Every finding on record at Evergreen Community of Johnson County

The facility identified a census of 79 residents with one kitchen and two kitchenettes. Based on observation, record review, and interviews, the facility failed to maintain sanitary dietary standards related to food storage. Findings included: - On 02/23/26 at 11:03 AM, during the kitchen initial tour, observation in the walk-in freezer revealed the following:One resealable bag of three fish fillets that was not labeled and dated.One opened bag of pepperoni, which was not labeled and dated. One opened bag of tater tots placed in a resealable bag; the bag was not dated. One opened bag of cauliflower florets, which was not labeled and dated. On 02/23/26 at 11:10 AM an observation in the kitchen's dry food storage room revealed one opened and undated bag of egg noodles. On 02/23/26 at 11:16 AM an observation in the kitchen's walk-in refrigerator revealed one metal bowl with plastic wrap covering the top. The bowl contained several slices of molded cheddar cheese. On 02/23/26 at 11:21 AM an observation in the kitchen's walk-in produce refrigerator revealed the following:One bag of broccoli with a manufacturer best if used by date of 12/21/25.Three bags of coleslaw mix. The coleslaw was soft, mushy, and appeared spoiled. One bag contained brown fluid in the corner of the bag.A plastic bin of eight jalapeno peppers. The peppers were moldy.A plastic bin of green bell peppers. The bin had six green bell peppers on top of the lid. The peppers on the lid were soft, wilted, and wrinkled.A plastic bin of red peppers. There were three peppers on top of the lid. The three peppers were soft, wilted, and wrinkled.A plastic bin of yellow peppers. There were six yellow peppers inside the bin that were soft, wilted and wrinkled. Three of the yellow peppers contained backend, moldy spots. On 02/23/26 at 11:36 AM in the kitchen's main area revealed one plastic container of choy noodles, not dated. On 02/23/26 at 11:50 AM an observation in a kitchenette refrigerator revealed two plastic bins of mixed fruit. The bins were not labeled or dated. On 02/23/26 at 11:50 AM an observation in a kitchenette cabinet revealed one opened bag of prunes and one opened bag of pretzels. The bags were not dated. On 02/23/26 at 11:58 AM an observation in a kitchenette resident refrigerator revealed a box of pizza. The pizza box was not dated or labeled with a resident's name. On 02/23/26 at 12:01 PM an observation in a kitchenette resident refrigerator revealed a plate with a hamburger and tater tots. The plate was covered in plastic wrap. The food was not dated or labeled with a resident's name. On 02/25/26 at 08:30 AM Dietary BB stated staff were expected to label and date any opened food items. He stated opened bags were to be placed in a resealable plastic bag, and the bag should have been labeled and dated. Dietary BB stated he, and the cooks, were supposed to go through the kitchen and check for spoiled foods. He further stated dietary aides often look at produce, such as the peppers, and places what they think are spoiled on top of the bins, instead of just throwing them away. He stated they left them there for him to look at. Dietary BB stated he had sent the dietary aides a message related to the spoiled peppers and stated it would be addressed in their next meeting. Dietary BB stated the dietary aides were responsible for checking the refrigerators in the kitchenettes after each meal to look for spoiled food and ensure food items were labeled and dated. He stated food placed in the resident refrigerators should have been wrapped, labeled, dated, and had the resident's name on them. The facility's Food Storage policy dated 02/12/26, documented sufficient storage facilities are provided to keep foods safe, wholesome, and appetizing. All Leftover food should be stored in a covered container or sealed Ziplock bag. Each Item Is clearly labeled with the product name and dated before being refrigerated. Leftover food Is used within 3 days or discarded. All foods should be stored in covered containers or sealed Ziplock bags, clearly labeled and dated. All foods will be checked to assure that foods (Including leftovers) will be consumed by their safe use by dates, or frozen (where applicable) or discarded.

The facility identified a census of 79 residents. The sample included 18 residents, with one resident reviewed for tube feeding (administration of nutritionally balanced liquefied foods or nutrients through a tube). Based on observation, record review, and interview, the facility failed to ensure R2's tube feeding was labeled with content in the feeding bag and dated with the date the feeding was given. Finding Included:- R2's electronic medical record (EMR), under the Diagnosis tab, recorded diagnoses of muscle weakness, difficulty in walking, hypertension (elevated blood pressure), dementia (a progressive mental disorder characterized by failing memory and confusion), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). R2's Quarterly Minimum Data Set (MDS) dated [DATE] recorded a Brief Interview for Mental Status score of 15, which indicated intact cognition. The MDS documented R2 had impairment on both sides of her lower body. The MDS documented R6 was dependent on staff for toileting and bathing. The MDS documented R6 had a feeding tube and received 51percent of her calories through tube feedings. The Tube Feeding Care Area Assessment (CAA) dated 05/30/25 documented R6 was admitted to this long-term care from another facility, after being sent to the emergency room. The CAA documented R6 had adequate hearing and vision, her speech was clear, BIMS score 15, Foley catheter (a tube inserted into the bladder to drain urine into a collection bag), was always incontinent with bowels, frequent pain, no falls, and significant weight gain. The CAA documented R6 was dependent on assistance with all activities of daily living (ADLs). R2's Care Plan documented the following:05/08/25 - Staff to assist R2 with maintaining or improving nutritional status characterized by weight loss and inadequate intake.05/09/25 - Staff to check residual, if residual was over 150 milliliters (ml), nursing would hold her feeding and call the physician.05/09/25 - Staff to elevate R6's head of bed at a 30-45 degree prior to enteral feed.05/09/25 - R6's calorie intake would be monitored by a Registered Dietitian. Review of the EMR under Orders tab revealed physician orders:Enteral feeding, elevate head of the bed to 30-45 degrees while administering medication and tube feedings dated 05/07/25.Enteral feeding, check tube placement prior to administration of medication and tube feedings every shift dated 05/07/25.Enteral feeding, check and record residual. If residual was greater than 150ml hold feeding and call the physician dated 05/07/25.Enteral flush PEG tube with at least 30ml water before and after medication every shift dated 09/19/25.Enteral feeding flush peg tube with 50ml water prior to starting Nutren (nutritional supplement) 2.0 at 08:00 PM at bedtime dated 09/19/25.Enteral Feed at bedtime Nutren (nutritional supplement) 2.0 continuous feeding pump via PEG tube at 70mls/hour (hr) for 12hrs total, 840ml per day (08:00PM - 08:00AM), Flush tube with 60ml water every hour dated 10/03/25.Enteral feeding, change feeding syringe daily, label and name and date every shift dated 05/07/25.Enteral Feed every shift for medication pass: mlix/reconstitute each medication with 15ml water. Each medication should be prepared and administered separately, followed by 15ml water flush between each dose. Do not crush and combine multiple medications together dated 02/19/26. On 02/23/26 at 07:27 AM, R2 laid on her back in her bed, with her head elevated at 45 degrees. R2 watched TV. R2's enteral feeding bags were hung on her feeding pump. R2's enteral feeding bag was not marked with the contents in the bags, or the date and time the enteral feeding was started. On 02/24/26 at 07:35 AM R2 laid in her bed with her head elevated at 45 degrees. R2 was watching TV. R2's enteral feeding was hung via pump; the pump was running at 70 ml/hr. R2's feeding tube bags were not labeled with the contents in the bags or the date the enteral feeding was started. On 02/25/26 at 08:10 AM, Licensed Nurse (LN) G stated the night shift hangs the bags and was to label and date the feeding bags with the contents and the date. LN G stated we have had different nurses working the night shift. LNG stated the day shift would take the bags when the feeding had ended. On 02/25/26 at 01:23 PM, Administrative Nurse D stated the nurse that hangs the bags would mark the back with the date and the contents inside the bag. She stated it was the night shift nurse's responsibility to ensure feeding bags were marked with the date, time, rate and formula when the bags were started. The facilities Administering Nutritional Formulas through an Enteral Tube policy, undated and documented, staff would label bag and tubing with date and time; hang bag on the pole and make sure bag was above the stomach; clamp tubing. The staff would check expiration date of formula; cleanse top of feeding container with a disinfectant before opening it (if using a canned formula); pour formula into feeding bag and allow solution to run through tubing (Prime the tube); close clamp. Staff would attach feeding setup to feeding tube, open clamp & regulate drip according to physician's order or allow feeding to run in over 30 minutes.

The facility identified a census of 70 residents. The sample included 19 with seven reviewed for accidents. Based on record review, interviews, and observations, the facility failed to utilize safe heat therapy practices for Resident (R) 64. This deficient practice resulted in a second degree (potentially painful burn which affects the first and second layer of the skin) burn on R64's right knee. The facility additionally failed to ensure a safe environment related to maintaining R22's wheelchair and bed fall-prevention alarm. This deficient practice placed R22 at risk for preventable accidents and injuries. Findings Included: - The Medical Diagnosis section within R64's Electronic Medical Records (EMR) included diagnoses of epilepsy (brain disorder characterized by repeated seizures), seizures (violent involuntary series of contractions of a group of muscles), osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain), muscle weakness, and Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure). R64's Quarterly Minimum Data Set (MDS) completed 04/15/24 noted a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The MDS indicated he was independent with toileting, transfers, bathing, dressing, and personal hygiene. The MDS indicated he had no skin impairments or pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). R64's Functional Abilities Care Area Assessment (CAA) completed 01/19/24 indicated he was independent with all of his activities of daily living (ADLs). The CAA indicated he had times of urinary incontinence and was at risk for skin breakdown. The CAA instructed staff to assist him as needed. R64's Care Plan initiated 02/11/23 indicated he was at risk for altered skin integrity. The plan instructed staff to complete weekly skin checks. The plan noted he received a second-degree burn on his right knee related to heat therapy (04/18/24). The plan indicated he would not have any heating packs applied to his right knee until his wound healed. A Facility Reported Incident (FRI) report 7318 dated 04/17/24 indicated Consultant GG worked with R64 in the therapy room. The report indicated R64 complained of knee pain and Consultant GG applied a moist heating pack to R64's right knee. The report indicated the heating pack did not have a protective cover and Consultant GG improvised using multiple layers of towels. The report indicated Consultant GG completed R64's therapy treatment, removed the towels, and noted R64 acquired a blister with clear fluid on the outside of his right knee from the heating packs. The burn measured 2.1 centimeters in length and one centimeter wide. Consultant GG reported the injury to nursing services, R64's medical practitioner, and R64's representative. The report's video review documented Consultant GG applied a gait belt around the towels on R64's right knee. Heat therapy services were immediately suspended by the facility until protective covers for the heating packs could be found or ordered. On 04/30/24 at 01:05 PM R64 sat in his recliner with his meal. R64 reported his burn no longer hurt but was still present. R64 pulled up his right pant leg to reveal his burn wound. R64's wound bed was clean with no signs of infection. The blister was no longer present. R64 denied pain or itching at the wound site. R64 stated the wound occurred when therapy did not use the right cover on their heating packs. He stated he did not realize the wound was occurring during his therapy treatment until the pack was removed. He stated he had never been burned or injured during therapy before or since this incident. He stated therapy was holding off on his treatments until his wound recovered. On 05/01/24 at 08:30 AM Consultant GG stated on 04/17/24 she provided therapy services for R64 when he complained of right knee pain, and she attempted to use a heating pack. She stated she searched throughout the facility for the appropriate safety covers for the heating packs but was unable to find them. Consultant GG stated she worked at the facility since 2020 and always had the covers for the packs but was unable to find them on that day. She stated she used multiple layers of terry cloths over the pack to provide a barrier and it was common practice to use two or more layers of towels on heating packs if the appropriate covers were not available. She stated she checked with R64 throughout his therapy to ensure he was okay and not in pain. She stated she checked his skin throughout his therapy service and once they completed his therapy she removed the pack and found the burn. She stated she immediately reported it to nursing staff. She stated she reported to Administrative Nurse D about not having the correct protective covers for the heating packs. On 05/01/24 at 12:41 PM Administrative Nurse D stated the facility had the correct covers and Consultant GG just needed to ask staff where the covers were. She stated the facility investigation indicated the burn may have come from Consultant GG applying an inappropriate barrier around the heating pack and the pressure from the gait belt during his physical therapy exercises. She stated the facility ordered extra safety covers and completed in-service training with both nursing and therapy staff related to burns, accidents, heating packs, and skin protection. She stated R64's therapy services would be held until his wound healed. The facility's Hydrocollator (thermostatically controlled water bath used to heat cloth pads) Pack Usage policy dated 01/2024 indicated hot moist pack treatments are to be used as a component of a patients plan of care for skilled therapy services. The policy indicated moist hot packs will be the appropriate size and pack cover for the area being treated. The policy noted staff would utilize the appropriate equipment and placement for heat therapy. The facility failed to utilize safe heat therapy practices during therapy for R64. These deficient practices resulted in a second degree burn on R64's right knee. - The Medical Diagnosis section within R22's Electronic Medical Records (EMR) included diagnoses of dementia (a progressive mental disorder characterized by failing memory, and confusion), anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), cognitive-communication deficit, muscle weakness, and a need for assistance with personal cares. R22's Quarterly Minimum Data Set (MDS) completed 04/02/24 noted a Brief Interview for Mental Status (BIMS) score of four indicating severe cognitive impairment. The MDS indicated she required partial to moderate assistance with dressing, toileting, bathing, transfers, and personal hygiene. The MDS indicated she was occasionally incontinent of bowel and frequently incontinent of the bladder. The MDS indicated she had two non-injury falls since her admission. The MDS indicated she had no behavioral concerns or refusals of care. R22's Dementia Care Area Assessment (CAA) completed 01/09/24 indicated she had a cognitive decline but was able to make her needs known. The CAA indicated intervention will be put in place to minimize her risks related to her cognitive impairment. R22's Fall CAA completed 01/09/24 indicated she had a history of falls related to her impaired mobility. The CAA indicated staff were to assist her with her activities of daily living (ADLs) and care as needed. R22's Care Plan initiated 11/01/21 indicated she was at risk for falls due to poor safety awareness and balance. The plan indicated she was able to ambulate independently in her wheelchair but required the assistance of one staff member for transfers (01/05/24). The care plan indicated R22 had a non-injury on 03/27/24 while she attempted to self-transfer from her bed. The plan indicated a pressure sensor pad was implemented for her bed and wheelchair (03/28/24). On 04/30/24 at 07:08 AM R22 was awake in her bed. She appeared confused and was attempting to transfer herself from her bed to her wheelchair. R22 attempted several times to reposition herself in her bed. The pressure sensor pad was underneath her. At 07:15 AM R22 lifted herself from her bed and moved to her wheelchair. R22 wheeled herself outside her room and down the hallway to the medication room. Staff did not come to the room to intervene in the self-transfer. On 04/30/24 at 07:38 AM an inspection and pressure test of R22's bed pressure sensor pad revealed the alarm did not relay to the relay box posted in the nurse's station in response to the pressure test. On 05/01/24 at 07:25 AM A test of R22's pressure sensor pad in her wheelchair revealed the alarm did not relay to the audible relay box posted in the nurse's station in response to the pressure test. Certified Nurses Aid (CNA) P acknowledged the pressure pad was not functioning and the relay box should have a loud audible alarm when R22 attempted to move from surface to surface. She stated the relay box should alarm for both R22's bed and chair alarms. She stated the bed alarms were usually checked weekly, but she was not sure why the sensors were not working. On 05/01/24 at 07:30 AM the facility posted a direct care staff member in R22's room until her bed alarms could be replaced. On 05/01/24 at 07:45 AM Licensed Nurse (LN) G stated staff was expected to check to functionality of the pressure sensor pads each shift to ensure they were working. She stated R22 frequently transferred without asking for staff assistance and was a fall risk On 05/01/24 at 12:41 PM Administrative Nurse D stated staff were expected to check the alarms each shift to ensure their function. She stated the facility will be replacing R22's alarm due to it not operating consistently. She stated the facility ordered extra alarms to keep on hand in case other alarms malfunctioned. The facility's Fall Prevention and Management policy (undated) indicated the facility would identify residents at risk for falls and implement interventions to reduce to risks identified. The policy indicated staff were to ensure environmental conditions remained safe for residents at risk and equipment remained in working functional order. The facility failed to ensure a safe environment related to maintaining R22's wheelchair and bed fall prevention alarm. This deficient practice placed R22 at risk for preventable falls and injuries.

