55's urine was dark amber with blood clots noted in the tubing. Review of a nurse's note dated 6/7/14 at 9:54 a.m. revealed the resident had reddish, brown drainage from his/her genitals. His/her Foley catheter had dark, reddish urine in the Foley catheter collection bag. Review of a nurse's note dated 6/7/14 at 8:26 p.m. revealed the resident had sharp shooting pain to his/her genitals. Review of a nurse's note dated 6/8/14 at 5:42 a.m. revealed the resident continued to have drainage from his/her genitals and reddish, brown urine in the collection bag. Review of a nurse's note dated 6/8/14 at 9:55 a.m. revealed the resident had occasional bladder spasms and dark reddish urine. Review of a fax to the physician dated 6/8/14 at 6:27 p.m. revealed resident #55 had a lot of swelling and blood draining from his/her genitals. The reddish tinged drainage was present for a few days and seemed to be increasing. Review of a nurse's note dated 6/8/14 at 10:13 p.m. revealed the resident had off and on sharp shooting pain, still having blood tinged fluid leaking out of his/her genitals, which were very swollen. Review of a physician response to the 6/8/14 fax, dated 6/9/14 at 12:20 p.m. and received by the facility at 2:02 p.m., revealed an order for [REDACTED]. Review of a fax to the physician dated 6/9/14 revealed staff replaced resident #55's Foley catheter prior to the resident's Doctor ' s appointment. The resident had [MEDICAL CONDITION] to his/her genitals and the staff were unable to visualize the urinary meatus. Upon removal of the resident's Foley catheter, the tip was bloody. The resident reported the urge to void. The resident urinated 3 dribbles followed by frank (obvious) blood. It was very difficult to find the resident's meatus due to the [MEDICAL CONDITION]. The resident's genitals had some raw areas. The staff member was not sure the resident was able to urinate adequately without the catheter. The resident had 4+ [MEDICAL CONDITION] (a dent in the skin after pressed, 4+ meaning very deep) to all of his/her extremities. A physician response dated 6/9/14 at 4:55 p.m. revealed the physician was concerned that the bleeding may be due to the Foley catheter and gave an order to replace the Foley catheter if the resident was unable to void. Review of history and physical dated 6/16/14 revealed resident #55 admitted to the hospital from 6/16/14-6/19/14 for a severe UTI. During an interview on 10/22/14 at 2:26 p.m. licensed nursing staff C revealed resident #55 had a large [MEDICAL CONDITION] abdomen. The resident was continent of urine at times. Staff C reported resident #55 had swelling in his/her genitals that was present since admission. Staff C was unable to recall if the resident ever had a Foley catheter in place. Staff C reported resident #55 had tenderness during perineal care (washing of the genital and rectal areas) and had open sores on his/her genitals at one time. Staff C reported he/she notified the physician when a resident exhibited an elevated temperature, burning with urination, odor of urine, cloudy urine, urinary frequency, and new incontinence. Staff C reported he/she notified the physician when a resident with a Foley catheter exhibited a lack of urine output, color change in urine, sediment present in the urine, and any odor. Staff C reported he/she contacted the physician the next day if the physician did not respond to a concern, usually by fax. Staff C reported he/she called the physician at times and there was usually a way to get a hold of the physician by phone if needed. During an interview on 10/22/14 at 3:25 p.m. licensed nursing staff D revealed he/she notified the physician for any change from a resident's normal condition. Staff D reported if a resident had continued pain that the physician did not respond to, he/she contacted the physician again. Staff D reported when a resident had a Foley catheter he/she notified the physician of decreased drainage, mucus, and haziness of the urine. He/she reported he/she monitored residents with Foley catheters for swelling of the meatus, discharge, inflammation of the genitals, and discolored urine. Staff D reported if a resident with a Foley catheter exhibited anything abnormal he/she notified the physician. During an interview on 10/22/14 at 3:55 p.m. administrative nursing staff B revealed resident #55 had ascites to his/her abdomen, groin, perineal area, feet, and legs. Staff B reported he/she thought part of the reason for resident #55 to have a Foley catheter was for comfort. He/she reported resident #55 had problems with his/her genitals. He/she reported he/she expected there to be a certain [DIAGNOSES REDACTED]. Staff B reported he/she expected the staff to notify the physician when a resident exhibited a change in urine output, no urine output, a change in urine color, a change in urine consistency, and signs of blood. Staff B reported he/she expected the staff to re-approach the physician the next day for unresolved concerns if the physician did not respond initially. Interview with physician on I 10/23/14 at 12:25 p.m. revealed swelling in resident #55's genitals presumably was from anasarca, as the swelling was not only in the genitals. Physician I reported the fax on 5/18/14 went to the on call physician, who did not address the pain. He/she reported if the resident had continued unrelieved pain, he/she would have expected staff to notify him/her. Physician I reported the resident had a catheter placed for [MEDICAL CONDITION] and did not really have a standing order for how long to leave it in for retention, but reported it should not be left in longer than 2 weeks for [MEDICAL CONDITION]. Review of the facility policy for Catheters, dated 4/99, revealed Foley catheters were not routinely used to control urinary incontinence. Foley catheters were used, changed, and irrigated as ordered by the physician only by a licensed nurse. Review of the facility policy for Orders for Catheters, dated 4/99, revealed a physician order for [REDACTED]. The facility failed to ensure medical justification for the Foley catheter which resulted in complications from the catheter including severe pain, swelling, bleeding, and