Every finding on record at Emporia Presbyterian Manor

The facility reported a census of 51 residents with one kitchen. Based on observation, interview, and record review, the facility failed to provide sanitary conditions for food storage and preparation to prevent the spread of food borne illness to the residents of the facility. This placed the residents at risk for food-borne illness.Findings included:- Initial tour of the kitchen on 03/02/2026 at 07:29 AM with Dietary Manager BB, revealed the following areas of concern:An uncovered plastic tub containing metal spoons sitting on counter in dining area at entrance to kitchen.Five blocks of butter in a metal container uncovered on the counter.The refrigerator contained bowls of spaghetti, milk, cottage cheese, and yogurt on a tray covered with plastic wrap r with no open or use by date.The freezer contained 5 cups of pudding and a piece of pie, two packages of shredded cheese, 2 sheet pans of Jello and 7 sausage links that were not labeled and dated.The spice rack on the wall behind the stove had an open package of brown sugar that did not have an opened-on date. A container labeled turmeric with a use by date of 9/15/24 and a sticker on the container with an open date of 11/6/23 and a use by date of 11/5/24, a container labeled as crushed red pepper flakes, with a use by 3/21/25, a container of curry powder with an attached label showing opened on 11/6/23 and use by 11/5/24.A table in the kitchen against a wall had six stacks of plates that were not inverted.A container on a counter with numerous cake decorating gels. One decorating gel was dated opened on 5/1/25 by 11/6/25, and a container of colored sugar with an opened date of 11/22/24 and a use by date of 5/21/25.Observation on 03/02/2026 during kitchen tour, dietary staff FF, was not wearing a hair net underneath the ball cap they had on.Observation on 03/03/26 at 11:00 AM, during the pureed preparation, Dietary Staff FF did not change gloves or perform hand hygiene between tasks or when gloved hands were exposed to a new location or an unclean environment.Observation on 03/03/26 at 12:40 PM, Dietary Staff FF placed a cloth over the cap on the blender container during the blending cycle, (the cap had a large opening that a utensil for stirring could be placed through), the cloth was placed on counter in between blends, there were several clean & dirty cooking utensils and food debris on the counter's surface. Staff FF then placed the same cloth back on the blender cap for each blender cycle of each food item for the entire pureed meal preparation. Observation on 03/03/26, Staff FF did not properly sanitize the thermometer being used to obtain temperatures on the pureed food. Staff FF used a paper towel to wipe off the thermometer while obtaining temperatures on 3 different pureed food items.Observation 03/03/26 at 12:42 PM, Dietary Staff EE carried a plate of food from the kitchen to a resident in the dining room. Dietary Staff EE placed thumbs on the easting surface of the plate.On 03/04/2026 11:34 AM, Dietary Staff BB reported that all staff should perform hand washing at kitchen entry, kitchen re-entry and between tasks performed in the kitchen. Hand washing should also be performed in between gloving or when handling ready-to-eat foods. Changing gloves and hand hygiene should be done after every task; Any prepped or stored food should be covered & labeled with an opened on & use by date; All spices on the rack for use in the kitchen should be labeled and the expired spices should be thrown out. Hair net or a facial cover should always be worn when in the kitchen or anytime staff are around food. Counters, utensils, thermometers, towels and cooking vessels should be cleaned, sanitized and replaced with new if in contact with an unclean surface or item.On 03/04/2026 11:56 AM, Administrative Staff A reported that every time kitchen staff make a new order, any task or change gloves they should wash their hands or use hand sanitizer. All staff should wear a hairnet when they are in the kitchen or serving food. Staff should not put their thumbs or any part of their hand on the rim of the plate when carrying it to serve the residents. All food items should be labeled with a use by and the date it was wrapped. All dedicated utensils/Clean utensils, cooking or food prep vessels and counters, if compromised, should be replaced new one or the compromised item should be washed and sanitized before use again. Any thermometer used should be sanitized between uses. The facility Policy 5.01 HACCP Food Handling Principles dated 02/2026, documented that utensils, equipment, and surfaces are clean and sanitized prior to, and between uses. Employees are trained in safe food service techniques and personal hygiene annually, or more often as needed. All products are labeled and dated with the receiving date. Once opened, products are covered to prevent contamination and dated with an open date.

The facility had a census of 51 residents. The sample included 14 residents. Based on observation, interview, and record review, the facility failed to ensure staff labeled Resident (R)11's insulin (a hormone that lowers the level of glucose in the blood) flex pens when initially opened. Findings included:- On 03/02/26 at 07:15 AM, observation of the Medication cart located in the nurse's room revealed R11's Lantus (long-acting insulin) flex pen was not labeled with an opened date or an expiration date. R11's second Lantus insulin flex pen had an illegible date written on the pen as it had smeared and was not legible. On 03/02/26 at 07:20 AM, License Nurse G verified the nurses should label and date the insulin flex pens with the date opened. On 03/04/26 at 10:20 AM, Administrative Nurse D verified the nurse should label and date the insulin flex pens with the date opened. Medlineplus.gov directs open, unrefrigerated insulin pen can be used within 28 days; after that time, they must be discarded. The facility's Medication Storage policy, dated 02/03/25, documented medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. Medications are accessible only to licensed nurses, pharmacy personnel, or staff members lawfully authorized to administer medications. Medications are labeled for individual residents and stored separately from floor stock medications when not in the medication cart.

The facility identified a census of 51 residents. The sample included 14 residents, including five residents reviewed for unnecessary medications. Based on record review, interview and observation, the facility failed to follow orders for notification of the provider for blood sugars out of range for Resident (R) 3.Findings included:- R3's Electronic Medical Records (EMR), documented diagnoses which included diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin).R3's 05/06/2025 admission Minimum Data Set (MDS) documented R3 had a Brief Interview for Mental Status (BIMS) of 13, indicating intact cognition. The MDS noted R3 had a diagnosis of diabetes and received an insulin injection every day in the look back period of seven days. The Nutrition Care Area Assessment (CAA) documented R3 was at risk for impaired nutrition related to a stroke, morbid obesity and diabetes.R3's Care Plan dated 05/06/25 documented that R3 takes insulin and oral diabetes medications and directed staff to monitor and document side effects and effectiveness. Intervention on 08/03/25 directed the staff to check her fasting blood sugar as ordered and to notify the provider of readings less than 60 milligrams per deciliter (mg/dl) or greater than 350 mg/dl.R3's Physician Orders in the EMR documented an order for blood glucose monitoring two times a day. Call the doctor if the blood glucose level is less than 60 mg/dl or over 350 mg/dl; dated 07/29/25.Review of R3's blood glucose record under the Weights and Vitals tab for July 2025 through February 2026 found the following:07/07/25 a blood glucose level of 376 mg/dl07/08/25 a blood glucose level of 377 mg/dl07/09/25 a blood glucose level of 393 mg/dl07/11/25 a blood glucose level of 409 mg/dl07/12/25 a blood glucose level of 363 mg/dl07/13/25 a blood glucose level of 362 mg/dl07/14/25 a blood glucose level of 423 mg/dl07/15/25 a blood glucose level of 382 mg/dl07/18/25 a blood glucose level of 382 mg/dl07/19/25 a blood glucose level of 418 mg/dl07/21/25 a blood glucose level of 406 mg/dl07/22/25 a blood glucose level of 365 mg/dl07/23/25 a blood glucose level of 418 mg/dl08/01/25 a blood glucose level of 411 mg/dl08/13/25 a blood glucose level of 366 mg/dl08/27/25 a blood glucose level of 596 mg/dl09/01/25 a blood glucose level of 357 mg/dl09/05/25 a blood glucose level of 372 mg/dl09/09/25 a blood glucose level of 442 mg/dl09/10/25 a blood glucose level of 369 mg/dl09/17/25 a blood glucose level of 442 mg/dl09/29/25 a blood glucose level of 455 mg/dl10/03/25 a blood glucose level of 386 mg/dl11/03/25 a blood glucose level of 391 mg/dl11/11/25 a blood glucose level of 357 mg/dl11/24/25 a blood glucose level of 363 mg/dl12/31/25 a blood glucose level of 397 mg/dl01/10/26 a blood glucose level of 352 mg/dl01/12/26 a blood glucose level of 351 mg/dl01/27/26 a blood glucose level of 369 mg/dl02/04/26 a blood glucose level of 421 mg/dl02/14/26 a blood glucose level of 359 mg/dl02/20/26 a blood glucose level of 358 mg/dl02/22/26 a blood glucose level of 353 mg/dl02/24/26 a blood glucose level of 355 mg/dl R3's Progress Notes in the EMR lacked notification to the provider for blood glucose over 350 mg/dl for the above dates. On 03/02/26 8:19 AM, R3 laid in bed with her over bed table close to the side of the bed. R3 stated she preferred to stay in bed and staff bring her breakfast to her. On 03/04/26 at 12:01 PM, Certified Medication Aide (CMA) R stated that the CMAs do the Accu-check (blood glucose monitoring test) and stated there are no parameters of when to notify the nurse or doctor. CMA R stated she notified the nurse if the blood sugar was under 100 mg/dl or over 185 mg/dl. On 03/04/26 at 12:03 PM, Administrative Nurse D stated nursing staff should notify the physician if the resident was symptomatic. Administrative Nurse D said staff usually faxed the doctor if the blood sugar was over /dl if the resident is not symptomatic. The nurse should document if she faxed or called and what the physician's response was. The facility's Notification Parameters- Primary Care Provider (PCP) dated 02/03/25 documented notification of the PCP in a timely, efficient, and effective manner can be accomplished when a system is consistently followed by licensed nursing staff. Licensed nursing staff have the responsibility of contacting a PCP anytime a resident has developed a clinical problem requiring PCP intervention.