The facility identified a census of 70 residents with one kitchen and two main dining rooms. Based on observation, record review, and interviews, the facility failed to follow sanitary dietary standards related to cleaning, food storage, equipment storage, and food preparation practices. These deficient practices placed the residents at risk related to food-borne illnesses and food safety concerns. Finding Included: - On 04/29/24 at 07:04 AM an initial walkthrough of the kitchen was completed. An inspection of a utensil storage rack next to the kitchen main entry revealed two Crock-pot lids and a water pitcher lid stored with the food/beverage side upward. An inspection of the kitchen's fryer station revealed old crumbs and food particles covering the outside of the fryer and the side of the baking oven next to it. An inspection of the kitchen's dry food storage revealed old pieces of food on the floor throughout the storage room. On 04/30/24 at 02:30 PM Dietary Staff CC completed hand hygiene and prepped the dinner puree meal. Dietary Staff CC prepared to make pureed tuna noodle casserole. Dietary Staff CC added three cups of pre-prepped tuna noodle casserole and one-half cup of chicken stock to the food processing machine. Dietary Staff CC started to food processor. Dietary Staff CC donned gloves without completing hand hygiene. Dietary Staff CC opened a drawer below the food processor, pulled out a four-ounce scoop (ice cream style scoop), and placed the scoop face down directly on the dirty food preparation area without a clean barrier. Dietary Staff CC stopped the food processor and prepared a tin food bin for the pureed meal. Dietary Staff CC utilized the scoop to transfer the pureed casserole into the food bin. An inspection of Connie's Place dining room refrigerator revealed six opened and unlabeled quart containers of ice cream and one opened bag of tater tots. An inspection of the walk-in freezer revealed an opened but undated bag of breaded chicken. On 05/01/24 at 10:10 AM Dietary Staff BB stated staff were expected to ensure clean hygienic food preparation and use clean utensils while serving or preparing meals. He stated staff were expected to store cooking utensils and plates with the food or eating surface downward. He stated staff cleaned the kitchen daily and checked stored food to ensure opened items were labeled and dated. A review of the facility's Food Services and Nutrition policy (undated) indicated the facility would promote a system that identified proper service, cleaning, and food storage. The policy noted all surfaces within the dining room and kitchen were to be cleaned and sanitized per professional standards. The policy indicated food would be labeled/dated and stored in a manner that is safe and maintains nutritional value. The policy indicated staff were to ensure safe food handling practices to prevent cross-contamination and food-borne illness. The policy indicated staff should complete hand hygiene in between touching surfaces related to direct food preparation, handling, and serving. The policy noted all kitchen and dining equipment be stored in a manner that prevents soiling or contamination of clean items. The facility failed to follow sanitary dietary standards related to cleaning, food storage, equipment storage, and food preparation practices. These deficient practices placed the residents at risk related to food-borne illnesses and food safety concerns.

The facility identified a census of 70 residents. The sample included 19 residents with one resident reviewed for hospice services. Based on observation, record review, and interviews, the facility failed to ensure collaboration between the nursing home and hospice services to identify hospice-supplied services, supplies, medication, and equipment for Resident (R)47. This deficient practice placed the resident at risk for delayed services and uncommunicated care needs. Findings Included: - The Medical Diagnosis section within R47's Electronic Medical Records (EMR) included diagnoses of senile degeneration of the brain, Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness), dysphagia (swallowing difficulty), memory deficit, left-sided hemiplegia (paralysis of one side of the body), left-sided hemiparesis (muscular weakness of one half of the body), and dementia (progressive mental disorder characterized by failing memory, confusion). R47's Quarterly Minimum Data Set (MDS) completed 04/09/24 noted a Brief Interview for Mental Status (BIMS) score of 12 indicating mild cognitive impairment. The MDS indicated he required partial assistance during meals. The MDS indicated he utilized a manual wheelchair for mobility. The MDS indicated he had upper and lower extremity impairments on one side of his body. The MDS indicated he displayed coughing and choking while swallowing meals or medications. The MDS indicated he received hospice services (end-of-life comfort care). R47's Functional Abilities Care Area Assessment (CAA) completed 01/14/24 indicated he required maximum assistance from staff for all his activities of daily living (ADLs) and care as needed. R47's Care Plan initiated 01/09/24 indicated he was on hospice services related to his medical diagnoses. The plan indicated he would be supported through the dying process. The plan noted he would remain comfortable through the next review period. The plan indicated the facility and selected hospice service provider would coordinate a care plan and invite hospice staff to care plan meetings. The plan lacked documentation related to the hospice equipment, medications, services, and scheduled visits from hospice staff. On 05/01/24 at 09:51 AM, R47 sat in his Broda chair (specialized wheelchair with the ability to tilt and recline) in the assisted dining room. R47's drink was on the table to his left side. R47 attempted to reach the drink with his right arm several times but was unable to grab the covered cup. R47 moved his Broda chair with his right leg several times. R47's left leg pressed against the table metal bar. R47 grabbed his cup with his right hand. R47's lap tray remained on the floor under the television. On 05/01/24 at 09:51 AM Licensed Nurse (LN) G stated staff was not using the lap tray due to it did not fit R47's new chair. She stated hospice replaced his Broda chair, but the lap tray did not fit his new chair. She stated staff was to assist R47 during meals. On 05/01/24 at 10:10 AM Certified Nurse's Aide (CNA) P stated the care plans did not include information related to equipment, medications, supplies, and staffing visits provided by hospice. She stated she was not sure if any of the care plans had hospice information other than the name of the hospice company. On 05/01/24 at 12:41 PM Administrative Nurse D stated the care plans should at least include the hospice contact information, staff visits, and services provided. The facility's Hospice Services policy revised indicated the facility will coordinate with the selected hospice agency to provide services necessary for effective end-of-life care. The facility failed to ensure collaboration between the nursing home and hospice services to identify hospice-supplied services, supplies, medication, and equipment for R47. This deficient practice placed R47 at risk for delayed services and uncommunicated care needs.