UTI which resulted in hospitalization for treatment for [REDACTED]. - Review of resident #27's signed physician's order sheet dated 10/1/14 revealed the following Diagnosis: [REDACTED]. Review of the Annual MDS (minimum data set) dated 5/15/14 revealed a BIMS (brief interview for mental status) score of 3 indicating severe cognitive impairment. The resident required limited assistance of one staff for toileting and was always continent of bladder. He/she was not on a bladder training program. The resident took a diuretic (medication to promote the formation and excretion of urine) for all 7 of the 7 day look back period. Review of the Urinary Incontinence CAA (care area assessment) dated 5/15/14 revealed the resident had confusion and [MEDICAL CONDITION]. The CAA summary revealed the resident recognized the urge to void (urinate) and had control of his/her bladder. Review of the Quarterly MDS dated [DATE] revealed a BIMS score of 3. The resident required extensive assistance of one staff for toileting and was occasionally incontinent of bladder. The assessment indicated the resident was currently on a toileting program. The resident took a diuretic for all 7 of the 7 day look back period. Review of #27's Comprehensive ADL (activities of daily living) care plan dated 5/27/14 revealed the resident had difficulty dressing due to Kyphosis (a [MEDICAL CONDITION] bone disease of the spine which caused unnatural curvature and weakness), and forgetfulness. The care plan interventions directed staff to assist the resident to the bathroom before and after meals, at HS (bedtime), and at least 1 time at night. The care plan lacked specific interventions addressing the decline in urinary incontinence. Review of the resident's clinical record revealed it lacked documentation to support any assessments by the facility to address the decline in urinary incontinence. During observation on 10/22/14 at 7:10 AM, 7:20 AM, 7:45 AM, 8:00 AM, 8:15 AM, 8:30 AM the resident sat in a recliner chair in the front common area by the nurse desk and slept. At 8:45 AM the resident began waking and looking around at the activities of staff and residents in the facility. At 8:50 AM direct care staff walked with the resident from the recliner chair to the dining table. Staff asked the resident if he/she needed to use the bathroom, the resident indicated he/she did not. Staff proceeded to the dining area and seated the resident at the dining table. The resident's clothing was clean and dry. During observation on 10/22/14 at 12:45 PM resident #27 walked from the dining room area, and wandered up and down the halls. Direct care staff H approached the resident and asked if he/she needed to use the bathroom. The resident indicated he/she did not. Staff H reported the resident was always incontinent and had been toileted around 10:00 AM. Upon surveyor request staff J approached the resident and asked him/her to walk to his/her room. The resident complied and followed the staff to his/her bathroom. Staff J donned gloves and assisted #27 with his/her clothing. During observation the resident's brief contained a large amount of urine. Staff J reported this was an excessive amount of urine for the resident compared to his/her normal incontinence. During an interview staff J reported when the resident came to the facility he/she was independent with toileting and was always continent. Staff J reported the resident's cognition was worse and at times he/she did not know if he/she had urinated in his/her brief. Staff J reported they should not just ask the resident but staff should take the resident to the bathroom on a regular schedule. Staff J reported during the day the resident was continent when toileted on a regular schedule. During an interview on 10/21/14 at 4:15 PM direct care staff O reported the resident required one staff assistance for toileting. Staff O revealed the resident would not say he/she had to go to the bathroom but would indicate this by pulling his/her pants down, and wandering throughout the facility. Staff O stated the resident was incontinent sometimes and would void in the toilet even if he/she had been incontinent. Staff O reported the resident's frequency of incontinence had no changed since admission. During an interview on 10/22/14 at 9:27 AM Licensed nurse staff P revealed the resident was always continent when he/she admitted to the facility and no bladder assessments were warranted at that time. Staff P reported he/she used the staff documentation to code the Quarterly MDS for bladder continence and the documentation did indicate a decline in urinary incontinence. Staff P indicated when a decline happens a series of bladder assessments should be initiated at that time to determine causal factors and interventions should be implemented to prevent further decline or try to improve the incontinence status for the resident. Staff P revealed he/she must have overlooked the decline for the resident and did not initiate any bladder assessments or develop a care plan with interventions to address the issue. Staff P reported the facility would implement the assessments today and update the care plan with new interventions to improve the incontinence. During an interview on 10/22/14 at 10:00 AM Administrative staff A and Administrative Nurse staff B reported when a resident had a decline in urinary incontinence the facility protocol was to initiate a bladder diary, complete a bladder assessment, check for a bladder infection, and monitor the resident's cognition for any changes. Staff A and Staff B were unaware the assessments were not completed for resident #27. On 10/22/14 at 1:59 PM the surveyor attempted to contact the physician, the physician was out of the office until 10/23/14. Review of the undated facility Urinary Incontinence Policy revealed a resident incontinent of bladder will receive appropriate treatment and services to prevent urinary tract infections and to restore as much normal bladder function as possible. The facility failed to assess a resident with a decline in urinary incontinence to prevent further decline and to restore as much normal bladder function as possible.