The facility identified a census of 51 residents. The sample included 14 residents, including five residents reviewed for unnecessary medications. Based on record review, interview and observation, the consulting pharmacy failed to identify blood sugars out of range for Resident (R) 3.Findings included:- R3's Electronic Medical Records (EMR) documented diagnoses, which included diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin). R3's 05/06/2025 admission Minimum Data Set (MDS) documented R3 had a Brief Interview for Mental Status (BIMS) of 13, indicating intact cognition. The MDS noted R3 had a diagnosis of diabetes and received an insulin injection every day in the look back period of seven days. The Nutrition Care Area Assessment (CAA) documented R3 was at risk for impaired nutrition related to a stroke, morbid obesity, and diabetes. R3's Care Plan dated 05/06/25 documented that R3 takes insulin and oral diabetes medications and directed staff to monitor and document side effects and effectiveness. Intervention on 08/03/25 directed the staff to check her fasting blood sugar as ordered and to notify the provider of readings less than 60 milligrams per deciliter (mg/dl) or greater than 350 mg/dl. R3's Physician Orders in the EMR documented an order for blood glucose monitoring two times a day. Call the doctor if the blood glucose level is less than 60 mg/dl or over 350 mg/dl; dated 07/29/25. Review of R3's blood glucose record under the Weights and Vitals tab for July 2025 through February 2026 found the following:07/07/25 a blood glucose level of 376 mg/dl07/08/25 a blood glucose level of 377 mg/dl07/09/25 a blood glucose level of 393 mg/dl07/11/25 a blood glucose level of 409 mg/dl07/12/25 a blood glucose level of 363 mg/dl07/13/25 a blood glucose level of 362 mg/dl07/14/25 a blood glucose level of 423 mg/dl07/15/25 a blood glucose level of 382 mg/dl07/18/25 a blood glucose level of 382 mg/dl07/19/25 a blood glucose level of 418 mg/dl07/21/25 a blood glucose level of 406 mg/dl07/22/25 a blood glucose level of 365 mg/dl07/23/25 a blood glucose level of 418 mg/dl08/01/25 a blood glucose level of 411 mg/dl08/13/25 a blood glucose level of 366 mg/dl08/27/25 a blood glucose level of 596 mg/dl09/01/25 a blood glucose level of 357 mg/dl09/05/25 a blood glucose level of 372 mg/dl09/09/25 a blood glucose level of 442 mg/dl09/10/25 a blood glucose level of 369 mg/dl09/17/25 a blood glucose level of 442 mg/dl09/29/25 a blood glucose level of 455 mg/dl10/03/25 a blood glucose level of 386 mg/dl11/03/25 a blood glucose level of 391 mg/dl11/11/25 a blood glucose level of 357 mg/dl11/24/25 a blood glucose level of 363 mg/dl12/31/25 a blood glucose level of 397 mg/dl01/10/26 a blood glucose level of 352 mg/dl01/12/26 a blood glucose level of 351 mg/dl01/27/26 a blood glucose level of 369 mg/dl02/04/26 a blood glucose level of 421 mg/dl02/14/26 a blood glucose level of 359 mg/dl02/20/26 a blood glucose level of 358 mg/dl02/22/26 a blood glucose level of 353 mg/dl02/24/26 a blood glucose level of 355 mg/dl R3's Progress Notes in the EMR lacked notification to the provider for blood glucose over 350 mg/dl for the above dates. Review of the Drug Regimen Review (DRR) from August 2025 to February 2026 showed no documentation that the blood sugars were identified by the pharmacist as being out of range. On 03/02/26 8:19 AM, R3 laid in bed with her over bed table close to the side of the bed. R3 stated she preferred to stay in bed and staff bring her breakfast to her. On 03/04/26 at 12:03 PM, Administrative Nurse D stated she expected the pharmacist to know when a medication was out of the parameter and to notify the facility. The facility's Drug Regimen Review dated 08/2024 documented the pharmacist will complete a drug regimen review monthly and when needed, and identify medication without proper monitoring.

The facility had a census of 51 residents. The sample included 14 residents with one reviewed for dental care. Based on observation, record review, and interview, the facility failed to provide timely dental care for one sampled resident, Resident (R) 6.Findings included:- R6's Quarterly Minimum Data Set (MDS), dated [DATE], recorded R6 had a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. The assessment revealed R6 required staff assistance for personal hygiene, oral hygiene, toilet hygiene and had no oral or dental issues.The Care Area Assessment (CAA), dated 04/28/25, for activities of daily living (ADLs) failed to identify or document any sign/symptoms of dental problems or pain due to the broken, decayed, and missing teeth.The Activities of Daily Living (ADL) Care Plan, dated 01/12/26, recorded R6 required limited to extensive staff ADLs such as grooming, dressing, toileting and dressing. The Care Plan documented R6 had his own teeth, and they were in poor condition, carries and missing teeth and he required set up to partial assistance with oral cares. The care plan documented dental appointments would be set up as scheduled, needed and requested. The Interdisciplinary Notes dated 07/07/25, documented R6 had a dental appointment with Health Department -Dental due to a lost tooth and mouth pain. The notes documented R6 saw a dentist and the dentist documented he had extensive gross caries. The dentist recommended that staff brush R6's teeth and the patient would return to have fillings and extractions completed. However, the note documented the extractions would have to be performed by an oral surgeon not at the dentist's office. The 03/03/26 at 11:10 Interdisciplinary Notes, documented the resident was seen at the facility by a dental hygienist for a routine periodontal maintenance exam, and she documented R6 had pain in his upper left mouth and to the root tip area. The notes documented in the visual exam revealed moderate inflammation in the area and R6 would need further evaluation with the dentist. On 03/02/26 at 10:30 AM, R6 stated he had broken missing teeth, and had pain located in his right upper jaw area. R6 stated he had difficulty eating due to the tooth pain. Observation of R6's mouth revealed he had missing, decayed teeth and some broken off. On 03/04/26 at 09:30 AM, Administrative Nurse D verified the resident had broken, decaying teeth and had a dental appointment on 07/07/25 and verified the dentist's notes recommended filling and extractions. Upon review, Administrative Nurse D could not find any written documentation if a follow-up appointment was made after the 07/07/25 appointment and if it not the reason and follow treatment appointment was not made. Administrative Nurse verified there was no documentation in R6's medical records. Administrative Nurse D verified if R6 would have pain he should be evaluated by a dentist for recommendations and verified the residents should not have dental pain and not get treated for the pain. The facility's Dental Service policy, dated 02/03/25, documented residents are assessed for oral/dental needs initially, periodically and reviewed annually. The residents are referred to a dentist requested from the primary care physician for any identified or verbalized oral complaint/issue. Staff assist the residents to make an appointment and arrange transportation to and from the dentist's office. The policy documented for emergencies or oral discomfort, staff would obtain an order from the primary care physician and arrange for dental appointment within three days. The policy documented if the resident or responsible party refuses dental treatment, the nurse's notes it in the medical record and documents education as to risks to health status if no dental services are provided. The policy documented staff would record in the medical record interventions used to facilitate residents' ability to eat and drink while awaiting dental services.

The facility had a census of 51 residents. The sample included 14 residents. Based on observation, record review and interview, the facility failed to keep Resident (R) 58s protected health information (PHI) private on a medication cart that sat against the wall in A hall.Findings included: - On 03/03/26 at 08:29 AM, an observation revealed a medication cart parked against the wall in the A hall with a laptop computer sitting on the top. Certified Medication Aide (CMA) R walked away from the medication cart and into a resident's room. CMA R left the computer screen unlocked and opened and R58's PHI was on the screen, visible to all who passed by the medication cart. The information visualized included R58's medications, date of birth , allergy information, and code status. On 03/03/26 at 08:37 AM, CMA R stated she had stepped away from the cart to help a resident. She stated the policy was to ensure the CMA locked the medication cart and pushed the hide button. On 03/04/26 at 08:17 AM, Licensed Nurse (LN) I stated medication carts should be locked and the screen on the laptop should be closed, or staff could push the hide button, if the laptop was out of the staff's visual.On 03/04/26 at 08:04 AM, Administrative Nurse D stated the policy was to lock the medication cart. She stated nursing staff have the option to close the laptop or push the hide the screen button. She stated staff have been in-serviced on how the medication cart and laptop should be left, when the laptop or cart was not in their line of sight. The facility's Confidentiality policy, revised on 02/25 documented confidentially must be maintained in all areas of health information, whether oral, written, or electronic. Personnel must keep residents' information confidential except as permitted for continuity of care. Although information sharing was necessary in the healthcare environment confidentiality was breached when the information can be intercepted by unauthorized persons and connected to a specific individual.

The facility identified a census of 51 residents. The sample included 14 residents. Based on observation, record review, and interview, the facility failed to ensure reasonable accommodation of needs when staff failed to ensure Resident (R)8's call light was within his reach.Findings included:- R8's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of hypertension (elevated blood pressure), dementia (a progressive mental disorder characterized by failing memory and confusion), unsteadiness on feet, muscle weakness, and repeated falls.The admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of four, which indicated severely impaired cognition. The MDS documented R8 was dependent on staff for toileting and needed supervision or touching assistance from staff with eating.The Falls Care Area Assessment (CAA) dated 01/22/26 documented R8 was at risk for falls related to a history of falls, impaired mobility, weakness, dementia, urinary catheter, and required assistance with transfers/mobility.R8's Care Plan documented the following:01/28/26- R8 had been instructed to use call light for assistance.01/28/26- R8 was dependent on one or two staff for toileting throughout the day to manage bowel incontinence.On 03/03/26 at 10:20 AM, R8 sat in his room in front of the TV in his Broda chair (specialized wheelchair with the ability to tilt and recline). R8's pancake light laid in the middle of his bed. R8 could not reach his call light to call for assistance.On 03/03/26 at 10:21 AM, Certified Nursing Aide (CNA) N stated R8's call light was out of reach. CNA N stated R8's call light should be where he could reach the light and use the light. CNA N placed R8's light next to him on his bedside table, within his reach.On 03/04/26 at 08:34 AM, Licensed Nurse (LN) I stated residents call lights should always be within a resident's reach. She stated it was every staff member's duty to ensure call lights were within reach.On 03/04/26 at 08:04 AM, Administrative Nurse D stated residents should always have their call light where they can reach it. She stated the facility does on the spot training and in services on where to place a residents call light.The facility's Call Light System policy, revised 04/19 documented the community would have a call button or pull cord located next to each bed and in each resident's bathroom.

The facility had a census of 51. The sample included 14 residents. Based on record review, interview, and observation revealed the facility failed to provide care for Resident (R)11 and R19 in a manner that protected and promoted their dignity. Findings included:- On 03/02/26 at 12:10 PM, observation revealed R11 sat in a chair at the dining room table. Licensed Nurse (LN) G obtained R11's blood sugar reading using a glucometer (an instrument used to calculate blood glucose) from R11's right fourth finger. Continued observation revealed six residents were seated at the dining room awaiting lunch to be served, while other residents were seated in adjacent tables in the dining room, including one visitor and staff. On 03/02/26 at 12:20 PM, R11 got up from the dining room table, walked to her room, and laid down. Observation revealed she had see-through, thin material pink pants and her brief was visible through the pants. On 03/03/26 at 07:45 AM, R11 walked to the dining room table and sat down for breakfast. Observation revealed R11 had the same see through pant on she wore the day before and her briefs were visible through the pants. On 03/04/26 at 10:20 AM, Administrative Nurse D verified the nurse should not do blood sugar at the dining room table and R11 should not have pants on that are see through due to dignity concerns. The facility's Residents Dignity policy, dated 02/03/25, documented the facility would ensure the residents' right to dignified existence, self-determination and person-centered care with access to people and services inside and outside the community. The community would protect and promote the rights of each resident. The community would treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance and enhancement of his/her quality of life, recognizing each resident's individuality. The community would provide equal access to quality care regardless of diagnosis, severity, condition, or payment source. The community would support the resident in the exercise of his or her rights. The community would ensure residents can exercise his/her rights without interference, coercion, discrimination or reprisal. - R19's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of paraparesis (partial paralysis, usually affecting only the lower extremities), major depressive disorder (major mood disorder that causes persistent feelings of sadness), disorders of teeth and supporting structures, dysphagia (swallowing difficulty), and contracture (abnormal permanent fixation of a joint or muscle). The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 14 which indicated intact cognition. The MDS documented R19 had an impairment of both sides of his upper and lower body. The MDS documented R19 was dependent on staff for all activities of daily living (ADLs) except eating R19 needed supervising and touching assistance. R19's Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) dated 02/04/26 documented impaired mobility self-care deficit related to paraplegia and polyneuropathy (a condition that affects multiple peripheral nerves in the body, affecting sensation and movement). R19's Care Plan documented the following: 04/28/25-Setup assistance with adaptive equipment and supervision assistance with meals. 05/29/25-Half portions at meals to lose weight. 11/12/25-Mechanicl soft consistency. 02/04/26-Supervision to partial assistance with meals On 03/02/26 at 9:15 AM, Certified Nurse's Aide (CNA)M stood by R19's right side and assisted him with eating a bite of bacon. On 03/04/26 at 08:11 AM, CNA O stated staff have all been in serviced to sit next to the resident the CNA was helping. She stated nursing staff were never to stand over a resident to assist the resident with eating. On 03/04/26 at 08:35, Licensed Nurse (LN) I stated she was unsure how staff should be positioned when assisting residents with eating. LN I stated she had seen staff stand and sit. 03/04/26 at 08:04 Administrative Nurse D stated staff have been in serviced to sit in a chair, and converse with the resident the staff were assisting. The facility's Resident Rights and Responsibility's policy dated 02/25 documented the community would ensure the residents' right to a dignified existence, self-determination and person-centered care with access to person and services inside and outside the community. The community would protect and promote the rights of each resident. The community would treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life.