The facility identified a census of 70 residents. The sample included 19 residents with five residents reviewed for unnecessary medication. Based on observation, record review, and interviews, the facility failed to ensure a physician-documented rationale for extended use of an as-needed psychotropic (alters mood or thought) medication for Resident (R) 29, and R40. This deficient practice placed these residents at risk for unnecessary medication administration thus leading to possible harmful side effects. Findings included: - R29's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), delusion (untrue persistent belief or perception held by a person although evidence shows it was untrue), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). The Annual Minimum Data Set (MDS) dated [DATE] documented a staff interview that indicated severely impaired cognition. The Quarterly MDS dated [DATE] documented a staff interview which indicated severely impaired cognition. The MDS documented that R29 had received antipsychotics (a class of medications used to treat major mental conditions that cause a break from reality), antidepressants (a class of medications used to treat mood disorders), antianxiety (a class of medications that calm and relax people), and a diuretic (medication to promote the formation and excretion of urine) medication during the observation period. R29's Psychotropic Drug Use Care Area Assessment (CAA) dated 09/07/23 documented she received psychotropic medication which placed her at risk for adverse reactions. R29's Care Plan dated 12/28/22 documented that staff would provide comfort medication for pain, anxiety, and air hunger as ordered. R29's EMR under the Orders tab revealed the following physician orders: Lorazepam (antianxiety medication) oral concentrate 2 milligrams (mg) mg/milliliters (ml) give 0.25 ml by mouth three times a day for agitation, anxiety, and restlessness related to Alzheimer's disease for six months dated 03/17/24. Lorazepam oral concentrate 2 mg/ml give 0.25 ml every two hours as needed for mild to moderate anxiety or restlessness for six months and give 0.5 ml every two hours as needed for moderate to severe anxiety or restlessness for six months dated 03/17/24. A review of R29's EMR lacked evidence of physician rationale for the extended duration for the as-needed lorazepam. The facility was unable to provide a physician-documented rationale for the extended duration for the as-needed lorazepam upon request. On 04/30/24 at 09:28 AM R29 sat reclined in her Broda chair (specialized wheelchair with the ability to tilt and recline) next to her bed asleep. On 05/01/24 at 09:49 AM, Licensed Nurse (LN) H stated the physician reviewed the monthly pharmacy reviews and made any changes. LN H stated the physician decided the duration for any medication. On 05/01/24 at 12:39 PM, Administrative Nurse D stated she was unable to locate any documented physician rationale for the extended duration for R29's as-needed lorazepam. The facility's undated Antipsychotic Drug policy documented based on a comprehensive assessment of each resident, the interdisciplinary team would ensure a resident who had not used antipsychotic drugs was not given an antipsychotic drug unless antipsychotic drug therapy was necessary to treat a specific condition as diagnosed and documented in the resident's clinical record. After other non-pharmacologic interventions or alternatives have been considered or used. Antipsychotic medication was prescribed at the lowest effective therapeutic dose for the shortest effective duration. The facility failed to ensure the physician documented a rationale for the extended duration of use of as-needed lorazepam for R29. This deficient practice placed R29 at risk for the potential of unnecessary medication administration thus leading to possible harmful side effects. - R40's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), antianxiety (class of medications that calm and relax people), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and dementia (a progressive mental disorder characterized by failing memory, confusion). The Significant Change Minimum Data Set (MDS) dated [DATE] documented a staff interview that indicated moderately impaired cognition. The Quarterly MDS dated [DATE] documented a staff interview which indicated severely impaired cognition. The MDS documented that R40 received antianxiety (a class of medications that calm and relax people), antidepressant (a class of medications used to treat mood disorders), antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality), a diuretic (medication to promote the formation and excretion of urine), and opioid medication during the observation period. R40's Psychotropic Drug Use Care Area Assessment (CAA) dated 06/30/23 documented she received psychotropic medication which placed her at risk for adverse reactions. R40's Care Plan dated 05/31/23 documented staff would provide medication as ordered. The plan documented staff would monitor and notify her physician of any adverse reactions. R40's EMR under the Orders tab revealed the following physician orders: Lorazepam (antianxiety medication) intensol oral concentrate two milligrams (mg)/milliliters (ml). Give 0.5 ml by mouth every hour as needed for increased restlessness and/or anxiety for six months dated 01/24/24. A review of R40's EMR lacked evidence of a physician-documented rationale for the extended duration of R40's as-needed lorazepam. The facility was unable to provide a physician-documented rationale for the extended duration for the lorazepam upon request. On 04/29/24 at 09:12 AM R40 lay in bed with her eyes closed. The bed was lowered to the floor and there was a fall mat on the floor next to the bed. On 05/01/24 at 09:49 AM, Licensed Nurse (LN) H stated the physician reviewed the monthly pharmacy reviews and made any changes. LN H stated the physician decided the duration for any medication. On 05/01/24 at 12:39 PM, Administrative Nurse D stated she was unable to locate any documented physician rationale for the extended duration for R40's as-needed lorazepam. The facility's undated Antipsychotic Drug policy documented based on a comprehensive assessment of each resident, the interdisciplinary team would ensure a resident who had not used antipsychotic drugs was not given an antipsychotic drug unless antipsychotic drug therapy was necessary to treat a specific condition as diagnosed and documented in the resident's clinical record. After other non-pharmacologic interventions or alternatives have been considered or used. Antipsychotic medication was prescribed at the lowest effective therapeutic dose for the shortest effective duration. The facility failed to ensure the physician documented a rationale for the extended duration for as-needed lorazepam for R40. This deficient practice placed R40 at risk for the potential of unnecessary medication administration thus leading to possible harmful side effects.

The facility identified a census of 70 residents. The sample included 19 residents with two residents reviewed for accommodation of needs related to assistive devices. Based on observation, record review, and interviews, the facility failed to provide Resident (R)47 with a wheelchair lap meal tray as care planned for his meals. The facility additionally failed to ensure R39's call light remained within reach while unsupervised in her room. This deficient practice placed both residents at risk for impaired quality of life and care. Findings Included: -The Medical Diagnosis section within R47's Electronic Medical Records (EMR) included diagnoses of senile degeneration of the brain, Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness), dysphagia (swallowing difficulty), memory deficit, left-sided hemiplegia (paralysis of one side of the body), left-sided hemiparesis (muscular weakness of one half of the body), and dementia (progressive mental disorder characterized by failing memory, confusion). R47's Quarterly Minimum Data Set (MDS) completed 04/09/24 noted a Brief Interview for Mental Status (BIMS) score of 12 indicating mild cognitive impairment. The MDS indicated he required partial assistance during meals. The MDS indicated he utilized a manual wheelchair for mobility. The MDS indicated he had upper and lower extremity impairments on one side of his body. The MDS indicated he displayed coughing and choking while swallowing meals or medications. The MDS indicated he received hospice services (end-of-life comfort care). R47's Functional Abilities Care Area Assessment (CAA) completed 01/14/24 indicated he required maximum assistance from staff for all his activities of daily living (ADLs) and care as needed. R47's Care Plan initiated on 11/01/21 indicated he was at risk for a decline in his ADLs, nutrition, and communication related to his Parkinson's disease and left-sided paralysis. The plan indicated he required staff assistance for dressing, bed mobility, bathing, personal hygiene, and toileting. The plan noted he could independently eat his food by himself (01/09/24). The plan indicated staff was to set up his wheelchair lap tray during meals and anytime he is drinking. The plan noted the lap tray was to be removed when he completed his meal or drink (01/31/24). On 04/30/24 at 12:30 PM, R47 sat in the assisted dining room. R47 was assisted by staff as he ate his lunch. R47's lap tray lay on the floor next to the television area. At 01:11 PM R47 remained in his chair alone in the assisted dining area. R47's drink was positioned close to his left side on the table. R47's lap tray remained on the floor under the television. R47 struggled to grab his drink from the table and had to reposition his Broda chair (specialized wheelchair with the ability to tilt and recline) several times to get closer to the drink. On 05/01/24 at 09:51 AM R47 sat in his Broda chair in the assisted dining room. R47's drink was on the table to his left side. R47 attempted to reach the drink with his right arm several times but was unable to grab the covered cup. R47 moved his Broda chair with his right leg several times. R47's left leg pressed against the table metal bar. R47 grabbed his cup with his right hand. R47's lap tray remained on the floor under the television. On 05/01/24 at 9:56 AM Certified Nurse's Aide (CNA) P approached R47 and prepared to take him to his room. CNA P stated she was not sure why the lap tray was not being used. On 05/01/24 at 09:57 AM Licensed Nurse (LN) G stated staff were not using the lap tray due to it not fitting his new Broda chair. She stated hospice replaced his Broda chair, but the lap tray did not fit his wheelchair. She stated staff was expected to assist him during meals. On 05/01/24 at 12:41 PM Administrative Nurse D stated she was unaware staff were not using R47's lap tray. She stated she put it in place to prevent him from having to reach out further for his meals and to prevent any fall risks. She stated staff should have notified her of the concerns with the tray table not fitting so it could be replaced. The facility's Assistive Devices and Ambulatory Aids policy (undated) indicated the facility would ensure assistive eating devices would be provided to residents as care was planned and assessed. The facility failed to provide R47 with a wheelchair lap meal tray as care planned for his meals. This deficient practice placed the resident at risk for impaired quality of life and care. 49634 - R39's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of dementia (a progressive mental disorder characterized by failing memory), dysplasia oropharyngeal phase (difficulty initiating a swallow), combined systolic and diastolic heart failure (the heart cannot effectively contract with each heartbeat in diastolic heart failure your heart cannot relax between heartbeats), hypertension (HTN-elevated blood pressure), and anxiety (an emotion characterized by feelings of tension, worried thoughts, and physical changes). R39's Quarterly MDS dated [DATE] documented that a Brief Interview of Mental Status (BIMS) was not performed due to R39 being unable to. The MDS documented R39 was dependent on two staff for all toileting needs. The MDS documented R39 was dependent on two staff for positioning, transfers, and all activities of daily living (ADL). R39's Communication Care Area Assessment (CAA) dated 12/27/23 documented R39 had difficulty with communication at times. Staff were to allow time for communication, repeat things as needed, and anticipate R39's needs. R39's Fall CAA dated 12/27/23 documented she had impaired mobility and weakness. R39 used psychotropic (mind-altering) drugs and was at risk of falling. R39's Care Plan dated 12/20/22 documented R39 was a fall risk and staff should avoid using pillows behind R39 when in bed. R39 should support a side-lying position, and her bed was to be in a low position. R39's fall mat should be in place when she was unattended. Staff were to recline R39 in her Broda chair (specialized wheelchair with the ability to tilt and recline) chair when not sitting at the table to eat or performing an activity. On 04/29/24 at 07:16 AM R39's push-button call light was pinned to the call light cord. The call light was out of reach of R39 as she sat in her Broda chair, reclined. On 05/01/24 at 09:17 AM R39's push-button call light was placed in the middle of the bed, out of reach of the resident, who sat in her Broda chair. On 05/01/24 at 09:20 AM Certified Nursing Aide (CNA) M stated all call lights should be within the resident's reach, and a call light should be placed on the resident's chest or lap. CNA M stated R39 was unable to push the button on the call light and staff were to check on her periodically. On 05/01/24 at 12:42 PM Administrative Nurse D stated she expected staff to place the call lights where residents could reach them. The facility's Call Light Monitoring policy dated 09/23 documented the facility is equipped with a call light system that includes a wireless paper system. When the system is activated by residents in their bedrooms, an alert is sent to the pagers carried by direct care staff, nursing staff, nursing administration staff, and the Administrator. When any call light is reset, the pagers reflect it has been cleared. The facility failed to ensure that R39's call light was within reach. This placed R39 at risk for impaired physical, mental, and psychosocial well-being.

The facility identified a census of 70 residents. The sample included 19 residents, with one resident reviewed for activities. Based on observation, record review, and interviews, the facility failed to provide Resident (R)39 the opportunity to go to the activities she enjoys. This deficient practice placed R39 at risk for decreased psychosocial well-being. Findings included: - R39's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of dementia (a progressive mental disorder characterized by failing memory), dysplasia oropharyngeal phase (difficulty initiating a swallow), combined systolic and diastolic heart failure (the heart cannot effectively contract with each heartbeat in diastolic heart failure your heart cannot relax between heartbeats), hypertension (HTN-elevated blood pressure), and anxiety (an emotion characterized by feelings of tension, worried thoughts, and physical changes). R39's Significant Change Minimum Data Set (MDS) dated [DATE] lacked documented the interview for residents' preferences for customary routines and activities (section F) was not completed with R39, a representative, or per staff interview. R39's Quarterly MDS dated [DATE] documented that a Brief Interview of Mental Status (BIMS) was not performed due to R39 being unable to. The MDS documented R39 was dependent on two staff for all toileting needs. R39's Communication Care Area Assessment (CAA) dated 12/27/23 documented R39 had difficulty with communication at times. The CAA documented staff should R39 allow time for communication and repeat as needed; staff should anticipate R39's needs. R39's Care Plan documented R39 relied on staff to propel her in her Broda (a specialized wheelchair with the ability to tilt and recline). An intervention dated 06/29/21 directed staff to invite R39 to any church services as she enjoyed spiritual and religious activities. The plan, dated 12/08/22, documented R39 would engage in facility activities five times a week for social interaction and activities of leisure and interest, R39 enjoyed music. The plan documented an intervention dated 09/29/23 that documented that staff should invite R39 to all music-related activities. A review of the facility's Activity Calendar for 04/30/24 revealed Bible Study at 10:00 AM and live music in the Dug Out at 01:00 PM. On 04/30/24 at 09:50 AM R39 reclined in her Broda chair in her room. She was awake and looking at the TV. A continuous observation of R39 revealed staff did not offer or invite her to attend Bible Study. On 04/30/24 at 10:20 AM R39 reclined in her Broda chair next to her bed. On 04/30/24 at 10:21 AM one staff member entered R39's room. The staff member picked up R39's stuffed animal and placed it in her lap but did not offer to take the resident to the Bible Study which was in progress. On 04/30/24 at 11:36 AM staff took R39 out to lunch. R39 remained in the dining room until 01:35 PM when staff brought R39 back to her room. Staff did not offer or encourage R39 to attend the music activity that started at 01:00 PM. On 05/01/24 at 08:41 AM Certified Nurse Aide (CNA) O stated all CNAs knew what activities each resident liked to attend by their plan of care. CNA O stated she forgot to take R39 to the activities she enjoyed on 04/30/24 and stated the activity calendars were being changed and she did not see there were activities R39 would have enjoyed. On 05/01/24 at 10:00 AM Social Service X stated she oversaw the activities for R39's unit. Social Service X stated there were activity calendars posted everywhere. She stated there was one on the whiteboard in the dining area for all staff and residents to see daily. Social Service X stated there were also activity calendars in each resident's room. She stated the team for R39 was responsible for getting the resident to activities. She stated she saw R39 in the dining area so she did not take the resident to the live music playing in the Dug Out. The facility did not provide a policy for activities. The facility failed to ensure R39 was invited, encouraged, and assisted to go to activities she enjoyed. This deficient practice placed the resident at risk for decreased psychosocial well-being.