The facility had a census of 45 residents. Based on the review of a closed record and interviews, the facility failed to provide sufficient supervision as planned for 1 of 3 residents sampled for accidents. (#4) The resident experienced several falls, one which resulted in a fractured hip. Findings included: - The closed record for resident #4 included a physician's order [REDACTED]. Review of a quarterly MDS (minimum data set) dated 1/29/14 revealed the resident had short and long-term memory problems, severely impaired cognition, required the extensive assistance of two staff for transfers, walking in the room, and had two or more non-injury falls and one injury fall since the prior assessment. Review of the significant change MDS dated [DATE] revealed the resident had long and short term memory problems, severely impaired cognition and required extensive assistance of two staff for bed mobility and transfers. Review of the fall CAA (care area assessment) dated 3/17/14 revealed the resident had a fall on 2/26/14 when he/she stood up from the recliner and fell on the floor. The CAA indicated the resident had unsteady balance, unsteady gait, took small steps with transfers, experienced pain off and on, and had a history of [REDACTED]. The CAA indicated the resident had a [DIAGNOSES REDACTED]. Review of the fall care plan initiated on 12/4/2011 revealed the resident experienced forgetfulness due to a [DIAGNOSES REDACTED]. The care plan indicated family reported the resident had a history of [REDACTED]. On 5/9/13 staff added the intervention of a tabs alarm while in chair/bed due to left lower leg pain and swelling with difficulty bearing weight with ambulation. On 6/3/13 staff discontinued the tabs alarm due to restlessness while in the chair without getting up. On 8/11/13 staff documented on the care plan the failed trial of a FWW (front-wheeled walker) due to the resident's failure to remember to use the walker while wandering in the facility and the resident's refusal when staff reminded the resident to use it. On 1/2/14, staff added the intervention that when the resident did not want to go to bed, to keep the resident in a recliner (by the nurse's station). On 1/11/14, staff added the intervention for the resident to use a Merry Walker and for staff to keep close observation of the resident until the resident was ready for bed. The intervention lacked when staff were to have the resident use the Merry Walker. On 2/26/14, staff added an intervention that directed staff to use a tabs alarm when the resident sat in a chair or lied in his/her bed. On 3/6/14, staff added the intervention to use a chair sensor while the resident sat in a chair or lay in bed. Review of the facility's fall risk evaluations dated 1/29/13, 2/26/14 and 3/6/14 all revealed the resident at high risk for falls. Review of a fall investigation dated 1/2/14 at 8:15 P.M. revealed the resident fell from a recliner in the living area and was found lying on his/her left side. The staff documented the resident was not ready to go to bed and the new intervention was to keep the resident in the recliner. The record lacked evidence they thoroughly reassessed the resident to update the care plan with effective interventions to prevent falls. Review of a fall investigation dated 1/11/14 at 2:55 P.M. revealed the resident again fell from a recliner in the living area and staff found the resident lying on his/her left side. The new intervention from staff included "close observation" until ready for bed and the use of a Merry Walker. The investigation did not specify the frequency of how often staff needed to check on the resident, and lacked evidence the facility thoroughly reassessed the resident to update the care plan with effective interventions to prevent falls. Review of a fall investigation dated 2/26/14 at 9:20 P.M. revealed the resident fell to the floor from the front recliner in the living room area (area close to the nurse desk) for the 3rd time in 2 months. Staff did not witness the fall. The initial fall investigation written by the charge nurse indicated the nurse sat at the nurse station with his/her back turned, he/she heard a noise and noted the resident lying on his/her left side on the floor in front of the recliner. Review of a nurse note's dated 2/26/14 at 9:58 PM revealed the resident fell , and upon physical assessment no injuries were found after the nurse performed range of motion exercises. The nurse's note indicated staff notified the family and the DON (director of nursing) by phone and sent a fax to the physician. The physician signed and noted the fax on 2/27/14 at 10:35 AM. The investigation revealed the resident incontinent but had the time "unknown" of when staff last toileted the resident. It also revealed the last "known action before occurence" of the resident getting out of the chair, but did not include whether staff assisted the resident at that time. According to the nurse's notes from 2/27/14, the resident started to exhibit pain and did not want to walk, so the facility requested an X-ray from the physician. The physician agreed, and