The facility identified a census of 51 residents. The sample included 14 residents with five reviewed for immunization status. Based on record reviews and interviews, the facility failed to offer and administer or obtain an informed declination for the Pneumococcal Conjugate Vaccine (PCV20- vaccination for bacterial pneumonia infections) vaccination for Resident (R)3Findings included:- Review of R3's clinical record revealed the PCV13 was administered on 10/30/15, and the PSV23 was administered on 11/12/04. R3's clinical record lacked documentation the PCV20 was offered or declined and lacked documentation of a historical administration or a physician documented contraindication.On 03/04/26 at 08:04 AM, Administrative Nurse D stated the nurse who admitted the resident was responsible for ensuring the resident or family signed a consent or declination for immunizations. Administrative Nurse D stated the signed consent or declination form was uploaded in the resident's chart and Administrative Nurse D was notified if the resident was to receive any immunizations. Administrative Nurse D stated she was unable to find the consent or declination for R3 as the room the forms had been stored in had flooded. She stated R3 had signed the consent on 03/03/26 and the immunization was administered.The facility's Immunizations-Pneumococcal policy, revised 04/14/25, documented residents were provided the opportunity and encouraged to receive the Pneumococcal vaccines. At the time of admission, the nurse would determine the residents' vaccination history by resident information, the family or primary care provider and document on the immunization record.

The facility reported a census of 51 residents; the sample included 14 residents, with 9 residents reviewed for accidents. Based on observation, interview, and record review, the facility failed to provide follow-up fall assessments for Resident (R) 4 and failed to assess for R7's ability to safely use an electric recliner until after a fall occurred.Findings included:- R7's Electronic Medical Record (EMR) recorded diagnoses of, diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), restless leg syndrome (RLS - neurological disorder causing painful urge to move the legs, accompanied by creeping, crawling, or tingling,) and peripheral neuropathy (weakness, numbness, and pain from nerve damage, usually in the hands and feet. R7's Quarterly Minimum Data Set (MDS), dated [DATE], recorded the resident had a Brief Interview for Mental Status (BIMS) score of 12, which indicated moderate cognitive impairment. R7 required staff supervision with bed mobility and transfers. The Cognitive Loss Care Area Assessment (CAA), dated 04/21/25, recorded R7 had cognitive impairment. The Fall CAA, dated 04/21/25, did not trigger. The Activities of Daily Living (ADL) Care Plan, dated 04/21/25, directed staff to provide R7 set up to supervision assistance with most ADLs, nursing was to monitor declines, and provide therapy if needed. The ADL CAA documented R7 had impaired mobility and a self-care deficit due to impaired vision, impaired hearing, morbid obesity, and pain. The Fall Care Plan, dated 04/22/25, documented the resident was at risk for falls due to impaired vision, impaired hearing, right and left foot drop, and neuropathy. The care plan documented staff would have the resident's call light within reach and encourage the resident to use it for assistance as needed. The care plan documented the staff would ensure the resident wore appropriate footwear when ambulating or mobilizing in the wheelchair. The care plan documented staff would monitor the residents for declines The Fall Risk Assessment, dated 10/07/25 and 12/05/25, documented a score of 13.0, indicating R7 was at risk for falls. The electronic Health records lacked an assessment for the use of a lift chair for R7. The Nurse's Note, dated 12/05/25 at 01:25 AM, recorded the resident had a fall from her lift recliner when she raised the recliner to a high position and slid forward out of the recliner. Staff heard the resident yelling and upon entrance to R7's room, noted she was sitting on the floor on her bottom, with her legs stretched out in front of her. R7's recliner was noted to be all the way up. R7 verbalized she attempted to get out of her recliner and raised it too far, causing her to slide out of the chair and onto the floor. An assessment was completed and revealed R7 sustained a skin tear to her left upper hand measuring 1.4 centimeters (cm) by 1.0 cm. No other injuries were noted. Staff assisted R7 from the floor and returned her to the recliner with three staff assistance and the total body mechanical lift. The Physician's Order, dated 12/05/25 at 07:21 AM, instructed staff to cleanse the resident's skin tear to the back of R7's hand with skin cleanser, apply an antibiotic ointment, then cover with a dressing one time a day for three days and discontinue when healed. The Nurse's Note, dated 12/05/25 at 12:01 PM, documented R7's daughter agreed to disable the lift/recliner's automated functions and stated she would come to the facility and visit with the resident to lessen R7's anxiety with the change. On 03/02/26 at 11:30 AM, observation revealed R7 seated in her recliner and dressed in street clothes. The resident sat half off of the chair and scooted to the end of the recliner, yelling it was hot in her room and told staff to open her window. On 03/04/26 at 09:30 AAM, Administrative Nurse D verified the resident had a fall out of her electric recliner chair in December 2025. Administrative Nurse D verified the resident had impaired cognition and stated R7's family brought the electric lift recliner to her in October 2025, and the facility failed to complete an electric lift chair assessment at that time. Administrative Nurse D verified a lift chair assessment should have been completed when the chair arrived, yearly, and with a change of condition. The facility's Falls policy, dated 11/01/24, documented resident would be identified for risk of falls and interventions implemented to reduce risk. A Fall Risk Evaluation Tool would be completed for a resident on admission, quarterly and when there is a significant change of condition, and as applicable after a fall and if the resident was a high-risk status, that would be documented on the Comprehensive Plan of Care. - R40's Electronic Medical Records (EMR) documented diagnoses that included repeated falls, right arm fracture, anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), difficulty walking, and muscle weakness. R40's 07/03/25 Significant Change Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. The MDS documented R40 had a fall with a major injury. R40's Falls Care Area Assessment documented R40 was at risk for falls related to a history of falls, including a fall with a fracture, incontinence, impaired vision, impaired mobility, and medication use. R40's Care Plan documented R6 was at risk for falls; revised on 07/03/25, and documented R40 has been instructed to use her call light for assistance and directed staff to reinstruct as needed. R40's Incident Note dated 07/01/25 at 03:05 documented R40 laid on her right side with her right arm pinned underneath her on the floor in her room with blood droplets on the carpet. R40's right wrist was swollen. R40 had a skin issue on the right upper eye and the right side of her forehead. R40 was bleeding near her eye and swelling to the right upper eye and forehead. The provider was notified, and R40 was sent to the emergency room. The Neurological Checks for fall on 07/01/2025 at 07:20 AM have the initial check with vital signs from 03:15 PM. The second 15-minute check has vital signs from 03:18 PM. The third and fourth 15-minute checks, the two 30-minute checks and the first 60-minute checks were not completed because R40 was in the hospital. The second 60-minute check documented was completed on 07/01/25 at 10:00 AM, but the vital signs were from 03:29 PM. The third 60-minute check documented was completed at 07/01/25 at 12:14 PM, but the vital signs were documented at 03:32 PM. The fourth 60-minute check lacked a time it was completed, but the vital signs were time-stamped 06/29/25 at 07:00 AM, prior to the fall. The first shift check lacked a time it was completed, but the vital signs were time-stamped 06/29/25 at 07:00 AM, prior to the fall, and no assessment was completed. The fourth shift check lacked a time it was completed, but the vital signs were time-stamped 06/29/25 at 07:00 AM, prior to the fall, and no assessment was completed. The seventh shift check lacked a time it was completed, but the vital signs were time-stamped 06/29/25 at 07:00 AM, prior to the fall, and no assessment was completed. On 03/03/26 at 07:45 AM, R40 was independent in her room and walked into the bathroom. On 03/03/26 at 7:51 AM, R40 independently walked with her walker to the dining area, R40 parked her walker next to the wall and got into her chair without assistance. On 03/04/26 at 8:44 AM, Certified Nurse Aide (CNA) P stated when a resident fell, the nurses assessed the resident and documented vital signs for several days after. On 03/04/26 at 9:00 AM, Certified Nurse Aide (CNA) H stated the nurse completed a head-to-toe assessment when a resident fell. The nurse checked vital signs and started neurological assessments, notified the doctor and family. The nurse on duty opened the neurological assessment that they used to document the follow up neuros. The nurse completed the Post Fall Assessment and started the risk management. The nurse always started neurological checks if the fall was not witnessed or if the resident hit their head. On 03/04/26 at 12:03 PM, Administrative Nurse D stated when a resident fell the nurse was to assess the resident for injury which included vital signs and a neurological assessment. They assist the resident up or call emergency medical assistance. Start the neurological assessments unless you can prove they did not hit their head. Complete the other assessments. The facility's policy Neurological Assessment dated` 02/03/25 documented the neurological screening is conducted by a licensed nurse on residents who sustain a head injury. The neurologic screening in the EMR is completed every 15 minutes for an hour, them ever 30 minutes for an hour, then every hour for four hours, then every four hours for 16 hours, then every shift for three days.

The facility identified a census of 51 residents. The sample included 14 residents. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 8 remained free of significant medication errors when staff failed to administer his potassium (a medication for hypokalemia (low level blood potassium in the blood) ordered by physicians.Findings included:- R8's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of fluid overload, hypokalemia (low potassium), hypertension (elevated blood pressure), dementia (a progressive mental disorder characterized by failing memory and confusion), unsteadiness on feet, muscle weakness, and repeated falls.The admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of four which indicated severely impaired cognition. The MDS documented R8 received a diuretic (a medication to promote the formation and excretion of urine).R8's Dehydration/Fluid Maintenance Care Area Assessment (CAA) dated 01/22/26 documented a risk for dehydration related to the use of diuretics, impaired mobility, a wound, dementia, and constipation.R8's Care Plan documented the following:01/28/26-R8 was at risk for adverse reactions related to polypharmacy, and the use of Black Box Warning (BBW- highest safety-related warning that medications can have assigned by the Food and Drug Administration). R8 would be free from adverse drug reactions through the review date.R8's EMR under the Discontinued Orders tab revealed the following physician order:Potassium oral tablet, give 40 milliequivalent (mEq) by mouth three times a day related to hypokalemia until 02/17/26Review of the R8's Medication Administration Record (MAR) for February 2026 documented on 02/13/26: Pending confirmation, potassium oral tablet give 40 mEq by mouth three times a day related to hypokalemia until 02/17/2026. Start Date 02/14/2026 08:00 AM -Discontinue Date 02/20/2026.R8's clinical record lacked evidence that the potassium dose was administered or rescheduled and lacked evidence the physician was notified that the medication was not administered as ordered on starting 02/14/2026.On 02/13/26 at 05:00 PM, a Health Status Note documented the nurse received an order form Nurse Practitioner. The note stated new order for R8 whose potassium level was low; take Potassium 40 mEq three times a day for three days then recheck A Comprehensive Metabolic Panel (CMP) (a routine blood test) and magnesium level on Tuesday, 02/17/26.On 02/18/26, a Fax Form Non-Immediate Communication was faxed to the physician documented facility had received a verbal or [NAME] on 02/13/26 for Potassium 40 mEq three times a day for three days related to low potassium levels. This medication was missed and R8 did not receive the prescribed dose. Potassium level was rechecked on 02/17/26 with result of 3.8. The physician's response was, no need for potassium at this time.On 02/20/26 at 07:08 AM under Heath Status Note documented received response from physician concerning the following clarification requests: R8 does not require strict intake and output monitoring. Exchange Foley catheter (a tube inserted into the bladder to drain urine into a collection bag) with a 16French (type of foley) today and every 30 days. Potassium rechecked on 02/17/26 with a result of 3.8, no need for potassium.On 03/04/26 at 08:04 AM, Administrative Nurse D stated the potassium for R8 was missed. She stated the nurse on duty had not worked for several years. Administrative Nurse D stated the nurse on duty put the order in Pending, and the order never went on the MAR. She stated the second check for each order was the medical records nurse, since the order was stuck in Pending the second check was unable to catch the error. Administrative Nurse D stated as soon as the error was caught, a note was faxed to the physician.The facility's Medication Error policy, revised 02/25, documented the community would ensure that residents are free of any significant medication errors. Medication errors would be immediately reported to the physician and director of nursing or designee. Medication errors would be documented on care Incident Tracking Report. Notify resident's responsible party. If medication errors originated at the pharmacy, the pharmacy would be notified immediately. Medication errors would be tracked for quality insurance purposes.