The facility identified a census of 70 residents. The sample included 19 residents with five residents reviewed for activities of daily living (ADLs). Based on observation, record review, and interviews, the facility failed to ensure Resident (R)39 received the required assistance with ADLs. This placed R39 at risk for complications including skin breakdown, discomfort, and impaired psychosocial well-being. Findings included: - R39's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of dementia (a progressive mental disorder characterized by failing memory), dysplasia oropharyngeal phase (difficulty initiating a swallow), combined systolic and diastolic heart failure (the heart cannot effectively contract with each heartbeat in diastolic heart failure your heart cannot relax between heartbeats), hypertension (HTN-elevated blood pressure), and anxiety (an emotion characterized by feelings of tension, worried thoughts, and physical changes). R39's Quarterly Minimum Data Set, dated dated dated [DATE] documented that a Brief Interview of Mental Status (BIMS) was not performed due to R39 being unable. The MDS documented R39 was dependent on two staff for all toileting needs. The MDS documented R39 was dependent on two staff for positioning, transfers, and all ADL. R39's Urinary Incontinence and Indwelling Catheter Care Assessment Area (CAA) dated 12/27/23 documented R39 had bladder incontinence, and she was at risk for skin breakdown and infection. Staff were to assist R39 with all toileting needs and incontinent care. R39's Pressure Injury CAA dated 12/27/23 documented R39 had impaired mobility, weakness, and incontinence. She was at risk for skin breakdown. She had a recent wound to her great toe with a treatment in place. Staff were to assist R39 with all mobility, positioning, and toileting care as needed. R39's Care Plan revised 10/12/23 directed staff to assist R39 in repositioning every two hours during the daytime and every four hours when sleeping/nighttime. The plan dated 10/26/23 documented R39 was incontinent of bowel and bladder. The plan directed two staff to check and change R39 between 3-4 AM, 8-9 AM, 11-12 PM, 2-3 PM, 4-5 PM, 7-8 PM 7-8 PM, 10-11 PM and as needed per R39's three-day bowel and bladder diary. On 04/30/24 at 08:14 AM, R39 sat in a Broda chair (specialized wheelchair with the ability to tilt and recline) in her room. There were two staff also present in the room. R39's chair was tilted, and the TV was on. The staff placed a call light and a pink stuffed animal in R39's lap and exited the room at 08:17 AM. Continued observation revealed at 09:20 R39 remained awake and in the same position and the stuffed animal fell to the floor. At 09:35 R39 closed her eyes. At 09:50 AM R39 had her eyes open and remained in the same position. Ongoing observation revealed at 10:23 AM R39 remained in the same position in her Broda chair. A staff member entered the room and then immediately exited. At 11:00 AM, two staff entered R39's room and the door remained open. Staff picked up R39's stuffed animal from the floor. At 11:02 AM one staff left the room. At 11:05 AM, R39 remained in the same position as the entire observation, A staff member stood at R39's side and visited with R39 from 11:05 AM through 11:12 AM. Ongoing observation revealed R39 remained in the chair in the same position until 11:36 AM when staff entered the room and propelled R39 in the chair to the dining area. On 04/30/24 at 11:37 AM R39 sat in her Broda chair in the dining room where she remained until 01:35 PM. On 04/30/24 at 01:35 PM, Certified Nursing Aide (CNA) N brought R39 back to her room from lunch. CNA N stated she would be back to change R39. CNA N stated she knew what time R39 should be checked and changed even though she was agency staff; she stated she picked up the care plan for each resident she cared for at the nurse's nook. She stated R39 should have her brief checked and changed every other hour. CNA N stated she was going to get help since R39 was a two-person Hoyer (total body mechanical lift) for changes. On 05/01/24 at 10:28 AM Licensed Nurse (LN) I stated each CNA was assigned to residents each morning by the nurse in charge. LN I stated the CNA assigned to a resident was to read the care plan and take care of the resident as assigned. LN I stated if the resident was to be toileted or repositioned at a certain time, that was the CNA's duty. LN I indicated the CNA could get help from another unit. On 05/01/24 at 12:42 PM Administrative Nurse D stated she expected the CNA staff to change all residents by the bowel and bladder program documented in the care plan. Administrative Nurse D said the only time she would not expect the resident to be checked and changed during the care-planned time is if the resident refused. She stated that residents had the right to refuse. The facility's Activities of Daily Living documented the facility provides each resident with care, treatment, and services according to the resident's individualized care plan. Based on the individual resident's comprehensive assessment, community staff will ensure that each resident's abilities in activities of daily living do not diminish unless the circumstances of the resident clinic condition demonstrate that the decline was unavoidable. The facility failed to ensure R39 was assisted with ADLs as directed in her plan of care. This placed R39 at risk for complications including skin breakdown, discomfort, and impaired psychosocial well-being.

The facility identified a census of 78 residents. The sample included three residents reviewed for falls. Based on observations, record review, and interviews, the facility failed to ensure staff followed Resident (R) 1's care planned interventions to prevent falls. As a result of this deficient practice, R1 fell and sustained fractures of the right superior (upper) and inferior (lower) pubic rami (two sections of bone that branch off the pubic body). Findings included: - The Diagnoses tab of R1's Electronic Medical Record (EMR) documented diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion) moderate without behavioral disturbance, dizziness and giddiness, fracture of left pubis (pair of bones forming two sides of the pelvis) subsequent encounter for fracture with routine healing, orthostatic hypotension (blood pressure dropping with change of position), need for assistance with personal care, lack of coordination, and unsteadiness on feet. The Admission Minimum Data Set (MDS) dated [DATE] documented R1 had a Brief Interview for Mental Status (BIMS) score of three which indicated severe cognitive impairment. R1 required supervision with one staff for bed mobility; limited assistance with one staff for transfers, walking, locomotion, toileting, and personal hygiene; and extensive assistance with one staff for dressing. R1 had one noninjury fall since admission. The Quarterly MDS dated [DATE], documented R1 had a BIMS score of one which indicated severe cognitive impairment. R1 required extensive assistance with two staff for bed mobility, transfers, walking, dressing, and toileting; limited assistance with one staff for personal hygiene; and extensive assistance with one staff for locomotion. R1 had two or more noninjury falls since last assessment. The Cognitive Loss/Dementia Care Area Assessment (CAA) dated 03/24/23, documented the team reported some days R1 was more confused than others and she scored a three on her BIMS assessment. The Falls CAA dated 03/27/23, documented R1 had poor cognition, weakness, history of falls, and a recent fall. R1 was at risk for falls and staff assisted with all activities of daily living (ADLs) and cares as needed. R1's Falls Care Plan, initiated 03/27/23, documented R1 had diagnoses of dementia, weakness, dizziness, giddiness, and a history of falling which placed her at risk for falls. R1 had experienced multiple falls at home and had poor safety awareness and at times. She initiated transfers and mobility independently. The Care Plan documented an intervention, dated 05/30/23, which directed staff to encourage R1 to rise slowly from a seated position and to stand in place for a minute before walking. R1's ADLs Care Plan, initiated 04/03/23, documented R1 needed help with her ADLs. The Care Plan documented an intervention, dated 04/22/23, which included R1 used a gait belt with contact guard assist of one staff for transfers and mobility; R1 used a two-wheeled walker for short distance ambulation; staff were to follow with her wheelchair for longer distances. The plan directed if staff to provide assistance if they observed R1 self-transferring or walking by herself. The facility's Investigation dated 09/29/23, documented on 09/22/23 at approximately 09:45 AM, Certified Nurse Aide (CNA) M assisted R1 to stand from R1's bed using a gait belt and walker. R1 took a few steps toward the bathroom and communicated to CNA M she did not think she could stand much longer. CNA M wrote in her statement the wheelchair was across the room; she let go of R1 and ran to grab the wheelchair. She stated she almost made it behind R1 when R1 toppled to the right with her walker in hand and yelled ow when she hit the floor. The staff notified Emergency Medical Services (EMS), who then transported R1 to the hospital, where the hospital obtained a computed tomography (CT scan- test that used x-ray technology to make multiple cross-sectional views of organs, bone, soft tissue and blood vessels) scan of R1's pelvis. The scan revealed nondisplaced (remained aligned) fractures (broken bone) of the right superior and inferior pubic rami (pelvic bone). R1 returned to the facility in the evening hours of 09/22/23. In a Witness Statement on 09/22/23, CNA M stated on 09/22/23 at 09:30 AM, she asked the other CNAs what she needed to do next, and they gave her a list of people who needed help. She stated she chose R1 because R1 was a one-person assist. When she went to R1's room, R1 was still in bed, in her nightgown. CNA M and R1 talked about what she wanted to wear for the day and R1 chose a flannel t-shirt, pants, and socks. CNA M put on R1's socks, shoes, and gait belt then set her walker in front of her. CNA M stated she encouraged R1 to stand up on the count of three and they tried three times before she felt R1 could walk. CNA M stated once R1 was up, she took a few steps toward the bathroom and her right leg seemed to have been having trouble. R1 told CNA M she did not think she could stand much longer. CNA M stated the wheelchair was across the room, so she was hesitant to let go of R1, but she did, and ran across R1's room to grab the wheelchair. She stated she almost made it behind R1 when she toppled to her right with the walker in hand, yelling ow when she hit the floor. CNA M stated R1 hit her head/shoulder on the closet door and laundry basket on the way down. She moved the walker because R1 was wrapped up in it then went to the hall and yelled for the nurse. She stated the nurse and Certified Medication Aide (CMA) arrived to R1's room and asked CNA M and R1 questions and called EMS for possible injury to the head and neck. In a Witness Statement dated 09/29/23, Licensed Nurse (LN) G stated on 09/22/23 at around 09:45 AM, CNA M yelled for her. She stated she went into R1's room and saw R1's legs first. R1 laid on the floor directly in front of her closet, with her head on the inside of the closet. There was a basket on the floor in her closet and her neck/head were on that basket. LN G stated R1 laid on her right side and when asked if she hit her head, R1 stated yes, she thought she did. LN G asked R1 if she had any pain and R1 stated yes, her neck. LN G stated she told R1 not to move and she obtained R1's vital signs. After obtaining R1's vital signs, R1 stated she felt like she was going to throw up. LN G sent the CNA to call for EMS and tell them R1 possibly hit her head and had neck pain. The Miscellaneous tab of R1's EMR revealed a CT Pelvis without contrast on 09/22/23 that documented R1 had a nondisplaced fracture involving the right inferior ramus and a nondisplaced fracture of the right superior pubic ramus. On 10/03/23 at 12:45 PM, R1 sat in her recliner in her room and watched television. On 10/03/23 at 12:35 PM, CNA M stated on 09/22/23, R1 started taking a few slow steps while CNA M held onto her, then R1 stated she did not think she could stand up anymore. CNA M stated she asked R1 if she could stand for a just a moment while she got her wheelchair which she stated she could. CNA M said she was hesitant to let go of the gait belt but went to get the wheelchair on the other side of her room when R1's right leg gave out. She stated she did notice her right leg was having trouble while R1 was walking. CNA M stated she almost made it behind her with the wheelchair when R1 fell . She stated she did not know there was an option of an assisted fall, but she did know that now. CNA M stated R1's walker was wrapped around her. CNA M moved it off of R1, then immediately went to the door to yell for the nurse. The nurse and CMA came by and asked both her and R1 questions. They called EMS because R1 was hurting, and EMS got her onto a stretcher then took her to the hospital. CNA M stated she had access to the care plans and usually had a care plan that they carried around with them. She stated, at the time, R1 was a one-person assist with gait belt, and she did not know about the orthostatic changes intervention. She stated she knew now that she could have lowered R1 to the ground slowly and prevented injury and if R1 got back to her previous level of function, she would have R1 stand for a second before walking. On 10/03/23 at 01:02 PM, LN H stated nursing staff had access to the care plans and knew how to care for residents by following the care plan. She stated falls were prevented depending on each resident's fall interventions. LN H stated CNA M should have held onto R1's gait belt and called for help. She stated if R1 was starting to fall, CNA M could have helped lower her down. On 10/03/23 at 01:14 PM, Administrative Nurse D stated on 09/22/23, CNA M was getting R1 up and it took some time for R1 to get up. She stated R1 was close to the bathroom and closet when she told CNA M she needed to sit down and could not walk anymore. R1's wheelchair was across the room and CNA M went to get the wheelchair when R1 fell . Administrative Nurse D stated CNA M said it was her first-time hearing about assisted falls and the whole community was educated on assisted falls after the incident. She stated CNA M had access to R1's care plan at the time of the incident which had fall interventions on it. On 10/03/23 at 01:17 PM, Administrative Nurse E stated CNA M had never heard of assisted falls and she was educated that if in a situation like that again, CNA M could hold onto the resident and see if they could walk toward the wheelchair. She stated CNA M had access to the care plan at that time and she was educated on the care plan and the orthostatic interventions. Administrative Nurse E stated R1 did not have hypotension but experienced tachycardia (fast heart rate) when she changed positions and there was an intervention in place for R1 to sit on the edge of the bed, stand at the bedside, and allow her time before walking to regulate herself. She stated the CNAs carried the care plan and were expected to know the care plan to care for the residents. The facility's Fall Prevention and Management policy, last updated 09/24/23, directed every team member was responsible for checking the care plan of residents who were at risk for falls when beginning each day and throughout the assigned shift. The Care Plan Competency Policy, not dated, directed it was the responsibility of every staff member to read, understand, and follow the comprehensive and the certified care partner care plans prior to providing direct care to a resident and to report any changes, not matter how slight or significant to the Interdisciplinary Team for immediate care plan revision if indicated. If any staff member failed to adhere to the plan of care, it resulted in disciplinary action. The facility failed to ensure staff followed R1's care plan interventions to prevent falls. This deficient practice resulted in a fall with major injury for R1. The facility completed the following corrections by 09/29/23 CNA M was suspending pending investigation on 09/22/23. Education on falls was completed with community staff from 09/26/23 to 09/29/23. R1's care plan was updated on 09/27/23 with current transfer status. CNA M was educated on falls, orthostatic hypotension, and care plan competency on 09/29/23. Due to the facility corrective actions implemented prior to the start of survey, the deficient practice was cited at past-noncompliance. The scope and severity remained at a G.