staff obtained an X-ray on 2/28/14 that indicated the resident experienced a fractured hip. Once staff notified the physician of the findings, staff received an order to send the resident to the hospital for treatment. On 4/3/14 at 7:48 A.M. licensed nurse staff F revealed the resident required supervision since the resident frequently walked in the Merry Walker due to being restless and did not want to stay in one place for too long. Nurse F reported when the resident got tired, staff placed the resident in a recliner by the nurses' desk so staff could supervise him/her. During an interview on 4/3/14 at 2:36 P.M. administrative staff A and administrative nurse staff B revealed direct care staff placed the resident in a Merry Walker when he/she became anxious or restless so he/she could ambulate freely and safely. Staff B reported direct care staff also placed the resident in a recliner chair with the foot rest elevated. Staff reported the resident's recliner chair was positioned close to the nurse desk during periods of rest so nursing staff who sat at the nurse desk could supervise the resident. During an interview with physician G on 4/3/14 at 1:43 P.M. revealed he/she received a fax from the facility on 2/26/14 after office hours. Physician G reported any faxes that come in after business hours are not reviewed until the next business day. Staff G reported he/she did expect a phone call instead for any significant change in the resident's condition or issues related to pain. Staff G reported he/she did review a fax the next morning after the fall occurred for this resident. Staff G reported he/she did not receive any further communication from the facility regarding a decrease in ambulation or signs and symptoms of pain. Review of the facility's fall policy dated 6/19/2007 revealed with every fall occurrence, staff assessed the resident, review the fall prevention reference sheet for suggestions to implement and update the care plan as appropriate. Staff should assess the resident every shift for 72 hours including vital signs, pain and change of condition. The fall guidelines (Appendix B) instructed staff to notify primary care physician if the resident's condition changed. The facility failed to thoroughly investigate falls to prevent further falls and failed to provide necessary supervision of a restless resident who experienced a fall which resulted in a fracture.

The facility had a census of 45 residents. Based on the review of a closed record and interview, the facility failed to assess and promptly respond to a resident ' s acute pain related to a recent fall. (#4) The pain caused a change in the resident ' s ambulation. Findings included: - Review of resident#4 ' s signed physician's order [REDACTED]. and irrational fear). Review of resident #4 ' s quarterly MDS (minimum data set) dated 1/29/14 revealed the resident had long and short-term memory problems, required extensive assistance from two staff with walking, and had no pain symptoms. Review of the significant change MDS dated [DATE] revealed the resident had long and short-term memory problems, had a fall with serious injury since the previous assessment and received scheduled pain medication. Review of the care plan, dated 12/4/11, identified the resident had a history of [REDACTED]. The care plan directed staff to use the Merry Walker as needed to provide a safe environment and independent ambulation. On 5/2/13, staff added that the resident ambulated independently with a slow gait. On 2/11/14, staff added to the care plan that the resident ' s pain management of routine Tylenol worked to relieve the resident ' s pain, and the resident had no signs or symptoms of pain noted in the previous 3 months. Review of a nurses ' note dated 2/26/14 at 9:58 PM revealed the resident fell while in a recliner, and upon physical assessment directly after the fall the resident did not display any signs or symptoms of injuries. The nurse ' s note indicated staff called the family and the DON (director of nursing) to notify them of the non-injury fall, and sent a fax to the physician. Review of the fax sent to the physician on 2/26/14 revealed the physician reviewed it, signed it that he/she had noted the non-injury fall and returned the fax back to the facility on [DATE] at 10:35 AM. Review of a nurses ' note dated 2/27/14 at 11:24 A.M. revealed staff assisted the resident up for the morning meal. Nursing staff noted the resident moaned in pain, and that the resident ' s knees buckled at times during transfers. Staff documented that the resident received his/her routine Tylenol . The nurse ' s note revealed the resident had been restless so staff placed him/her in the Merry Walker. The nurse note revealed the resident did not ambulate while in the Merry Walker, but would stand in place at times. Staff sent a communication form to the physical therapy staff asking for an evaluation of the resident and treat, if necessary. The staff failed to assess the resident ' s pain or provide any interventions to relieve the pain, including asking the physician for additional or stronger pain