The facility reported a census of 46 residents with six residents selected for review and four residents sampled for notification of change. Based on record review and interview, the facility failed to notify the physician timely regarding lack of monthly catheter changes and failed to assess, document, and notify the physician with a change in condition when staff alerted the Licensed Nurse of swelling and redness to R2's penis and scrotum on 08/14/24 at 09:00 PM. On 08/15/24 at 03:52 PM, over 18 hours later, R2 required emergency medical transport for further evaluation and treatment. Findings included: - The Diagnosis tab for Resident (R) 2 included diagnoses of hemiplegia (paralysis of one side of the body) following cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain) affecting his right dominant side, aphasia (condition with disordered or absent language function), neuromuscular dysfunction of the bladder (the muscles that control the flow of urine out of the body do not relax and prevent the bladder from fully emptying), and need for assistance with personal care. The Annual Minimum Data Set (MDS) dated [DATE], assessed R2 with a Brief Interview of Mental Status (BIMS) score of 15 indicating intact cognition, he did not reject care, and had an indwelling catheter (tube placed in the bladder to drain urine into a collection bag). The Urinary Incontinence and Indwelling Catheter Care Area assessment dated [DATE] revealed due to R1's aphasia, he communicated by nodding, shaking his head, using hand gestures, and non-discernable vocalizations. R2 had a catheter due to neurogenic bladder, wore a leg bag for the catheter, and usually emptied himself per his preference. R2 usually did toilet transfers himself but would be safer with allowing staff to assist him. The Quarterly MDS dated [DATE], assessed R2 with a BIMS score of 13, indicating intact cognition, he rejected care daily, and continued to have an indwelling catheter. The Care Plan dated 08/12/21, revealed R2 may resist staff attempts to provide catheter care and the staff were to ensure he had the supplies to do his own cares at those times as he may of felt capable he could do it himself. The staff were to change his catheter every 30 days and R2 would frequently refuse to allow staff to do so. The staff were to observe for any pain and/or discomfort related to the use of the catheter and notify his physician as needed. R2 did not always get the valve tightened after draining his bag and it would leak, so the staff were to ensure his brief and clothes were clean and dry. Record review of the Electronic Treatment Administration Record (eTAR), dated April 2024 through August 2024, for R2 revealed the staff last changed his urinary catheter on 04/15/24. The eTAR instructed the staff to change the catheter monthly on the 15th and as needed. On 05/15/24, LN G documented a N for the catheter change, indicated treatment not administered. On 06/15/24 LN G documented a R for R2's catheter change, indicated resident refused. On 07/15/24 LN G documented R for R2s catheter change. The Interdisciplinary Notes dated 05/07/24 through 05/27/24 lacked notification to the physician regarding catheter change not administered. The facility failed to notify the physician R2's catheter did not get changed. The Interdisciplinary Notes lacked any entries between 08/07/24 at 03:21 PM and 08/15/24 at 03:03 PM. The Interdisciplinary Notes dated 06/20/24, revealed R2's physician was in the facility to see resident and discussed refusal of catheter changes. The facility failed to notify the physician until five days after the refusal. The Interdisciplinary Notes dated 07/18/24 revealed R2's physician was in the building and discussed resident refusal of catheter change. The facility failed to notify the physician until three days after the refusal. The Interdisciplinary Notes dated 08/15/24 at 03:03 PM, by LN H revealed R2 complained of not feeling well and pointed to his head when asked about pain. R2 accepted Tylenol (analgesic medication). A Certified Nurse Aide (CNA), lacked name, reported R2 had swelling of his scrotum and penis. LN H and Consultant Staff GG went to R2's room to assess and noted R2's penis and scrotum were swollen and red throughout, without warmth or tenderness to touch. The Interdisciplinary Notes dated 08/15/24 at 03:31 PM, by LN H revealed Consultant Staff GG seen R2 in the facility for a 60-day visit. Via a physician visit form, R2 had scrotal cellulitis (skin infection caused by bacteria) and catheter issues. The physician ordered Rocephin (antibiotic), one gram, intramuscular, every 24 hours, for three days, and Bactrim DS (antibiotic), twice daily, by mouth, for 14 days. The Interdisciplinary Notes dated 08/15/24 at 03:55 PM, by LN H revealed R2 had blood urine output, complained of increased pain, and feeling the need to empty his bladder. R2 agreed to go to the emergency room for evaluation. The staff called 911 and R2 left the facility with emergency medical services at 03:52 PM. On 08/20/24 at 08:35 AM, LN G stated she did not call R2's physician when he refused for his catheter to be changed. On 08/20/24 at 11:08 AM, LN H stated one of the CNA's, she could not recall who for sure alerted her on 08/15/24 that R2 had redness and swelling of his penis and scrotum. LN H stated R2 appeared not to feel very well, there was very little urine in his bag, and his urine was red. Consultant GG went with her to assess R2 and ordered Rocephin injection for three days and Bactrim DS for 14 days. LN H stated Administrative Nurse E accompanied her to tale with R2 about the Rocephin injection and Administrative Nurse E assisted R2 to the bathroom and emptied his urinary drainage bag which did not have much in it. R2 complained of feeling a lot of pressure and agreed to being sent out. Consultant Staff GG stated we could send him out if R2 became worse. LN H stated R2 was willing to go, and allowed the injection, which is how she knew he was not feeling well at all. LN H stated she did not receive any information in report about R2 having swelling and/or redness of his penis and scrotum. Additionally, LN H stated she would get report from the night shift of R2's refusal for the catheter to be changed, she did not try to change it when reported to her, she let Administrative Nurse D know, and waited for direction on how to go about that but did not receive any. LN H was not aware if the physician had been notified of not of R2's refusals, and stated if a resident refused she would fax the doctor to report the refusal. On 08/20/24 at 12:14 PM, Administrative Nurse E stated the CNA's (lacked names) told LN I about R2 having swelling to his penis and scrotum, and LN I did not document about it or report it on. The CNA's reported to LN H R2's complaint of pain and the swelling of his penis and scrotum, who did not know what the CNA's were talking about. Consultant Staff GG was in the facility at that time and so he went with LN H to look at R2. Administrative Nurse E stated LN H asked her to verify the Rocephin mixture with her and then she went with LN H to R2's room. Administrative Nurse E stated R2's penis was swollen and huge and one testicle was enormous and red and she could tell R2 did not feel well. Administrative Nurse E stated R2 had his leg beg and asked if he wanted it emptied, the bag lacked any fluids and inside the bag was a deep dark red/maroon color. Administrative Nurse E stated she informed R2 there was nothing in it, R2 denied emptying it when asked, and told R2 after pressing on bladder if he was not urinating, he should go to the hospital, which he agreed, and was sent to the emergency room . Administrative Nurse E stated LN H read R2's notes in the chart and it lacked documentation about the swelling. Administrative Nurse E stated what the CNA's observed on 08/14/24 should have been documented, reported to next shift, the on-call physician notified, and/or should have shipped him out. On 08/20/24 at 12:27 PM, attempted to interview LN I, which was unsuccessful. On 08/20/24 at 12:34 PM, attempted to interview CNA P, which was unsuccessful. On 08/20/24 at 12:36 PM, attempted to interview CNA Q, which was unsuccessful. On 08/20/24 at 12:38 PM, CNA LL stated on 08/14/24 she was in R2's room with CMA R and CNA M. CMA R assisted R2 to the bathroom while CNA LL and CNA M changed his sheets. CNA LL R2 could not stand for very long and normally R2 took himself to the bathroom. We had tried to put his catheter bag the correct way, but he would not let us, and she was not sure if he had urine in the bag or not because she was not close enough. CNA LL stated she did not bring up to the charge nurse, could not remember who it was, about needing help with toileting, but mentioned R2's catheter bag. On 08/20/24 at 02:00 PM CNA M stated she along with CMA R assisted R2 to the bathroom and get his sheets changed on 08/14/24, as R2 had a bowel accident. CNA M stated he had come out of his room and had feces coming out of his gown and showed us he was swollen. CNA M stated R2 required assistance of two in the bathroom and usually does on his own, but that night he struggled to standing up for very long. CNA M stated R2's urine in the drainage bag was dark red, looked lie blood, and his penis and scrotum were red and swollen. CNA M stated she reported to LN I around 09:00 PM on 08/14/24 the condition of R2's penis, scrotum, and the appearance of blood in his catheter bag, who said he was busy at the time but would go check on it. On 08/20/24 at 03:25 PM, Administrative Nurse D stated she expected LN I to assess R2 and report his change of condition, swelling, and urine color in the catheter bag to the physician. On 08/20/24 at 04:15 PM, CMA R stated on 08/14/24 she had assisted R2 in the bathroom and tried to do catheter care the best she could. CMA R stated R2's penis and scrotum, the whole area was bulging and red. CMA R stated R2 had come out of his room, which was strange as he liked to stay in his room. CMA R stated in the bathroom R2 required two staff to get him up and clean him after a bowel movement. CMA R stated she reported that to LN I as well as the catheter bag, at first, she has thought the bag looked purple and was full of blood, but then went back and told LN I it was just urine. CMA R stated she told LN I R2's penis and scrotum looked inflamed and did not look right. CMA R stated after that LN I had a phone call and did not know if he looked at R2 or not. The facility policy Notification Parameters - Primary Care Provider [PCP] dated 10/13/21, revealed Licensed Nurses have the responsibility of contacting a PCP any time a resident has developed a clinical problem requiring PCP intervention. Prior to contacting the PCP, an assessment must be performed by the Licensed Nurse. The following information should be available and provided to the PCP, as appropriate: vital signs, findings from a complete focused head-to-toe assessment, current mental status and whether it was a change, current diagnoses, allergies, current medications, relevant laboratory work/diagnostic studies, actions already taken, presence of advance directives, and hospice care/comfort measures. If situations requiring immediate action, contact emergency medical services to request immediate transport to the hospital. Notify attending PCP of the transport as soon as possible. The staff were to document in the clinical record assessment findings, all attempts to contact the PCP, information provided to the PCP, PCP's response and orders, resident status and response. For non-immediate notifications, the staff should notify the physician during normal office hours and generally not later than the next regular office day. The facility failed to notify the physician timely regarding lack of monthly catheter changes for May, June, and July 2024 for R2. The facility failed to assess R2 and notify the physician of R2's condition changes timely on 08/14/24 at 09:00 PM, who then over 18 hours later, required emergency medical transport for further evaluation and treatment on 08/15/24 at 03:52 PM.