The facility identified a census of 70 residents. The sample included three residents. Based on observations, record review, and interviews, the facility failed to ensure Resident (R) 1 remained free from accidents when Certified Nurse Aide (CNA) M transferred R1 from R1's wheelchair to the bed alone though R1's plan of care directed a two-person transfer. This deficient practice resulted in R1's right leg getting trapped under the bed and she suffered a fracture that required surgical intervention. Findings included: - The Diagnoses tab of R1's Electronic Medical Record (EMR) documented diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion) without behavioral disturbance, fracture of shaft of right tibia (bone of the lower leg) subsequent encounter for closed fracture with routine healing, and history of falling. The Significant Change Minimum Data Set (MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) score was not conducted due to R1 rarely/never understood. R1 required extensive physical assistance with one staff for bed mobility, transfers, dressing, and toileting; independent with locomotion; supervision with one staff for eating; and limited physical assistance with one staff for personal hygiene. R1 had no falls since the last assessment. The Quarterly MDS dated [DATE], documented a BIMS score of two, which indicated severe cognitive impairment. R1 required extensive physical assistance with one staff for bed mobility, dressing, and personal hygiene; extensive physical assistance with two staff for transfers and toileting; limited physical assistance with one staff for locomotion; and supervision with one staff for eating. R1 had two or more noninjury falls and one injury fall since the last assessment. The Cognitive Loss/Dementia Care Area Assessment (CAA) dated 01/28/22, lacked an analysis of findings. The Falls CAA dated 02/02/22, documented R1 was at risk of falling and staff assisted with all activities of daily living (ADLs) and cares as needed. The Care Plan, last revised 09/21/21, directed R1 needed one assist with ADLs and staff encouraged her to ask for assistance with ADLs. The Care Plan documented an intervention, initiated on 09/01/21 (resolved on 12/15/22), that R1 needed assistance with two staff for transfers with Hoyer (mechanical lift) lift if she showed increased weakness and when she felt stronger, two staff assistance. The Care Plan documented an intervention, initiated on 12/15/22 after the incident, that R1 required two staff assistance with Hoyer lift for transfers. The facility's Investigation dated 12/15/22, documented on 12/08/22 around 08:30 PM, Administrative Nurse E received a call from Administrative Nurse F that R1 was being sent to the hospital for further evaluation due to possible right leg fracture. Upon investigation, it was reported that CNA M attempted to transfer R1 and during the transfer, R1's right leg got caught under the bed. Root cause analysis of the incident indicated R1 required two persons assist for all transfers. When a one-person assist was performed, R1's leg was not properly positioned during the transfer causing her leg to break. Staff statements were reviewed, and though the statements were inconsistent, there was a failure to follow R1's care plan. The X-ray report on 12/08/22 documented an acute mildly displaced right distal tibia and fibular (bone of the lower leg) fractures. In a notarized Witness Statement on 12/09/22, CNA M stated she walked into R1's room between 07:30 PM and 08:00 PM to help her get ready for bed. CNA M propelled R1 to the bathroom but R1 was too weak to stand so CNA M went to get help from another CNA. She returned with CNA N and assisted R1 with toileting and putting her pajamas on. CNA M stated she and CNA N took R1 back into R1's room by the bed and R1 was able to hold onto the bed rail while CNA M transferred her. CNA N stood beside R1 while CNA M transferred her and R1 complained of right leg pain. CNA M stated she put R1 back into the wheelchair to see what R1 was talking about. Both CNAs noticed that R1 was holding her leg, stating it hurt. CNA N went to get the nurse for assessment. Licensed Nurse (LN) G assessed R1 and told CNA M to put R1 in the bed while she called to notify someone about R1's leg. In a notarized Witness Statement on 12/09/22, CNA N stated she asked CNA M if she needed help and CNA M said yes. CNA N stated she entered R1's room and R1 was sitting on the toilet. CNA N put on gloves and assisted CNA M with care. Both CNAs transferred R1 from the toilet to her wheelchair without any issues. CNA M propelled R1 out of the bathroom while CNA N picked up trash from R1's bathroom. CNA N exited R1's bathroom and saw CNA M transferring R1, she noted CNA M lifted R1 and turned her inwards to the bed when her right foot got caught under the bed and twisted. CNA N stated she heard a pop and told CNA M that she thought R1's leg looked broken. CNA N left the room and told LN G that there was an incident in R1's room and it appeared R1's leg was broken. LN G stated CNA N alerted her at approximately 07:05 PM that R1 needed to be assessed for a possible broken leg. In a notarized Witness Statement on 12/13/22, Administrative Nurse D stated on 12/09/22 around 11:00 AM, she called the hospital for a report regarding R1's status in the emergency room (ER). She spoke with the nurse taking care of R1 who stated R1's tibia was broken and R1 was to have surgery that day. In a notarized Witness Statement on 12/14/22, Administrative Nurse E stated on 12/08/22 around 08:30 PM, she was the on-call nurse manager when she received a call from Administrative Nurse F reporting that R1 was being sent to the hospital for further evaluation due to possible right leg fracture. She stated she directed Administrative Nurse F to find out what happened and how R1 broke her leg and obtain staff statements regarding the incident. Administrative Nurse E stated Administrative Nurse F informed her that LN G told her that CNA N was in R1's bathroom cleaning up trash and clothing while CNA M was with R1 in her bedroom. CNA N stated to LN G that she heard a pop and looked over to see CNA M transferring R1 from her wheelchair to her bed and that R1's right foot got caught under the bed and twisted. In a notarized Witness Statement on 12/15/22, LN G stated upon arrival to R1's room, R1 was sitting on the edge of her bed with legs in front of her. LN G immediately noticed that there was an area on the right lower leg that appeared concave with moderate swelling above the concave area, the skin was slightly discolored and warm to touch. LN G stated when she gently touched the area, R1 stated ooh, that's sore and she was moving her ankle and toes without the appearance of pain. During this movement, LN G witnessed what looked like two bones under the skin separating. LN G advised CNA M to stay with R1 while she made a phone call to the doctor. R1 was transported to the hospital via EMS at 08:13 PM. LN G stated she asked CNA N what happened, and CNA N told her she was in R1's bathroom picking up trash and clothing while CNA M was with R1 in her bedroom. CNA N stated she heard a pop and looked over to see CNA M transferring R1 from her wheelchair to her bed. CNA N told LN G that R1's foot got caught under her bed and twisted. On 12/27/22 at 02:21 PM, R1 laid in bed with her eyes closed, there was a pillow under her right side, and she appeared comfortable. On 12/27/22 at 02:30 PM, CNA O stated she knew how to transfer a resident by looking at their care plan that she carried with her. She stated if a resident required two staff for transfers, they always had two staff for transfers. On 12/27/22 at 02:49 PM, LN H stated staff knew how to transfer a resident by looking at the care plan and staff always carried the care plan on them. She stated staff were always expected to have two staff for transfers if the resident required two staff for transfers. On 12/27/22 at 03:00 PM, Administrative Nurse D stated staff knew how to transfer a resident by looking at the care plans which they were expected to always carry on them. She expected staff to always have two staff for transfers if the resident required two staff for transfers. She stated she did immediate education to staff that were present and working on 12/09/22 and most of the staff had been educated on following care plans and transfers by the end of the investigation on 12/15/22 with education ongoing for any staff new to the building. The facility's Fall and Accident Prevention and Management policy, last revised 2022, directed each resident was provided services and care that ensured the resident's environment remained as free from accident hazards as was possible and each resident received adequate supervision and assistive devices to prevent accidents. The facility's non-mechanical lift transfers policy, last revised 2022, directed staff followed individualized comprehensive care plan related to type of transfer and staff followed care plan instructions for number of assistants required. The facility failed to ensure R1 remained free from accidents when CNA M transferred R1 from her wheelchair to her bed by herself for a two-person transfer. This deficient practice resulted in R1's right leg getting trapped under the bed and she suffered a fracture that required surgical intervention. The facility completed the following corrective measures: On 12/09/22, CNA M was terminated from the facility. On 12/09/22, staff working the day of the incident were educated on following care plans and transfers. Between 12/10/22 to 12/15/22 all facility staff were educated on following care plans and transfers. On 12/15/22 R1's care plan was updated to reflect that R1 required a two-person Hoyer lift with transfers. This deficient practice was cited as past non-compliance.

The facility identified a census of 72 residents. The facility had one main kitchen and three satellite kitchens. Based on observation and interview the facility failed to ensure food stored in the satellite kitchen refrigerator was properly stored, labeled and dated. The facility failed to ensure that expired items in the satellite refrigerators were discarded. The deficient practice left the resident at risk of food borne illnesses. Findings included: - An inspection of a satellite kitchen/dining closest to the main lobby on [DATE] at 08:29 AM revealed the following: One gallon jug of milk sat directly on the serving counter without a cooling ice bath or any way to maintain adequate temperature. A large bin of ice sat on a wheeled cart with the ice scoop stuck directly in the ice. A dish storage cart was stored in the dining room with the clean dishes (plates and bowls) stored eating surface up and uncovered. An inspection of a satellite kitchen area refrigerator on [DATE] at 08:49 AM revealed the following: Several pieces of bacon wrapped in a paper towel that was not in a sealed bag and was not labeled or dated. A tomato was stored in sealed plastic zip lock bag that was not labeled or dated. A sealed plastic bag with hard-boiled eggs had an expiration date of [DATE] that had not been discarded. A container of cottage cheese had an expiration date of [DATE] that had not been discarded. There were four dessert cups with an expiration date of [DATE] that had not been discarded. On [DATE] at 02:47 PM Dietary CC stated that all foods stored in the refrigerator should be labeled and dated. The homemakers and aides were responsible for ensuring that food items were thrown away daily if expired or did not have labels on them. The facility failed to ensure that food items stored in the satellite kitchen was stored properly, labeled and dated and discarded when items were expired and failed to ensure sanitary storage of dishes for resident use. This deficient practice placed residents at risk for food borne illnesses.