medications to manage the resident ' s pain. Review of nurses' note dated 2/27/14 at 10:54 P.M., revealed 2 direct care staff assisted the resident into his/her bed. The note revealed the resident would not bear weight on his/her left leg and showed signs of pain with facial grimacing and resistance. The charge nurse also noticed the resident had an external rotation to the left leg (a sign of a [MEDICAL CONDITION]/leg). The medical record lacked an assessment of the resident ' s ongoing pain or interventions the staff took to relieve the resident ' s pain, including calling the physician for additional pain medication. The nurse note revealed staff planned to contact the physician the next morning. Review of a nurses ' note dated 2/28/14 at 9:16 A.M. revealed nursing staff faxed the physician and that the staff had communicated with the family " multiple times " regarding the resident ' s pain with the plan to keep them updated. The fax to the physician described the resident ' s signs and symptoms of pain, and the external rotation of the resident ' s left leg, but did not include the results of any pain assessments or requests for additional pain medications to help the resident with the pain. The physician then gave orders for staff to obtain an x-ray of the resident ' s left hip via mobile x-ray services. The mobile x-ray services completed the x-ray and at 10:30 a.m. sent a fax to the facility identifying the resident had a [MEDICAL CONDITION]. A note later that day identified staff assisted the resident up out of bed and at 5:18 p.m. the resident rested in a recliner. At 6:09 p.m., the resident left the facility to go to a local hospital for surgical repair of the left hip. Review of the MAR (medication administration record) for February 2014 revealed the resident did not receive any PRN (as needed) pain medication. During an interview on 4/3/14 at 7:48 A.M. licensed nurse staff Nurse F revealed he/she worked the day shift on 2/27/14 and stated he/she noticed during the day the resident grimaced with transfers, was a little slower and would holler out when transferred. Nurse F reported he/she conducted PROM (passive range of motion) with the resident and the resident could not pin point if the pain was in the hip or knee of the left leg. The nurse did not call the physician and report the pain or the changes in the resident ' s ambulation. Nurse F stated the facility did not use any formal pain assessments, that all pain residents experienced were documented in the nurse notes only. On 4/3/14 at 12:12 P.M., licensed nurse E stated that when the staff assisted the resident into bed on 2/27/14 the resident had pain and external rotation of the left leg. Staff stated he/she offered to notify the physician that evening, but the family (who was present in the room at the time) told staff E it would be okay to call the physician in the morning due to the resident had no pain when lying still in the bed. On 4/3/14 at 1:43 P.M., Physician G revealed he/she received a fax from the facility on 2/26/14 after office hours that the facility reported the resident had a non-injury fall. Physician G stated the fax did not include any information about any changes in the resident, including increased pain or decreased ambulation. Physician G reported he/she would have expected to get a phone call instead of a fax if the resident had a significant change, including increased pain. Physician G stated he/she did not receive any further communication from the facility regarding an increase in pain or decrease in ambulation. During an interview on 4/3/14 at 2:36 P.M. administrative staff A and administrative nurse staff B revealed the evening after the resident fell , the resident showed no signs of injury and it was " questionable " the following day. However, after review of the nursing documentation, staff B reported the nurse staff should have called the physician with the changes noted in the resident ' s condition and increase in pain. Review of the facility ' s pain management policy, dated 10/2003, revealed staff were to provide appropriate assessment and intervention to control a resident ' s pain. It directed staff to assess a resident for pain upon admission, quarterly with the MDS, with any significant change, return from the hospital or anytime the resident complains of pain at a new location. Physical signs such as grimacing, limping, changes in vital signs, or behavioral changes were to be monitored for the resident who had difficulty in communicating. A pain scale was to be used for pain assessment. For residents with decreased cognitive impairment or when non-responsive residents were assessed, staff were to use the Discomfort Indicator Scale or Wong/Baker Faces. The type of assessment used was to be charted on the Pain Assessment Flow Sheet or in the nurse ' s notes. The facility failed to assess, develop or implement new interventions to address the newly developed acute pain during ambulation for a resident that experienced a fall. The failure to address the resident ' s pain resulted in a decreased ability to ambulate and transfer.