The facility reported a census of 46 residents with five residents selected for review, including three residents sampled for accidents. Based on record review and interview, the facility failed to investigate a fall on 07/16/24, conduct a complete assessment, and implement a new intervention following the fall for Resident (R)1, that had previous falls in the facility. On 07/17/24, R1 had an additional fall, which the facility failed to complete an assessment and implement a new intervention following the fall. Additionally, the facility failed to notify the responsible party and the physician following falls on 07/16/24 and 07/17/24. Findings included: - The Diagnosis tab lacked diagnosis for R1. The Minimum Data Set (MDS) tab in the electronic medical record revealed R1 entered the facility on 07/12/24 and discharged on [DATE]. The Admission MDS was not due during R1's stay. The Fax sheet dated 07/12/24, from the physician office included diagnoses for medication use, which included mixed incontinence and dystonia (impairment in muscle tone). The Baseline Care Plan dated 07/12/24 at 09:19 AM, located in the attachment tab, revealed R1 was orientated to person and place and had upper and lower dentures. He used a walker for mobility and required supervision for walking, limited to extensive assistance for transfers, and limited assistance for bed mobility. R1 had incontinent and continent episodes of bowel and bladder and required staff assistance with peri-care. R1 was a fall risk and interventions included a low bed and a wireless bed alarm/pad. The Fall Risk Assessment Tool dated 07/13/24, assessed R1 with a risk score of 18 indicating a high risk for falls. The facility Incident log, dated 05/21/24 through 08/19/24, revealed R1 fell on [DATE] at 07:00 PM and acquired a skin tear, and again on 07/14/24 at 09:50 PM. The log lacked any additional falls. The Interdisciplinary Notes dated 07/12/24, revealed the facility installed a handlebar in front of the toilet in R1's room to prevent falls. The Interdisciplinary Notes dated 07/12/24 through 07/17/24 revealed R1 fell four times during his six-day stay at the facility. The Interdisciplinary Notes dated 07/13/24 at 11:14 PM, revealed at 07:00 PM, an unidentified Certified Nurse Aide (CNA) notified Licensed Nurse (LN) G that R1 was on the floor. LN G assessed R1 to be alert and oriented, sitting on the floor by the nurse's station door with one hand holding onto a chair. R1 had a skin tear to his right elbow. The assessment revealed the fall was witnessed by three unidentified CNA's/Certified Medication Aides (CMA's). R1 required two facility staff to assist him to a chair. R1 stated he was standing up to go to his room and missed his walker handle and fell bottom down. The facility staff reminded R1 to never get up alone without nurse's help. The Interdisciplinary Note dated 07/14/24 at 11:20 PM, revealed at approximately 09:50 PM, an unidentified CNA notified LN G that R1 was sitting on the floor facing his bed with a new brief in his hand. R1 stated he slid from the bed when trying to reach for something. R1 required two staff to assist him to bed and they placed a fall mattress next to his bed. The Interdisciplinary Notes dated 07/15/24 at 11:40 AM, revealed response received from his physician about R1's diagnoses which included R1 had dementia (progressive mental disorder characterized by failing memory, confusion). The Interdisciplinary Notes dated 07/16/24 at 05:25 AM, revealed at approximately 05:00 AM, an unidentified CNA notified LN G that R1 was bleeding from his mouth. LN G examined R1, who had a small bleeding open wound on the inside of the upper lip, which looked like he bit his lip. The Interdisciplinary Notes dated 07/16/24 at 10:01 AM, revealed R1 came out to breakfast and LN J examined his mouth and a cut was present on his upper lip. R1 stated he lost some of his teeth. LN J examined and R1 did not have his lower denture in place and a chipped tooth to the right front upper denture plate. R1 stated he fell out of bed onto the floor. The facility failed to fully investigate the fall, conduct neurological checks (an assessment of sensory neurons and motor responses, to determine whether the nervous system is impaired), and implement a new intervention following the fall to prevent further falls. Furthermore, the facility failed to notify the responsible party and the physician. The Interdisciplinary Notes dated 07/17/24 at 11:26 AM, revealed an unidentified CNA informed LN K that R1 was sitting on his fall mat. R1 was on a fall mat with just a brief on and required two staff to assist him to the edge of the bed. The note lacked any further information regarding the fall, lacked assessment of resident for injury, lacked any new interventions following the fall, and lacked notification to the responsible party and the physician. The facility Notification Report dated 07/13/24 through 08/20/24, for R1 revealed the facility notified R1's family member and the physician on 07/13/24 at 07:30 PM and of his fall. On 07/14/24 at 10:20 PM the facility notified R1's family member and at 10:50 PM notified R1's physician. The report lacked a fall on 07/16/24 and 07/17/24. On 08/20/24 at 01:55 PM, LN L reported when a resident reports a fall and unseen by staff or evidence of and /or injury evident, that would be treated as a fall. LNL stated when a resident falls, the staff were to notify the physician, responsible party and Administrative Nurse D. On 08/20/24 at 02:10 PM, R1's family member stated the staff informed her of the fall in the dining room and the next day when she came in R1 told her he had stumbled on the bed on his way back from the bathroom a little after 03:00 AM. The family member stated two days later the same thing happened during the night, R1 had tripped fell towards the side of the bed and when he was talking, she noticed he did not have his bottom plate in and the big tooth on the top plate was broken. R1's family member stated she was not made aware of those falls and when addressed with Administrative Nurse D why the staff did not notify her, Administrative Nurse D responded probably because it was the middle of the night. R1's family member stated she had told the facility to call her or text, she had her phone with her 24 hours a day, seven days a week. R1's family member stated it was that day she informed the facility she was going to take him home and did the following day as she felt the facility had neglected him. On 08/20/24 at 03:00 PM, attempted to reach CNA N for an interview, which was unsuccessful. On 08/20/24 at 03:03 PM, attempted to reach CNA O for an interview, which was unsuccessful. On 08/20/24 at 03:15 PM, attempted to reach LN G for an interview, which was unsuccessful. On 08/20/24 at 03:20 PM, Administrative Nurse D reported when a resident falls, staff were to use the facility's standard fall protocol, assess for injury, start vital signs, and start neurological checks if the fall had been unwitnessed or if there was a suspicion or observation of them hitting their head. Follow up vital signs are to be done for 72 hours after a fall, and notification to the physician and the family after every fall. If a resident with cognitive impairment says they fell out of the bed, then that should be investigated. Each fall should have a new intervention put in place. The facility policy Fall dated 10/12/22, revealed following a fall the staff were to assess the resident for injury, treat the initial injury, obtain a complete set of vital signs including one orthostatic (measurements of blood pressure and pulse taken with the patient in the supine, sitting, and standing positions to assess low blood pressure and possible blood pooling in the lower extremities resulting in dizziness) blood pressure, and blood sugar if indicated. The staff were to document assessment of resident and investigative elements, review the Fall Intervention Reference sheet for ideas and document in the care plan. Residents with unwitnessed falls should be considered to have hit their head unless they are a reliable historian and can definitely say they did not hit their head. Baseline neurological checks will be done on residents observed on the floor or have unwitnessed falls. With the occurrence of a fall, the staff were to notify the responsible party, physician, and the Registered Nurse (RN) supervisor. If off hours, the staff were to notify the RN on call. The facility failed to investigate a fall on 07/16/24, conduct a complete assessment, and implement a new intervention following the fall for Resident (R)1, that had previous falls in the facility. On 07/17/24, R1 had an additional fall, which the facility failed to complete an assessment and implement a new intervention following the fall. Additionally, the facility failed to notify the responsible party and the physician following the falls on 07/16/24 and 07/17/24.

The facility had a census of 48 residents. The sample included 13 residents. Based on record review and interview, the facility failed to ensure the required members, including the infection preventionist, attended the Quality Assessment and Assurance (QAA) Committee meetings at least quarterly. This placed the residents who resided in the facility at risk for decreased quality of care. Findings included: - On 04/12/23, 07/19/23, 10/18/23, 01/24/24, the facility's Quarterly Quality Assurance Performance Improvement (QAPI) Meeting Attendance Sheets lacked evidence the designated infection preventionist attended the meetings. On 04/15/24 at 12:30 PM, Administrative Nurse D verified the lack of a designated infection preventionist signature on the quarterly meeting sign-in sheets and stated the facility had not employed an infection preventionist at the times of the quarterly meetings. The facility's Quality Assurance Process Improvement Plan (QAPI), revised 01/15/24 documented that the goal of the QAPI was to promote autonomy while maintaining safety and quality of care. The steering committee, comprised of department directors, would oversee the QAPI process and would meet monthly to prioritize and monitor the plans in place as well as new projects. The facility failed to ensure the required participants, including the infection preventionist, attended QAPI/QAA meetings at least quarterly. This placed residents at risk of decreased quality of care.

The facility identified a census of 48 residents. The facility had three medication carts. Based on observation, record review, and interview, the facility failed to ensure reconciliation of controlled medications (substances that have an accepted medical use, and have a potential for abuse, ranging from low to high, and may also lead to physical or psychological dependence) was completed consistently and per industry standards. This placed residents at risk of medication misappropriation. Findings included: - On 04/11/24 at 07:50 AM a review of the April 2024 Eight Hour Verification Controlled Substance Count sheet on the locked memory care unit revealed a missing signature either for the on-coming nurse signature or the off-going nurse signature on 13 of 62 opportunities. On 04/15/24 at 10:45 AM a review of the April 2024 Eight Hour Verification Controlled Substance Count sheet on the nurse's cart revealed a missing signature either for the on-coming nurse signature or the off-going nurse signature on four of 84 opportunities. On 04/15/24 at 10:50 AM a review of the April 2024 Eight Hour Verification Controlled Substance Count sheet on the medication aide's cart revealed a missing signature either for the on-coming nurse signature or the off-going nurse signature on 12 of 84 opportunities. On 04/11/24 at 07:50 AM Certified Medication Aide (CMA) R stated that the narcotic sign-on/off sheets should be signed by both the nurse and or medication aide when coming on shift or when going off shift after the narcotic count has been completed and reconciled by both staff. On 04/15/24 at 10:55 AM Licensed Nurse H stated that at the beginning or end of every shift, each staff member either coming on or going off their shift should be signing off that the count had been completed on the controlled narcotic medications. On 04/15/24 at 11:00 AM Administrative Nurse D stated she was aware that all the nursing staff passing medications had not been signing off and on for the narcotic counts as they should have been doing. Administrative Nurse D stated had just started a performance improvement project (PIP) to reconcile this issue. Administrative Nurse D stated the facility had not had an issue with controlled medications missing or the count being off on them. The Medication Storage-Controlled Meds policy last revised 10/08/21 documented that the nurse on duty who accepted the count would maintain possession of the key to the controlled medication storage areas at all times until the next count. The Count Reconciliation Log will be placed in front of each narcotic sign-out book. At the beginning of each narcotic count, count the number of medication accountability records to see that the number of count sheets matches the number on the reconciliation log. At each shift change, a physical inventory of controlled medications was to be conducted by two licensed/certified staff, one oncoming, and one offgoing, and was documented on the Eight Hour Verification Controlled Substances Count form. The Director of Nursing (DON) or designee should routinely complete an audit of controlled substances using the Weekly Narcotic Audit form. This audit was to ensure records were accurate and was a part of the community's Quality Assurance and Performance Improvement (QAPI) process. A record of the audit would be maintained in the quality assurance (QA) records. The facility failed to ensure an accurate reconciliation of controlled medications was completed. This placed residents at risk of medication misappropriation and diversion.