The facility identified a census of 72 residents. The sample included 18 residents with two reviewed for accommodation of needs. Based of observations, record review, and interviews, the facility failed to ensure R10's Broda chair (specialized wheelchair with the ability to tilt and recline) had foot pedals/rests. This deficient practice placed R10 at risk for injuries related to the lack of foot pedals. Findings included: - The Medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R10's Quarterly Minimum Data Set (MDS) dated [DATE] noted a Brief Interview for Mental Status (BIMS) assessment could not be completed due to severe cognitive impairment. The MDS indicated that she required extensive assistance from two staff to move to areas off the unit. A review of R10's Falls Care Area Assessment (CAA) dated 12/06/21 indicated that she was a high risk for injuries related to medication use, medical diagnoses, impaired mobility and weakness. R10's Care Plan dated 05/24/21 noted the she required extensive assistance from two staff for transfers, dressing, personal hygiene, toileting, and bathing. The care plan noted that she required a Hoyer lift (total body mechanical lift used to transfer residents) for all transfers. The care plan indicated that she utilized a pedaled Broda chair. The plan noted that R10 could propel herself around but needed assistance from staff when going to the dining room. On 09/15/22 at 07:55AM Certified Nurses Aid (CNA) O propelled R10 in her Broda chair from her room to the Mount Chalet dining hall. R10's chair had no foot pedals or foot rest and her feet were drug on the floor as staff pushed her to the dining area. R10 wore slip-on house shoes. In an interview on 09/19/22 at 04:30PM with CNA O, she stated that a resident's leg/feet should never drag on the floor while being propelled in the chair. She stated that the wheelchairs should have pedals for the residents to rest their legs. In an interview on 09/19/22 at 04:45PM, Administrative Nurse D stated that staff should never allow a resident's feet to drag or slide while being transferred or assisted with locomotion in a wheelchair. She stated that R10's current chair did not have the foot pedals, but the facility had ordered her a new chair with the pedals. A review of the facility's Fall Prevention and Management Protocol revised 02/2019 indicated that each resident's care plan will identify individualized interventions for assessed risks associated with falls. The care plan noted that staff will seek to identify environmental factors that may contribute to falls. The facility failed to ensure R10's Broda chair had foot pedals in place to prevent R10's feet from dragging on the floor when staff propelled the wheelchair. This deficient practice placed R10 at risk for injuries related to the lack of the foot pedals.

- On 09/14/22 at 12:03 PM R15 sat in a Broda chair (special wheelchair) in the dining room. Her drink on the table was placed out of her reach. R15 sat in the dining room table from 12:03 PM to 12:25 PM with a drink she was unable to reach until staff sat down next R15 to assist her with lunch. On 09/14/22 at 12:14 PM Certified Nurse Aide (CNA) M stood beside R68 in the dining room as she assisted R68 with her lunch. On 09/19/22 at 02:01 PM Certified Medication Aide (CMA) R stated staff should sit down next to the resident that they are assisting at meals times and talk to the resident not other staff members. CMA R stated the staff try to deliver the food to everyone at the table around the same time. On 09/19/22 at 02:18 PM Licensed Nurse (LN) H stated staff should always sit next to the residents at meal time to encourage and assist them if needed. LN H stated the staff tried to serve everyone at the same table at the same time. On 09/19/22 at 04:35 PM Administrative Nurse D stated staff should sit down next to the resident when they assist with a meal. Administrative Nurse D stated staff should deliver every resident seated at a table their meal as close together as possible. The facility Right to Dignity policy lasted revised 01/11/17 documented staff would provide each resident with independence and dignity during dining experience regardless of the amount of assistance the resident required. Staff would sit next to the resident to assist with their meal. The facility failed to ensure R15, who required assistance, did not wait for long periods of time at the table without staff assistance and failed to ensure R68 was treated in a dignified manner when staff stood over the resident to assist with dining, instead of sitting next to the resident. This had the risk for an undignified dining experience. The facility identified a census of 72 residents. The sample included 18 residents with four reviewed for resident rights. Based of observations, record review, and interviews, the facility failed to provide dignified urinary catheter care while transferring R9's to the spa. The facility further failed to ensure a dignified dining experience for R15 and R68. This deficient practice placed the affected residents at risk for impaired psychosocial well-being. - The Medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R9's Quarterly Minimum Data Set (MDS) dated [DATE] noted a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The MDS indicated that he had an indwelling catheter (tube placed in bladder to facilitate urine drainage). The MDS indicated that he was taking antibiotic (medication used to fight bacterial infections) medication. A review of R9's Indwelling Catheter Care Area Assessment (CAA) dated 09/20/21 noted that he was at risk for complications related to his bladder obstruction and required staff to monitor signs of infections and urine retention. A review of R9's Care Plan revised 09/12/22 revealed he had a suprapubic catheter (urinary bladder catheter inserted through the skin) placed on 09/14/21. The care plan indicated that staff were to monitor the catheter for sings of infections, flush the catheter, and provide catheter care as ordered. On 09/13/22 at 10:30AM R9 sat in his room. R9 reported that he often preferred to handle and empty his own catheter, but the facility provided education on hand hygiene before and after use. R9's catheter bag was observed inside a black privacy barrier (bag) located underneath his wheelchair. On 09/15/22 at 03:32PM staff pushed R9 in a wheelchair on the Mount Chalet hallway towards the spa room. R9's catheter urine collection bag hung loosely off the left side of his wheelchair with the bottom of the collection bag and the tubing dragging on the hallway floor. The bag contained visible urine with no dignity bag in place. In an interview completed on 09/19/22 at 02:30 PM with Certified Nurses Aid (CNA) M, she stated that even though R9 liked to empty and manage his catheter, staff were still responsible for ensuring the it was placed properly and emptied on a regular basis. She stated that the resident should always have a dignity or privacy bag in place. In an interview on 09/19/22 at 09/19/22 at 02:40 PM Licensed Nurse (LN) G stated that R9's catheter bag should be positioned lower than the level of his bladder and should never touch a soiled surface. She stated that the residents should have two dignity/privacy bag for both the bed and the wheelchair. She stated that the catheter bag should always be covered to protect the resident's privacy. A review of the facility's Dignity policy revised 01/2017 indicated that staff will refrain from any practice considered demeaning to a resident including leaving urinary catheters uncovered, refusing to comply with the resident's toileting request, or not providing privacy during clinical or personal cares. The facility failed to provide dignified urinary catheter management while transferring R9 to the spa. This deficient practice placed R9 at risk for complications related to decreased psychosocial well-being.

The facility identified a census of 72 residents. The sample included 18 residents which two residents reviewed for hydration. Based on observation, record review, and interviews, the facility failed ensure fluids were available within reach for Resident (R) 68, which placed her at risk of dehydration and adverse consequences. Findings included: - R68's Electronic Medical Record (EMR) from the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 99, staff interview documented moderately impaired cognition. The MDS documented that R68 required supervision of one staff member assistance for consumption of nourishment and fluids. The MDS documented R68 pocketed food in her mouth during the look back period. The Quarterly MDS dated [DATE] documented a BIMS score of zero which indicated severely impaired cognition. The MDS documented that R68 required extensive assistance of one staff member to provide nourishment and fluids. The MDS documented R68 pocketed food in her mouth during the look back period. R68's Activities of Daily Living [ADLs] Functional/Rehabilitation Potential Care Area Assessment (CAA) dated 03/31/22 documented she required assistance for ADL's. R68's Care Plan dated 03/08/22 directed staff to keep a blue coffee cup with a lid and straw with ice water at her bedside; R68 did better with lighter weight cups. Review of the EMR under the Orders tab revealed and order for regular diet with regular texture dated 03/21/22. On 09/15/22 at 07:34 AM R68 laid on her right side on the bed with her eyes closed. R68's water cup was on the bedside table located across the room by the recliner and out of reach of R68. On 09/15/22 at 11:28 AM R68 sat in a wheelchair in her room and watched TV. R68's water cup was located on the bedside table out of reach. On 09/19/22 at 08:34 AM R68 laid on the bed with her water cup on the bedside table which was pushed up against the wall out of her reach. On 09/19/22 at 03:11 PM Licensed Nurse (LN) I stated every resident should be offered the fluids of their choice. LN I stated residents should not be forced to drink fluids. LN I stated fluids of their choice should be in reach of the resident when in their rooms. On 09/19/22 at 03:36 PM Certified Nurses Aide (CNA) N stated fluids of the resident's choice should be offered at meals. CNA N stated several cups should be offered to each resident or refilled after the resident had consumed the fluids. CNA N stated their water pitcher or fluids should be in reach when the resident was in their room. On 09/19/22 at 04:34 PM Administrative Nurse D stated the resident should be offered the drinks of their choice. Administrative Nurse D stated the care plans should document the resident's favorite beverage. Administrative Nurse D stated the resident's water should always be in their reach when they are in their rooms. The facility Resident Hydration policy last revised 2022 documented since most elder residents are at risk of dehydration, team members who work in the neighborhoods would be provided education about the signs and symptoms of dehydration. Offering fluids to residents who are at risk for dehydration would be the responsibility of all neighborhood team that are qualified to assist a resident with fluid intake. Nursing staff would offer and assist residents with fluids before and after ADL care and between meals. The facility failed to ensure R68's fluids were within her reach which placed her at increased risk of dehydration and other unwanted adverse consequences.

The facility identified a census of 70 residents. The sample included 18 residents with two residents reviewed for limited range of motion (ROM). Based on observation, record review and interview the facility failed to ensure that staff obtained and applied Resident (R)66's physician ordered splint to her right hand. This placed R66 at risk for further decrease in ROM. Findings included: - The electronic medical record (EMR) documented diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual Minimum Data Set (MDS) dated [DATE] documented R66 had both long and short-term memory loss. R66 required extensive assist of two staff members for her activities of daily living (ADLS). R66 required the use of a wheelchair for mobility. R66 had one fall since the last assessment. The Fall Care Area Assessment (CAA) dated 08/20/22 documented R66 was at the facility for long-term care service care with a history of acute kidney failure. Staff anticipated and met R66's needs, followed facility fall protocol in the event of a fall, and provided a safe environment. The ADL Care Plan dated 11/23/21 for R66 directed staff that R66 was to wear a resting splint on her right hand with a pillow to elevate. Team member should place splint to R66's right hand for up to three hours every morning as tolerated making sure it was snug but not tight. Staff were to check skin integrity when splint was applied and removed. R66 also wore a compression glove to her right hand to decrease [CONDITION(S)] that was to be applied in the morning and removed at night. R66 used an arm tray for her right arm to rest on when she was up in her wheelchair to help elevate her right arm and decrease [CONDITION(S)]. Under the Orders tab in the EMR R66 had an order dated 05/18/22 to place resting splint to right hand for up to three hours every morning as tolerated to decrease risk of contracture (an abnormal permanent fixation of a joint). On 09/14/22 at 07:48 AM an observation revealed a sign taped to R66's wall next to her bed that said Apply resting splint to right hand for three hours in the morning. Apply [CONDITION(S)] splint under if [CONDITION(S)] present. On 09/14/22 at 08:52 AM R66 sat in her wheelchair in her room watching tv, her right arm rested on the arm tray attached to her wheelchair. R66's resting splint was not present on R66's right hand. Further observations revealed R66 did not wear the splint during the AM hours on this date. On 09/15/22 at 08:47 AM R66 did not wear her splint. R66 stated that she had not had her splint since she returned from the hospital on 09/02/22 and she had told staff that it was missing. R66 further stated that she was unsure if the facility ordered or tried getting her a new one. On 09/19/22 at 3:15PM Licensed Nurse (LN) H stated as far as she knew, R66 had her splint on everyday in the morning. LN H was not aware that if the splint was missing. On 09/19/22 at 3:34 PM Certified Nurse Aide (CNA) P stated that R66 should wear her splint in the morning for three hours but R66's splint was missing since she returned from the hospital. On 09/19/22 at 4:29 PM Administrative Nurse D stated she was aware that R66 had not had her splint for her right hand since her return from the hospital; the facility ordered R66 a new one that had not arrived yet. The facility policy for splint application was not provided by the facility. The facility failed to ensure the splint was available and applied to R66's right hand which placed R66 at risk for development of contractures and further loss of use of her right hand.