The facility had a census of 48 residents. The sample included 13 residents. Based on observation, record review, and interview the facility failed to provide a clean, comfortable, and homelike environment in Resident (R) 35's room. This placed the resident at risk for impaired comfort and dignity. Findings included: - On 04/09/24 at 08:10 AM, observation revealed R35 rested in bed with his eyes closed. There was an overwhelming urine odor in the room. R35's urinary catheter (a tube inserted into the bladder to drain the urine into a collection bag) was not visible. On 04/09/24 at 10:00 AM, R35's room door was open, and a strong urine odor was noted in the hall in front of R35's door to his room. Further observation revealed an approximately 12-inch (in) x 12-inch area of a yellowish wet spot visible on his sheet. R35 was not in his room. On 04/10/24 at 08:10 AM, observation revealed R35's door was closed, but an overwhelming urine odor was still evident by the entrance to his room. On 04/10/24 at 10:00 AM, observation revealed two maintenance staff cleaned R35's carpet and air-conditioner. There was a strong urine odor noted in the room. On 04/11/24 at 08:00 AM, R35's room door was closed, but a strong urine odor was noted by the door to his room. On 04/11/24 at 08:31 AM, observation revealed R35 sat up in bed with his glasses on. There was an overwhelming urine odor noted in the room. On 04/15/24 at 08;30 AM, observation revealed R35 rested in bed with his eyes open. There was a strong urine odor in the room. R35's clinical record including the plan of care lacked interventions or documentation regarding staff or facility efforts to decrease the urine odor in R35's room. On 04/11/24 at 01:17 PM, Licensed Nurse (LN) G) stated the urine odor in R35's room was from R35 emptying his urinary catheter bag. LN G said most of the time, the urine ended up on the floor. LN G said R35 refused to let staff assist him with emptying it. On 04/10/24 at 09:35 AM, Administrative Staff A verified the urine odor in R35's room and stated she was unaware of where the urine odor was coming from. Administrative Staff A said she would have maintenance clean the carpet and check the room out. On 04/10/24 at 10:16 AM, Administrative Nurse D stated R35 was fiercely independent and emptied his catheter bag himself. Administrative Nurse D said R35 frequently spilled urine on the carpet. Upon request, the facility did not provide a room cleaning policy. The facility failed to provide a clean, comfortable, and homelike environment for R35. This placed the residents at risk for impaired comfort and dignity.

The facility had a census of 48 residents, with three reviewed for the Center for Medicare and Medicaid Services (CMS) beneficiary liability notices. Based on record review and interview, the facility failed to provide a CMS Form 10055 which included the estimated costs for Resident (R) 32 and R41. This placed the residents at risk for uninformed decisions regarding skilled services. Findings included: - The Medicare Advance Beneficiary Notice (ABN) Form 10055 informed the beneficiaries that Medicare may not pay for future skilled therapy and did not provide an estimated cost to continue their services. The form included an option for the beneficiary to (1) receive specified services listed, and bill Medicare for an official decision on payment. I understand if Medicare does not pay, I will be responsible for payment, but can appeal to Medicare. (2) receive therapy listed, but do not bill Medicare, I am responsible for payment of services. (3) I do not want the listed services but lacked documentation regarding which option the residents choose. A review of the ABN Form 10055 provided to R32 (or their representative) lacked the estimated cost to continue services or which option R32 chose when the resident's skilled services ended on 04/09/24. A review of the ABN Form 10055 provided to R41 (or their representative) lacked the estimated cost to continue services and which option R41 chose when the resident's skilled services ended on 11/10/23. On 04/11/24 at 11:11 AM, Administrative Staff B stated she was responsible for providing the CMS Form 10055. Administrative Staff B verified the forms for R32 and R41 did not include the estimated cost to continue services or the option the residents or their representative chose. Administrative Staff B said she was unaware she was supposed to provide the estimated cost and said she must have missed the fact the residents or representatives had not chosen an option for the beneficiaries. On 04/11/24 at 11:11 AM, Administrative Staff A verified the facility lacked documentation staff provided the estimated cost on the ABN form. Upon request, the facility did not provide a policy regarding beneficiary notification. The facility failed to provide R32 and R41 with the estimated cost to continue services or the option chosen on the CMS Form 10055, placing the residents at risk for uninformed decisions regarding skilled services.

The facility reported a census of 41 residents, with one resident reviewed for elopement. The facility failed to ensure staff provided appropriate supervision for cognitively impaired Resident (R1), who resided in a locked memory care unit, when staff accompanied the resident to the Chapel in the Independent Living Facility area for podiatry services, then left the resident with the contract service staff. On 08/24/23 at 10:10 AM, R1 exited the chapel, ambulated with his walker approximately 100 feet to the unlocked facility exit door, and exited the facility door. R1 then turned right, walked around the front of the building, approximately 400 feet, and sat on the bench under the canopy outside of the entrance door to the facility. On 08/24/23 at 10:25 AM, Certified Nurse Aide (CNA) M observed R1 seated on the front bench, outside of the facility, and notified Administrative Nurse A by phone. CNA M reported she sat outside with R1 for approximately five minutes after notifying Administrative Nurse A, but then left R1 unattended outside of the facility as she left the parking area. R1 remained unattended outside for approximately 15 minutes, per interview and review of camera footage. This deficient practice placed the resident in immediate jeopardy. Findings included: - R1's unsigned Physician Order Sheet (POS), documented the facility admitted the resident on 11/13/22 with diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure) and dementia (progressive mental disorder characterized by failing memory, confusion). The Quarterly Minimum Data Set (MDS), dated [DATE], documented the resident with a Brief Interview of Mental Status (BIMS) of five, which indicated the resident had severely impaired cognition. He was independent with bed mobility, transfer, toileting, and ambulation. He required a walker for mobility. R1's Care Plan, dated 07/22/23, documented staff placed a photo of R1 on his bedroom door to assist him with finding the location of his room. The resident resided on the locked memory care unit. The resident was able to ambulate independently with a four-wheel walker. The Elopement Risk Screen, dated 07/16/23, documented a score of 12, with a score of 10 or greater indicating the resident had a high risk for elopement. Documentation of the elopement screen risk revealed the resident was in a secured area. Review of R1's Electronic Health Records (EHR), on 08/24/23, lacked documentation of R1's elopement (an incident in which a cognitively impaired resident with poor or impaired decision-making ability/safety awareness leaves the facility without the knowledge of staff). Review of R1's Electronic Health Records (EHR), on 08/25/23, the Incident Note, documented Licensed Nurse (LN) G accompanied R1 to the Chapel, for podiatry services. When podiatry completed the resident's podiatry visit, podiatry staff advised LN G that R1 was told he could go back to his room. On 08/24/23 at 10:25 AM, the resident was outside of the facility and sat himself on a bench outside of the facility entrance. Activity Staff Z assisted the resident with his walker into the facility and ambulated with him back into the locked memory care unit. Administrative Nurse D assessed the resident after he was brought back inside the facility. Administrative Nurse D reviewed arial cameras and determined the resident ambulated with his walker approximately 100'from the chapel to the exit door. The resident exited the facility, turned right, then ambulated with his walker to the front of the facility, approximately 400 feet, and sat down on a bench near the front facility entrance. The resident had an unwitnessed exit. According to information found at the website Underground (wunderground.com), on 08/24/23 at 09:53 AM for the local area, the temperature was 93 degrees Fahrenheit, with wind speeds of nine miles per hour. On 08/29/23 at 09:33 AM, Administrative Nurse D confirmed the resident exited the facility by the Chapel located in the Independent Living area, walked around the facility to the front door. She reported she viewed the video footage and R1 exited the building on 08/24/23 at 10:10 AM. She reported CNA M notified her by phone that the resident was outside by himself. LN G reported Activity Staff Z brought the resident inside the facility and ambulated with him to the secured memory care unit. She reported the resident was outside without staff, according to the video, for approximately 15 minutes, and staff brought him back into the facility at 10:25 AM. After he was brought inside and returned to the locked memory care unit, she began staff education at 11:00 AM related to the need for staff members to remain present with residents from the locked unit, at all times. On 08/29/23 at 11:16 AM, Licensed Nurse (LN) G reported on 08/24/23 at approximately 10:00 AM, she assisted R1 from the locked unit to the chapel for podiatry services. She left the chapel to take another resident back to the locked unit, and when she returned, R1 was not in the Chapel area. Contract Podiatry Staff reported R1's services were completed, and the contracted Podiatry Staff member told R1 he could go back to his room. She reported when she stepped out into the hallway to look for the resident and report him missing from the chapel, she saw someone (staff) ambulating with him back towards the locked unit. On 08/29/23 at 11:30 AM, Certified Nurse Aide (CNA) M reported on 08/24/23 at 10:25 AM, she observed R1 sitting on the bench at the front entrance of the facility, without staff accompaniment. She reported she recognized R1 from the locked memory care unit and notified Administrative Nurse D via telephone. CNA M reported she waited approximately five minutes and staff members did not come to assist the resident back into the facility. She was running behind taking another resident to an appointment and she left the resident unattended on the bench as she left the facility parking lot. CNA M verified she should have waited until facility staff arrived to assist R1 into the facility before she drove away. The facility Hazardous Wandering and Elopement (Unwitnessed Exit) Policy, dated 10/12/22, documented that the community would exercise reasonable care to prevent injuries and ensure a secure environment for residents. When staff fail to follow the unwitnessed exit policy, the staff would be counseled, re-educated, and disciplined accordingly. The facility failed to ensure staff provided appropriate supervision for cognitively impaired Resident (R1), who resided in a locked memory care unit, when staff accompanied the resident to the Chapel in the Independent Living Facility area for podiatry services, then left the resident with the contract service staff. The resident left the Chapel, went out the door, walked around to the front of the facility, and sat down, unaccompanied by staff and without staff knowledge. On 08/29/23 at 02:46 PM, Administrative Staff A was provided a copy of the IJ template and notified the facility failure to prevent neglect with the failure to ensure staff provided appropriate supervision to cognitively impaired Resident (R)1, when staff left him unattended while podiatry services performed in the Chapel, at the Independent Living area. When contracted podiatry services completed, R1 left the Chapel, went out the door, walked to the front of the facility to the entrance door, and sat down. CMA M observed the resident outside by himself, notified Administrative Nurse D by phone, waited approximately five minutes, and then left the facility, drove away, and the resident remained outside, without staff. The facility identified and implemented the following corrective action completed on 08/25/23 at 11:00 AM. 1. On 08/24/23 at 11:00 AM, immediate verbal re-education to the on-duty staff regarding that no memory care resident would leave the memory care without staff accompanying them off the unit and the necessity of staying with the residents. 2. On 8/24/23 at 04:00 PM, The Director of Nursing verbally informed the charge nurse, to ensure communication continued for the night shift. The Medical director was also notified. 3. On 08/25/23 at 11:00 AM, The Quality Assurance Nurse had a written Teachable Moment for staff to read, sign. This was completed at approximately 11:25 AM. 4. As needed staff (PRN) and any staff member that was not educated due to not working would be educated regarding elopement prior to being allowed on work. 5. The facility will bring this to the next Quality Assurance and Performance Improvement (QAPI) meeting. The surveyor verified the implemented corrective actions while onsite 08/29/23 at 03:30 PM.