The facility identified a census of 79 residents. The sample included 18 residents. Based on record review and interviews, the facility failed to document a recapitulation of the facility stay upon discharge from the facility for Resident (R) 74, sampled for discharge. This placed R74 at risk for an interruption in the continuity of care and/or unidentified care needs. Findings included: - R74's Electronic Medical Record (EMR) from the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS documented that R74 required supervision of one staff member for activities of daily living (ADL's). R74's [CONDITION(S)] Drug Use Care Area Assessment (CAA) dated 04/07/22 documented she received an antidepressant medication (class of medications used to treat mood disorders and relieve symptoms of depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness). R74's Care Plan dated 02/02/22 documented R74 would like to be asked about returning to the community. Review of the EMR under Progress Note tab documented on 06/21/22 at 09:36 AM R74 left the facility at 09:20 AM. R74 and her representative signed the inventory form, removed R74's personal belongs and were given a copy of the community transfer form. The facility was unable to provide the recapitulation of R74's stay. On 09/19/22 at 02:08 PM Licensed Nurse (LN) H stated the charge obtained a discharge order from the physician for a resident's discharge from the facility, which would include all the resident's current orders. LN H stated the charge nurse then completed the discharge summary under the Assessment tab and documented the discharge under the Progress Notes tab. On 09/19/22 at 04:34 PM Administrative Nurse D stated the charge nurse on the unit obtained a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Administrative Nurse D stated the charge nurse completed the discharge summary and recapitulation of the resident's stay at the facility. The facility Move In, Transfer, and Move Out policy last revised 11/14/17 documented staff would complete the transform form and discharge summary. The facility failed to document a recapitulation for R74's stay at the facility after her discharge to another facility. This placed her at risk for an interruption in the continuity of care and/or unidentified care needs.

The facility identified a census of 72 residents. The sample included 18 residents with five residents reviewed for accidents. Based on observation, record review and interview the facility failed to ensure resident (R)36's bed was placed at a safe level while occupied. The facility failed to ensure R67 was transferred with the required assistance as directed in the plan of care. This deficient practice placed R36 and R67 at risk for accidents and related injuries. Findings included: -The electronic medical record for R36 documented diagnoses of obstructive and reflux [CONDITION(S)] (obstruction prevents flow of urine), [CONDITION(S)] ([CONDITION(S)]-a non-cancerous enlargement of the prostate which can lead to interference with urine flow, urinary frequency and urinary tract infections), spinal stenosis (a [CONDITION(S)] condition of the spine that could cause weakness and loss of use of extremities), and malignant neoplasm of prostate (a cancerous tumor of the prostate). The Annual Minimum Data Set (MDS) dated [DATE] documented R36 had a Brief Interview for Mental Status (BIMS) score of 14 which indicated intact cognition. R36 required extensive assistance of one to two staff members for his activities of daily living (ADLs). R36 had no history of falls. The Quarterly MDS dated [DATE] documented R36 had a BIMS score of 14. R36 required extensive assistance of one to two staff for ADLs. R36 had no history of falls since the prior assessment. The Fall Care Area Assessment (CAA) dated 04/14/22 for R36 documented weakness and impaired mobility. R36 was at risk for falling. Staff assisted R36 with all ADLs and cares. R36 used a wheelchair for mobility. The ADL Care Plan revised 09/09/22 documented R36 had quarter rails on the bed to assist with repositioning and transfers. R36 needed assistance of one for his ADLs and transfers and if R36 was tired or weak, he may need assistance of two. The care plan lacked information regarding any documented preference for R36 to have his bed in the highest position. A 07/22/22 a Fall Risk Assessment documented a score of 13 which indicated moderate risk. On 08/05/22 at 07:55 AM a Health Status Note documented R36 was confused at night, kept singing and was ready to get up and go to work. No agitation noted. On 8/17/22 at 06:44 AM a Health Status Note documented R36 was singing at night in his sleep. R36 stated that he was experiencing weird dreams at night. He also felt like he was in a different place. On 09/13/22 at 01:35 PM observation revealed R36 laid in his bed. The bed was in the high position (equal to or greater than three feet high). R36 said he did not request his bed to be left in the high position, but he was ok with it. On 09/14/22 at 09:00AM R36 laid in bed asleep; his bed height was at a level equal to three feet or less. On 09/15/22 at 07:16 AM R36 laid in bed resting; his bed was at the high position. On 09/19/22 at 02:38 PM Licensed Nurse (LN) H stated the height of the bed should be at a knee to thigh high level while occupied. LN H said a resident's bed should not normally be in real high position, but R36 has been known to move his bed up to a high level. R36 had been educated on the risk of falling when his bed was in a high position. On 09/19/22 at 3:34 PM Certified Nurse Aide (CNA) P stated that at times R36 moved his bed height into a high raised position; staff had talked with R36 about the potential risk of him falling due to the bed being so high. On 09/19/22 at 4:29PM Administrative Nurse D stated that the bed height really depended on the resident's preference and the bed height should not be high in the air. Administrative Nurse D said some residents liked the bed to be at a height where their feet touch the floor while sitting on the bed. She further stated R36 did raise his bed to a high position now and then and R36 had been told about the risk of falling when his bed was that high. The facility policy Fall Prevention and Management Protocol updated 02/23/19 documented that each resident would be assessed for the risk factors for falling at move in, return from a health care facility and after a fall in the neighborhood. The interdisciplinary team (IDT) will develop a plan for care with interventions that would reduce the resident's risk for falls. The plan would include specific information about the resident's routine and personal habits that may place the resident at risk for falls. The facility failed to ensure that R36's bed was maintained at an safe level. This deficient practice placed R36 at risk of an injury related to falls. - R67's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of difficulty walking, cognitive communication deficit, muscle weakness, [CONDITION(S)] (paralysis of one side of the body) affecting left nondominate side, depending on other enabling machines and devices. The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS documented that R67 required extensive assistance of two staff members for transfers. The MDS documented walking and moving from a seated to a standing position did not occur during the look back period for R67. The Quarterly MDS dated [DATE] documented a BIMS score of 15 which indicated intact cognition. The MDS documented that R67 was totally dependent on two staff members for transfers. The MDS documented walking and moving from a seated to a standing position did not occur during the look back period for R67. R67's Fall Care Area Assessment (CAA) dated 02/03/22 documented R67 had impaired mobility, weakness, and medications which increased his risk for falls. Staff assisted R67 with all his cares as needed. R67 had impaired mobility, weakness, use of an antidepressant, and risk for falling. R67's Care Plan last revised 10/13/21 directed staff he required assistance of two staff members and a Hoyer (total body mechanical lift) lift for transfers. On 09/14/22 12:12 AM Certified Nurse Aide (CNA) O and Licensed Nurse (LN) J left the Hoyer lift in the hallway out side R67's door. Staff entered the room to dress R67 prior to transfer into his wheelchair. On 09/14/22 at 12:26 PM LN O exited R67's room and stated R67 was in his wheelchair. LN O stated he walked R67 to the wheelchair and staff did not use the Hoyer lift. Observation revealed R67 sat upright in a wheelchair next to the bedside table. On 0915/22 at 03:40 PM CNA N stated she was the restorative aide and was currently worked with R67 for strengthening and walking. CNA N stated not all staff had been trained for safe transferring without the use of the Hoyer for R67. On 09/19/22 at 02:01 PM Certified Medication Aide (CMA) R stated the care plan contained the information for how to care for each resident and how much assistance each resident required for activities of daily living (ADLs)s. CMA R stated staff should follow the care plan for safety. CMA R stated staff were able to view the care plan on the Kardex (a medical information system used by nursing staff to communicate important information on their patients. It is a quick summary of individual patient needs that is updated at every shift change). On 09/19/22 at 02:18 PM LN H stated all staff had access to the care plan on the Kardex and the nurses could make changes to the care plan when needed. LN H stated the staff refer to the care plan to find out how much assistance was needed for each resident. On 09/19/22 at 04:34 PM Administrative Nurse D stated staff had access to the care plan from the Kardex on the computer to review the assistance each resident need for their ADL's. Administrative Nurse D stated therapy assessed the resident for safety related to transfers. The facility Fall Prevention and Management Protocol policy last revised 02/23/19 documented each resident would be assessed for the risk factors for falling at move in, return from a health care facility and after a fall in the neighborhood. The interdisciplinary team (IDT) will develop a plan for care with interventions that would reduce the resident's risk for falls. The plan would include specific information about the resident's routine and personal habits that may place the resident at risk for falls. Each resident would be assessed after each fall by a licensed nurse. The nurse will attempt to identify the cause of the fall and document in the nursing notes. The staff would seek to identify environmental factors that may contribute to falls. The plan of care would be reviewed, and a new intervention would be added to help prevent future falls if indicated. The IDT would review the fall in the Risk Meeting for two weeks to ensure appropriate interventions were working to help prevent falls. The facility failed to follow the care plan for transfers for R67, which placed him at risk of injury from falls.

The facility identified a census of 72 residents. The sample included 18 residents with two reviewed for quality of care. Based of observations, record review, and interviews, the facility failed to follow the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This deficient practice placed the residents at risk for complications related to heart failure. Findings Included: - The Medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R6's Quarterly Minimum Data Set (MDS) dated [DATE] noted a Brief Interview for Mental Status (BIMS) score of 14 indicating intact cognition. The MDS indicated no weight changes within the last six months. The MDS noted he received diuretic (medication to promote the formation and excretion of urine) medication. The MDS noted he required extensive assistance from two staff for all activities of daily living (ADL's) A review of R6's Urinary Incontinence Care Area Assessment (CAA) dated 04/19/22 indicated he was taking diuretic medication with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R6's Care Plan initiated 04/04/22 indicated that he was at risk for weight fluctuations related to his heart failure and medications. The care plan noted that R6 was on [MEDICATION(S)] (diuretic medication) for congestive heart failure and staff were to obtain and monitor his weights as ordered. The care plan noted that he required a Hoyer Lift (total body mechanical lift used to transfer residents) and two staff for assistance with all transfers. A review of R6's EMR under physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of R6's EMR under Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 09/13/22 at 08:20AM R6 was in his room talking to his roommate. R6 sat in his Broda chair (specialized wheelchair with the ability to tilt and recline) with his feet resting on the foot pedals. He had his lower left leg foot brace on and reported that he had already ate his breakfast. In an interview completed on 09/19/22 at 02:30 PM with Certified Nurses Aid (CNA) M, she stated that the nurses created the daily weights list for the CNA staff to follow. She stated that the list was made based on the residents' care plan and physician orders. CNA M stated that each morning the nurse printed out a communication sheet for the CNA staff that contained the residents' required assistance levels, transfer status, weights, and individual care needs. On 09/19/22 at 02:51 PM Licensed Nurse (LN) G stated that the daily weight list was printed out and given to the direct care staff each morning. She said the residents were weighed based upon what their physicians order indicated. She noted that all residents were weighed monthly, but some residents may be weighed weekly or daily. She stated nurses and CNA staff could review the residents' care plans to see how a resident was transferred for weighing. On 09/19/22 at 04:40 PM Administrative Nurse D stated that all weights obtained should have been documented. She stated that if a resident missed a weigh-in or was not available to be weighed, the nurse should have completed a progress note showing why it was missed. She stated that it could have also been noted on the MAR. The facility did not provide a weight monitoring policy. The facility failed follow the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This deficient practice placed R6 at risk for complications related to congestive heart failure and fluid overload. - The electronic medical record for R17 documented diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) dated [DATE] documented R17 had a Brief Interview for Mental Status (BIMS) score of three which indicated severely impaired cognition. R17 required supervision to limited assistance of one staff for her activities of daily living (ADLs). R17 received a diuretic (a medication used to promote the formation and excretion of urine). The Quarterly MDS dated [DATE] documented R17 had a BIMS score of two which indicated severely impaired cognition. R17 required limited assistance of one staff with her ADLs. R17 received a diuretic on seven of seven days during the lookback period. The Cognition Care Area Assessment (CAA) dated 05/10/22 documented R17 had some confusion and scored a three on her BIMS. R17 needed help at times with decision making. The Falls Care Area Assessment (CAA) dated 05/10/22 documented R17 had weakness, impaired mobility and staff assisted with all ADLs and cares as needed. The Nutritional Care Plan dated 05/12/22 directed staff to obtain and monitor weights as ordered and notify the physician of significant weight changes. Under the Orders tab, R17 had an order dated 07/05/22 for a weekly weight every Wednesday for [CONDITION(S)]. The Weights/Vitals tab for R17 documented weights on 07/07/22, 08/03/22, and 09/08/22. The Treatment Administration Record (TAR) lacked documentation for a weekly weight to be obtained. R17's clinical record lacked evidence a weekly weight was obtained. On 09/14/22 R17 laid in her bed asleep. She had her oxygen (O2) canula (a hollow tube used to deliver supplemental oxygen) on. On 09/19/22 at 07:51AM R17 sat in her wheelchair in her room with her O2 canula on. On 09/19/22 at 3:17 PM Licensed Nurse (LN) H stated the aides normally got the resident's weight. LN H said some of the residents did have parameters with their weights which directed when the physician should be notified if there was a significant change. On 09/19/22 at 3:34 PM Certified Nurse Aide (CNA) P stated that the aides were responsible for obtaining the weights and the care plan should tell staff how often each resident should be weighed. CNA P said after staff obtained the weight, the weights were turned in to the nurse. On 09/19/22 at 04:29 PM Administrative Nurse D stated that weights were normally only obtained monthly unless a resident had a specific order from the physician that required a more frequent weight. Administrative Nurse D said the nurse gave the aides a list of the residents that needed weights. The facility failed to provide a policy addressing weights. The facility failed to ensure R17 had a weekly weight for [CONDITION(S)] as ordered by the physician. This deficient practice put R17 at increased risk for excess weight/fluid retention and adverse side effects.