The facility had a census of 36 residents. The sample included 13 residents. Based on observation, record review, and interview the facility failed to identify and assess risk factors for ileus (obstruction of the intestines, caused by immobility of the bowel) and bowel obstruction (a blockage of the flow of bowel stream) and failed to provide the necessary care and services to respond to symptoms related to an ileus for Resident (R) 37, who admitted to the facility with a diagnosis of ileus on [DATE]. R37's care plan lacked direction to staff regarding bowel management. On [DATE] R37 reported abdominal pain, nausea, and vomiting. She had a liquid stool on that day. On [DATE] R37 reported abdominal pain and the staff failed to assess bowel sounds or consider the symptoms relative to the resident's history of ileus. R37 then had no recorded bowel movement from [DATE] through [DATE] and the staff did not perform a bowel assessment in response to the lack of bowel movements. The record documented R37 had one bowel movement on [DATE] and two bowel movements on [DATE]. On [DATE] R37's representative expressed concern to nursing staff of R37's distended abdomen and reported R37 needed to have a bowel movement, or she may end up back in the hospital. In response, staff noted the bowel movements from the two previous days, administered an as needed medication from a standing order, but failed to assess R37's bowel sounds to identify concerns prior to administration of the medication. On [DATE] R37 had increased abdominal pain and distention, transferred to the emergency room , and was diagnosed with a bowel obstruction. On [DATE] R37 returned to the facility on hospice services related to an unresolved ileus. She expired on [DATE]. The facility failure to identify risk factors related to a history of ileus, implement a bowel management plan of care, and adequately assess and respond to the lack of bowel movements and related symptoms placed R37 in Immediate Jeopardy. Findings included: - R37's Electronic Medical Record (EMR) documented the resident admitted to the facility on [DATE] with a diagnosis of an ileus. R37's Significant Change Minimum Data Set (MDS), dated [DATE], documented R37 had a Brief Interview of Mental Status (BIMS) score of 11, which indicated moderately impaired cognition. The MDS documented R37 required extensive staff assistance with most activities of daily living (ADL) except supervision with eating. The MDS documented R37 was always continent of bowel and not on a bowel toileting program. R37's Care Area Assessment (CAA) did not trigger for bowels. R37's ADL Care Plan, documented the resident had impaired physical function related to left femoral neck fracture, weakness, and impaired mobility. The care plan documented an intervention dated [DATE] directing R37 required limited to extensive staff assistance with ADL such as grooming, repositioning, toileting, bathing, transfers, and locomotion. An intervention dated [DATE] directed staff not to leave R37 alone in the bathroom. The care plan lacked direction to staff regarding bowel management or R37's history of ileus until after [DATE]. The Nurse's Note, dated [DATE] at 04:18 PM, documented at 12:30 PM, R37 reported to the nurse she had stomach pain, nausea, and a protruding (bulging) abdomen. R37 reported she had not had a bowel movement (BM) that day. The note recorded the BM charting revealed R37 had a large BM on [DATE]. The note documented staff assisted R37 to a commode per R37's request and R37 had a large liquid stool. The Nurse's Note, dated [DATE] at 04:27 PM, documented staff reported to R37's family member the resident was not conversing that day per usual. R37 complained of abdominal discomfort. The note lacked evidence the staff performed an abdominal/bowel assessment in response to R37's complaint or condition. Review of R37's Bowel Observation Sheet and the EMR revealed R37 had no recorded bowel movement from [DATE] through [DATE]. R37's clinical record lacked evidence and/or documentation staff preformed a bowel assessment in response to the lack of bowel movements. The Bowel Observation Sheet documented on [DATE] R37 had one bowel movement and on [DATE], the record indicated R37 had two bowel movements. The Nurse's Note, dated [DATE] at 05:00 PM, documented R37's family member voiced concern about R37's stomach and how never been so big. The note documented R37's abdomen was distended since admission, appeared to have increased in size recently. R37's family member stated, if R37 did not have a bowel movement here soon, she's going to explode or she'll need to go to the hospital. The note documented the family member requested R37 have something to make her have a bowel movement. The note documented staff reviewed and noted the bowel movements from the two previous days, administered an as needed medication from a standing order, but failed to assess R37's bowel sounds to identify concerns prior to administration of the medication. The Nurse's Note, dated [DATE], documented R37 had increased abdominal pain and distention and was sent to the emergency room (ER). The Nurse's Note, dated [DATE] at 06:12 PM, documented a family member reported to the facility R37 admitted to the hospital for diagnoses of bowel obstruction. The Nurse's Note, dated [DATE] at 12:48 PM, documented R37 was readmitted to the facility on hospice (end of life care) services regarding a diagnosis of unresolved ileus. Review of R37's EMR revealed she expired on [DATE]. On [DATE] at 08:31 AM, Certified Nurse Aide (CNA) M stated she wrote down on a sheet when a resident had a BM and placed the information in the charting in the computer. CNA M said if a resident lacked a BM for three days, the computer alerted the aide, the aides then reported to the nurse, and the nurse printed out a lack of bowel movement sheet. On [DATE] at 08:26 AM, Licensed Nurse (LN) G stated she did not know how frequently the nurse should monitor or assess a resident with a history of ileus, but she thought it was probably every shift. LN G stated signs/symptoms of a bowel obstruction were abdomen distension, no bowel movement, and/or abdominal pain. LN G stated liquid BM could move around a bowel obstruction, but not solid BM. LN G stated if a resident had pain and abdomen distension, she would send them to the emergency room . LN G stated the facility did not have a policy or protocol regarding care of ileus or bowel management. On [DATE] at 09:18 AM, Administrative Nurse D verified staff had not assessed R37's bowels on the dates recorded above. Administrative Nurse D stated staff should have assessed R37's bowels on those dates, should have measured her abdomen girth, and should have sent her to the emergency room earlier. Administrative Nurse D confirmed she could not see interventions on the care plan prior to [DATE], for bowel management and/or care of an ileus but stated the MDS coordinator would need to verify because Administrative Nurse D was not familiar with where the information would be found. On [DATE] at 12:09 PM, LN H verified R37's care plan lacked a section for bowel management and stated the computer program did not have a section for bowel management, so it was sometimes placed in the ADL section of the care plan. LN H verified R37's care plan lacked directives related to bowel management in any section. On [DATE] at 11:00 AM, Physician Consultant HH stated he expected staff to notify him sooner regarding R37's abdominal distention, nausea, and pain. Consultant HH said R37 had chronic problem with her bowels, and she had all kinds of workups for slow, inactive colon and big, dilated bowel, but if he had been notified earlier, he would have sent her to the hospital two days sooner. Physician Consultant HH stated if he had known about R37's problems it might have made a difference in her outcome. Physician Consultant HH stated he expected staff to monitor R37's bowels, check her vitals, and listen for bowel sounds. Consultant HH concluded staff should have been doing bowel assessments and notified him earlier, so R37 could have been sent to the ER earlier. The facility's Bowel Elimination Policy, revised [DATE], documented the charge nurse would be responsible for ensuring that documentation was completed each shift for each resident in regard to their individual bowel function. If two days have passed with no bowel movement, initial measures are to be implemented including but not limited to offering prune juice, prunes at meals, increasing fluid intake, offering food choices with a high fiber content, encourage increased physical activity, encourage a routine toileting schedule, etc., if not contrary to the resident's physical condition. If a resident had no bowel movement recorded in there days or nine consecutive shifts or has positive signs and symptoms of constipation/impaction/bowel obstruction, the licensed nurse would perform an evaluation to include auscultation and palpation. the physician would be notified of bowel status and assessment findings including medication utilization. If the resident is not demonstrating any signs of distress, the physician would be notified of the lack of bowel movements for three days. The licensed nurse would communicate bowel elimination issues and the status of intervention during shift report. The licensed nurse would complete documentation of all assessments or evaluations, treatments, response to treatments, and communication with the physician. The facility failed to identify and assess risk factors for ileus and bowel obstruction and failed to provide the necessary care and services to respond to symptoms related to an ileus for R37. The deficient practice placed R37 in Immediate Jeopardy. On [DATE] the facility implemented the following corrective actions to remove the immediacy: 1. The facility identified the standards of practice related to identification of risk factors, assessment techniques and care of an unresolved ileus. The nursing staff were re-educated related to the standards of practice, the facility's policy and the expected performance to assess residents with a history of ileus, identify resident care needs, train staff and monitor staff performance to deliver care to residents at risk for ileus, and/or obstruction. 2. The Director of Nursing provided education, examples, demonstration and monitoring methods of bowel care expectations. The nursing staff acknowledged understanding and demonstrated competency. 3. The Director of Nursing provided education to direct service staff to accurately record resident bowel activity at the time of the occurrence. The direct service staff acknowledged understanding of the importance of recording bowel elimination results or the lack thereof. 4. Nursing staff and direct service staff were educated on the protocols for intervention in an absence of bowel elimination and the importance of continual assessment and recording results. 5. The Director of Nursing provided education to the licensed nursing staff to develop and publish a care plan addressing each identified need of the resident. The licensed staff acknowledged understanding and demonstrated competency. 6. The licensed nurses were educated on the expectation to provide agency staff the resident interventions to meet the expectations of the care plan. After implementation of the corrective actions, the deficient practice remained at the scope and severity level of G.

The facility had a census of 36 residents. The sample included 13 residents. Based on observation, record review and interview, the facility lacked posting of the Ombudsman and State Hotline contact numbers which placed the residents at risk of unmet care concerns and impaired ability to contact to the state agencies. Findings included: - On 11/21/22 at 03:15 PM Social Service Designee (SSD) X reported the Ombudsman and state reporting information was posted on C Hall, which was under construction and not accessible to residents. On 11/21/22 at 03:21 PM Administrative Staff A verified the Ombudsman and state reporting information was not posted in a visable location due to construction since September 2022. On 11/22/22 at 09:12 AM Administrative Nurse D stated the Ombudsman and state reporting information should be posted where residents could see them. Upon request the facility failed to provide a policy which regarded the Ombudsman and state reporting information. The facility failed to provide the residents information which included contact information for the Ombudsman and state reporting contacts which placed the residents at risk for unmet concerns related to care and services.

The facility reported a census of 48 residents with 16 selected for review, including two residents reviewed for accidents. Based on observation, interview and record review, the facility failed to ensure the two residents reviewed remained free of accidents including resident (R) R23 who experienced 10 falls without appropriate interventions put into place and with the last fall, on 07/30/19, resulting in a head injury which required four staples and R39 who experienced a fall without appropriate interventions in place. Findings included: - R23's signed Physician order [REDACTED]. The admission Minimum Data Set (MDS), dated [DATE], recorded the resident with a Brief Interview for Mental Status (BIMS) of seven, indicating severely impaired cognition. There were no behaviors or rejection of care. Wandering occurred one to three days in the look back period. He required limited assistance with activities of daily living, unsteady on his feet and was only able to stabilize with staff assistance. He had no impairment to his range of motion, and used a cane or walker for mobility. He had a history of [REDACTED]. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 12/14/19, documented the resident was a new admission on the memory care unit. He had some word finding difficulty, but could make his needs known and engage in conversation. The Falls CAA, dated 12/14/19, documented for staff to provide assistance with activities of daily living, strengthening and increased mobility. The resident had difficulty walking due to pain in his right knee, causing an abnormal gait. He also had dementia, was forgetful, and had confusion at times. He ambulated using a cane. The quarterly MDS, dated [DATE], recorded the resident with a BIMS of five, indicating severely impaired cognition. His inattention fluctuated and he wandered one to three days on the look back period. He required extensive assistance with bed mobility, transfers, locomotion, dressing, toileting, and personal hygiene. He was unsteady on his feet and could only stabilize with human assistance. He used a walker and was incontinent of bowel and bladder. He had two or more more falls with injury since the last assessment. The resident's cognition care plan, dated 06/18/19, directed staff that the resident had a BIMS score of five, indicating severely impaired cognition, had word finding difficulty and did best with yes/no questions. The resident often had confusion and disorientation with episodes of delusions that included agitation. The resident's activities of daily living care plan, dated 06/18/19, directed staff the resident needed assistance with grooming, repositioning, and used a cane for ambulation. The resident did not use a call light due to his impaired cognition. Staff were to approach in a calm manner as the resident's frustration increased due to delusions which increased his risk for falls. His patterns of behavior increased in the evening. The resident's fall care plan, dated 06/18/19, included the following dated interventions; 12/9/18, place the resident on the Falling Leaf Program (When staff walk by the resident's door staff would look in on him). 12/16/18, use a bolster on the outside of the bed. 12/27/18, check on the resident frequently, as he does not use a call light and ambulates with a cane with one staff, limited assistance of one staff member. 12/28/18, provide stand by assistance when staff observes the resident ambulating. 01/10/19, do not lay clothes out for the next day, as the resident thinks he has to get up at night. 01/24/19, provide a urinal. 02/1/19, AM cares between 8-9 AM. 02/5/19, do not leave him awake and unattended in the bedroom. 02/13/19, reposition him in bed so the hall lights do not shine on his face 03/23/19, assure staff are following the care plan intervention dated 12/28/18, and provide stand by assistance when he is ambulating by himself. 04/3/19, the resident continues to stand independently even though he is unsafe to do so. 04/8/19 , the resident continues to stand independently even though he is unsafe to do so. 04/29/19, the resident continues to stand independently even though he is unsafe to do so. 04/30/19, the resident continues to stand independently even though he is unsafe to do so. 06/12/19, the resident continues to attempt actions beyond his ability. He most likely will continue to fall due to his poor cognition. 06/23/19, the resident continues to attempt actions beyond his ability. He most likely will continue to fall due to his poor cognition. 07/19/19, the resident continues to attempt actions beyond his ability. The Fall Risk, dated 12/14/18, score was 16, which put him at high risk for falls and indicated the resident had a history of [REDACTED]. The care plan lacked development of appropriate fall prevention strategies after each fall. Progress Notes revealed the following: 04/04/19 at 12:38 AM, resident yelling out for help. Nurse and CNA (certified nursing aide) found the resident on the floor leaning against a chair in front of the night stand at the foot of the bed. He was wearing only one non-skid sock and had an abrasion on left buttock from carpet burn. Resident said he hit his head on the chair. 04/08/19 at 03:49 PM, resident witnessed falling by RN (registered nurse) after attempting to stand and losing his balance. 04/29/19 at 09:59 PM, nurse alerted to resident falling in the hallway. Resident noted on bottom. Staff reports resident was walking out of room backwards, stumbled, fell to his bottom and hit his head. No abrasion or skin issue to head. 04/30/19 at 01:10 PM, informed from a medication aide the resident was on the floor. Upon assessment found a small amount of blood from the left side of his forehead. Staff applied pressure to the area, and a hematoma (collection of blood outside a blood vessel when the blood vessel becomes injured) observed to left forehead. The Physician Communication Sheet, dated 04/30/19, informed the physician of this resident's fall, hitting the left side of his forehead and received a hematoma. 06/12/19 at 6:31 PM, resident talking to CNA behind nurses desk, door opened up and resident lost balance. Nurse slowed down the resident's fall and used arms to protect resident's head. Resident on floor on left side. No new skin occurrences. 06/23/19 at 03:31 PM, nurse informed resident was on the floor. Observed the resident sitting on the floor inbetween the bed and the bathroom. The resident was barefoot. Wet spot in front of the resident suspected to be urine. Resident had an abrasion to the right ring finger. 06/29/19 at 02:09 AM, notified by CNA the resident fell . Entered room to find him sitting against his bed railing facing the bathroom and holding himself up with his left arm. The nurse asked him what he was doing, and he said, trying to get out. Noted a left upper arm skin tear. Denies pain. 07/20/19 at 04:42 AM, nurse informed she was needed in the resident's room. Upon arrival the nurse found the resident gripping on to the front of the wheelchair, with his left hand wedged between the wheelchair and door, and kneeling with his left knee on the floor. The resident complained of right knee pain. 7/29/19 at 05:59 PM, the resident was found on the floor in his room, laying on his left side along the door. He was bleeding from his forehead and left shoulder. The abrasion for his forehead measured 3 cm (centimeters) by 1.5 cm. A skin tear to his shoulder had jagged edges and measured 2 cm by 2 cm . The resident stated, they threw me around like a kitten, I hit my head on the door, I did not know why I was up. The Physician Communication Sheet, dated 07/29/19, informed the physician the resident fell at 11:25 AM. There was an abrasion to the left side of his forehead measuring 3 cm by 1.5 cm. There was a skin tear to the top of his left shoulder measuring 2 cm by 2 cm with jagged edges. 07/30/19 at 08:40 PM, the resident was found on the floor bleeding from his head. The nurse aide held pressure to stop the bleeding. The resident did not speak. The facility called Emergency Medical Services immediately. On 07/30/19 at 09:12 PM, the facility received a phone order from the primary care physician to send the resident to the emergency room per ambulance. 07/31/19 at 02:54 AM, documented staff received a call from the nurse at the hospital who stated the resident received four staples to his [MEDICAL CONDITION]. The resident would return back to the facility. Review of the available Fall Investigation Reports for the above documented falls, lacked a root cause analysis for the falls or appropriate interventions to prevent the resident from repeated falls. On 07/31/19 at 7:26 AM, observation upon entering the resident's room revealed a blood stain on the carpet approximately 12 inches x 4 inches from the fall the previous night when he hit his head on the floor. A cut to the back of the resident's head showed four staples. The resident transferred with assistance of two staff and use of a gait belt to his wheelchair then was taken to the bathroom. On 07/31/19 at 11:00 PM, observation revealed the resident sat in a recliner on the day hall with the night charge nurse sitting beside him. On 7/31/19 at 11:05 PM, Licensed Nurse G reported the resident was on a one to one since his fall with injury. When the resident had a fall, the staff updated the care plan Sometimes all it took to update a care plan was to change one word, like if the care plan said to use reminders to use the call light. She would change the intervention to keep using reminders to use the call light and it would be considered updated. On 07/31/19 at 2:41 PM, with Administrative Nurse D, reported with or without injury there may or may not be new interventions put in place. This resident continued to stand independently even though it was unsafe to do so. I would consider using the resident continued to stand independently even though he was unsafe to do so as an updated intervention as it was reiterating that the resident needed continued monitoring. The facility policy for falls, dated 03/26/19, documented staff would review fall interventions from the reference sheet for ideas as to which interventions to implement and then document the new intervention in the care plan. The Quality Assurance nurse would review fall interventions documented in the resident's care plan and would update as needed. The facility failed to determine the root cause and then develop and implement appropriate interventions for cognitively confused R23 following 10 falls in 4 months to prevent further falls, with the last fall resulting in the resident receiving a [MEDICAL CONDITION] which required an emergency room visit and four staples in his head. - R 39's signed physician's orders [REDACTED]. The annual Minimum Data Set (MDS), dated [DATE], recorded the resident with a BIMS (Brief Interview for Mental Status) of six, indicating severely impaired cognition, fluctuating inattention, and no behaviors or rejection of care. Wandering occurred one to three days during the look back period. He required extensive assistance with dressing, personal hygiene, and limited assistance with bed mobility, toileting and supervision with transfers, ambulation and locomotion. His balance was steady at all times with no impairment with range of motion. There was one fall with minor injury on 07/02/18. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 04-10-19, documented the resident's BIMS score was six (severely impaired cognition). He had difficulty with word finding and completing sentences. He was able to answer simple questions and engage in brief conversations. He was frequently confused and had night time wandering issues. Staff were able to redirect. The ADL Functional/Rehabilitation Potential CAA, dated 04/19/19, documented to provide nursing support to complete activities of daily living. He wandered into other residents rooms often at night and was usually easily redirected back to his room by staff. The Falls CAA, dated 04/10/19, documented to provide the safest environment that was free of falls. He had a history of [REDACTED]. His most recent fall risk score was 10, which made him a high fall risk. The most recent BIMS score was six, indicating severely impaired cognition. Sometimes when the resident was unsettled, safety would be a concern. The quarterly MDS, dated [DATE], documented the resident with a BIMS of seven, indicating severely impaired cognition. He required limited assistance with bed mobility, dressing, toileting, and personal hygiene and supervision with transfers, ambulation and locomotion. There were no falls prior to admission, one non injury fall, and one fall with minor injury since admission. The plan of care, last reviewed 07/17/19, revealed the following interventions related to falls: 1/17/19, bed in lowest position. 03/19/19, frequent reminders not to bend or reach out for objects. 05/11/19, continuous visibility for safety. 07/18/19, bolster pillow while in bed. 07/30/19, Falling Leaf Program. (When staff walk by the resident's door staff would look in on him). A Progress Note, dated 07/13/19 at 01:35 AM, a Certified Nurse Aide (CNA) notified the Licensed Nurse (LN)the resident was on the floor. Resident was lying on his right side with right arm under him, legs bent slightly with right foot resting against the bottom of the recliner with his head against the other recliner. Call light was not going off. While performing ROM (range of motion) he would not allow the LN to move his lower left extremity. He rated his pain as a 10 out of 10 on the pain scale. The LN notified the physician and called EMS (Emergency Medical Services) who transported the resident to the hospital. At 05:38 AM, hospital staff notified the LN the resident transferred to another hospital due to a left [MEDICAL CONDITION]. The Fall Investigation Report, evidenced staff would put a bolster pillow in place in the resident's bed upon his return to the facility for safety. A Physician's Note, dated 07/16/19, instructed staff the resident would be readmitted back to the facility and staff were to place a bed alarm for the resident related to his falls. A progress note, on 07/17/19 no time documented, evidenced facility staff notified the physician that they did not utilize bed alarms however made changes to the resident's care plan to place a bolster pillow in the resident's bed to prevent the resident from rolling out of bed. A progress note, on 07/17/19 at 6:39 AM, documented the resident was found on the floor. When the nurse entered the room, the resident was on his knees and bending over against the bed. He had a hard time following direction when staff tried to get him off the floor. The care plan for falls, dated 07/18/19, instructed staff the resident was to use a bolster pillow for safety. On 07/31/19 at 8:08 AM, Certified Nurse Aid (CNA) staff M and N transferred the resident from the recliner to a wheelchair with use of a gait belt. Staff took the resident to the bathroom and again transferred him with use of a gait belt. Direct care staff N, confirmed staff placed the bolster pillow in the resident's bed after he rolled out of bed on 7-17-19. On 07/31/19 at 2:05 PM, Licensed Nurse (LN) H confirmed staff placed the bolster pillow in the resident's bed after he rolled out of bed on 07/17/19, and the bolster pillow was not put in place when the resident returned to the facility. On 07/31/19 at 2:41 PM, Administrative Nurse D, confirmed staff should have placed the bolster pillow in place when the resident returned to the facility after hospitalization for the [MEDICAL CONDITION]. (As planned in the Fall Investigation Report, dated 07/13/19). The facility policy for Falls, dated 03/26/19, documented staff would review fall interventions from the reference sheet for ideas as to which interventions to implement and then document the new intervention in the care plan. The Quality Assurance nurse would review fall interventions documented in the resident's care plan and would update as needed. The facility failed to implement appropriate, planned (07/13/19 Fall Investigation Report) interventions following the resident's return from the hospital to prevent further falls.