The facility identified a census of 72 residents. The sample included 18 residents with two reviewed for urinary catheter (insertion of a catheter into the bladder to drain the urine into a collection bag) care. Based of observations, record review, and interviews, the facility failed to provide care and services required for catheter care for Residents (R) 9 and R36. This deficient practice placed both residents at risk for complications related to urinary tract infections and catheter related complication. Findings Included: - The Medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R9's Quarterly Minimum Data Set (MDS) dated [DATE] noted a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The MDS indicated that he had an indwelling catheter. The MDS indicated that he was taking antibiotic (medication used to fight bacterial infections) medication. A review of R9's Indwelling Catheter Care Area Assessment (CAA) dated 09/20/21 noted that he was at risk for complications related to his bladder obstruction and required staff to monitor signs of infections and urine retention. A review of R9's Care Plan revised 09/12/22 revealed he had a suprapubic catheter (urinary bladder catheter inserted through the skin) placed on 09/14/21. The care plan indicated that staff were to monitor the catheter for sings of infections, flush the catheter, and provide catheter care as ordered. A review of R9's Health Status note dated 05/06/22 indicated that he acquired a [CONDITION(S)] ([CONDITION(S)]-resistant Staphylococcus aureus- a type of bacteria resistant to many antibiotics) in his urine and took [MEDICATION(S)] (antibiotic medication). A Health Status note dated 08/28/22 indicated that R9's catheter became clogged and was replaced. On 09/06/22 a Health Status note indicated that R9 complained that his catheter needed to be flushed because it was hurting. The note indicated that staff attempted to flush the tubing without success and the catheter had to be removed. The note stated that once the catheter was removed a large amount of urine drained from the ostomy site (surgical opening in the abdominal wall). The note indicated that the catheter was reinserted with immediate urine flow into the tubing with R9 expressing immediate relief. On 09/10/22 a Status Note indicated that staff identified thick looking urine and completed a urinalysis. On 09/12/22 R9's Health Status notes indicated positive culture of bacteria in his urine and he was started on antibiotics for seven days. On 09/15/22 at 03:32PM staff pushed R9 in a wheelchair on the Mount Chalet hallway towards the spa room. R9's catheter bag was loosely hanging off the left side of his wheelchair with the bottom of the collection bag and the tubing dragging on the hallway floor. The bag contained visible urine with no dignity bag in place. In an interview completed on 09/19/22 at 02:30 PM with Certified Nurses Aid (CNA) M, she stated that even though R9 liked to empty and manage his indwelling catheter, staff were still responsible for ensuring the it was placed properly and emptied on a regular basis. She stated that the facility did not track output on urinary catheters. She stated that the urinary catheter bags should be positioned below the resident's bladder and never should touch the floor or soiled surfaces. In an interview on 09/19/22 at 04:05PM with Administrative Nurse E, she stated that the facility recently has increased training towards ensuring infection control practices are being followed to prevent infections from poor hand hygiene and cares provided to the residents. She stated that staff should have ensured that the catheter never touched the ground and was placed properly. A review of the facility's Catheter Care policy (no revision date) indicated that catheter care will be provided to all residents with indwelling catheter as least twice daily. The policy noted that the purpose of catheter care is to prevent possible urinary tract infections from bacteria spreading into the bladder. The policy noted that staff were to monitor for signs of [CONDITION(S)]'s, blockages within the tubing, and placement of the tubing and catheter bag. The facility failed to provide sanitary urinary catheter care for R9, who had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . This deficient practice placed both residents at risk for complications related to urinary tract infections and catheter related complication. -The electronic medical record for R36 documented diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual Minimum Data Set (MDS) dated [DATE] documented R36 had a Brief Interview for Mental Status (BIMS) score of 14 which indicated intact cognition. R36 required extensive assistance of one to two staff members for his activities of daily living (ADLs). R36 required the use of an indwelling catheter for urinary continence. R36 had no history of falls. The Quarterly MDS dated [DATE] documented R36 had a BIMS score of 14. R36 required extensive assistance of one to two staff for ADLs. R36 required the use of an indwelling catheter for urinary continence. R36 had no history of falls since the prior assessment. The Urinary Catheter Care Area Assessment (CAA) dated 04/14/22 for R36 documented weakness and impaired mobility. R36 had a Foley catheter in place which place him at risk for infection. Staff managed all cares. The Catheter Care Plan revised 07/20/21 directed staff that R36 had a 16 French (fr) 10 cubic centimeters (CC)Foley catheter. A licensed nurse would change the catheter every month and as needed. Position the catheter bag and tubing below the level of the bladder. Change the urinary leg bag and bedside drainage bag every seven days on Sunday night and as needed. Monitor/record/report to the physician for signs and symptoms of urinary tract infection ([CONDITION(S)]) such as: blood tinged urine, cloudiness, and no urine output. The July Treatment Administration Record (TAR) documented orders dated 06/27/22 to change urinary leg bag and bedside drainage bag every seven days on Sunday night and as needed due to catheter. The July TAR documented an order dated 12/15/21 for a catheter 16 fr 10 cc. Change every month and as needed every evening shift on the 16th of the month for infection prevention. The clinical record lacked documentation staff monitored urine output. On 07/15/22 at 10:00 AM a Health Status Note documented R36 had complaints of pain down in lower umbilical area stated it may be around catheter area. Staff noted the catheter drainage bag was empty. The nurse had not received report of no urine output for R36. Staff attempted to reach the night shift Certifed Nurse Aid (CNA) but were unable. The nurse changed the catheter with no comfort or relief noted. The morning nurse received report of the issue and was advised of R36's baseline and that he may need to be sent to the hospital after an assessment. On 07/15/22 at 11:47 AM a Health Status Note documented the nurse assisted with trouble shooting the lack of urine output. The nurse received report that the catheter had just been changed by the night shift nurse and irrigated with but still had no urine output. The resident was uncomfortable with a visibly distended abdomen. Bladder irrigation was performed with two to three cubic centimeters (cc) of sterile water, which caused the resident to be in increased discomfort. The catheter balloon was emptied, and the catheter was repositioned. Urine was visualized in the catheter tubing and approximately 500-600 ccs of urine drained and the resident verbalized relief. Emergency Medical Services (EMS) arrived on scene; R36 verbalized a desire to stay at the facility and not go to hospital. On 07/15/2022 06:15 PM a Health Status Note documented at approximately 06:00 PM the nurse sent R36 out via EMS to be further evaluated due to the resident's complaints of abdominal pain and unstable vital signs. The nurse noted 1250 cc of output of urine from resident's Foley catheter. This nurse administered as needed pain medication but the medication was not effective in treating the resident's abdominal pain almost one hour after administration. The nurse notified the doctor and family and called EMS to transport the resident to the hospital. The resident left the facility at 06:15 PM via stretcher with EMS to the hospital. A Physician's Report dated 09/07/22 documented R36 had several UTIs since April 2022 (April, July, August). On 09/13/22 at 07:55 AM an R36 laid in his bed, the bed was in a high position (equal to or greater than three feet high). R36's catheter bag that hung from his bed was visibly full of urine. On 09/15/22 at 12:01 AM R36 laid in bed. His catheter bag was in a shopping bag on the floor. On 09/19/22 at 01:35 PM Certified Medication Aide (CMA) R stated that the facility does not record the urine output on residents with a catheter unless there is a specific order from the physician. Staff should be checking the urine output from the catheter frequently throughout the shift and report any excessive or decrease output to the nurse. On 09/19/22 at 02:38 PM Licensed Nurse (LN) H stated that typically the facility does not keep track of urine output on residents with a catheter unless there was a specific order from their physician to do so. On 09/19/22 at 04:29 PM Administrative Nurse D stated that as a rule the facility generally did not document or keep a record of a resident's urine output. Administrative Nurse D said she expected the aides to let the nurse know if a resident had a change in the amount of urine output noted. On 09/19/22 at 05:43 PM Administrative Nurse F stated that the night shift nurse on 07/14/22 changed R36's catheter, but had not been made aware that R36 had no urine output until later that morning when she went to assist with reinserting/adjust R36's catheter. R36 had complaints of discomfort and his abdomen was distended. EMS was called initially but R36 did not want to go. The facility did not keep a record of urine output for the residents that have a catheter unless a physician specifically asked for one. A review of the facility's Catheter Care policy (no revision date) indicated that catheter care will be provided to all residents with indwelling catheter as least twice daily. The policy noted that the purpose of catheter care is to prevent possible urinary tract infections from bacteria spreading into the bladder. The policy noted that staff were to monitor for signs of [CONDITION(S)]'s, blockages within the tubing, and placement of the tubing and catheter bag. The facility failed to provide adequate care and services related to R36's catheter which resulted in no urine output for many hours and subsequently R36 required treatment at the hospital. The deficient practice placed R36 at risk for infection or further urinary problems.

The facility reported a census of 78 residents. The sample included six residents reviewed for accidents. Based on observation, record review, and interviews the facility failed to ensure one resident was free from injury when staff failed to provide the necessary services as directed by Resident (R) 1s' plan of care. R1 required physical assistance from two staff members with the Hoyer lift (total body mechanical lift used to transfer residents) to transfer R1 from one location to another safely. The Hoyer lift was used by one staff member to transfer R1 between the bed and Broda (specialized wheelchair with the ability to tilt and recline) chair. Subsequently, R1's bilateral arms were extended further than her documented contractures (abnormal permanent fixation of a joint) which resulted in a dislocated right elbow that required medical attention at an orthopedic office and further evaluation at an acute care hospital. Findings included: - R1's Electronic Medical Record (EMR), under the [DIAGNOSES REDACTED]. The Significant Change Minimum Data Set ((MDS) dated [DATE] recorded R1 had short-term and long-term memory problems. R1's activities of daily living (ADL) documented total assistance of two staff members for bed mobility, transfers, dressing, toilet use and personal hygiene. It also documented R1 had functional limitation in range of motion (ROM) impairment on both sides upper and lower extremities. The Quarterly MDS dated [DATE] recorded R1 had short-term and long-term memory problems. R1 required total assistance of two staff members for ADLs, but also included personal hygiene required two staff members. It documented R1 had functional limitation in ROM with impairment on both sides, upper and lower extremities. The Care Area Assessment (CAA) for Activities of Daily Living Functional/Rehabilitation Potential dated 09/16/2020 did not trigger. The Care Plan revised 01/21/2020 for ADLs directed staff that R1 needed help of two staff members with a Hoyer lift for all transfers and R1 was dependent on team members to dress and undress her. On an undated, unsigned Witness Statement Certified Nurse Aide (CNA) M documented he entered R1's room to wake R1 up. CNA M dressed R1 and attempted active range of motion to R1's upper extremities. After a few moments, CNA M continued to dress R1. CNA M transferred R1 to her wheelchair after he dressed her. CNA M then placed R1 in the dining room for breakfast. At approximately 03:45 PM, CNA M observed redness around R1's elbows and notified the nurse on duty. The Progress Note dated 01/25/2021 at 01:25 AM documented R1's arms were red, purple and swollen bilaterally around the elbow. It further documented small cuts were noted on the inner parts of the elbows. The Progress Note dated 01/25/2021 at 09:15 AM documented R1 had an appointment at the orthopedic office on 01/25/2021. The Progress Note dated 01/25/2021 at 02:06 PM documented the orthopedic physician recommended R1 be evaluated at the emergency room (ER). R1 transferred to the ER. The Orthopedic Visit Note dated 01/25/2021 at 02:38 PM documented R1's right upper extremity had a skin tear and weeping over the medial (the middle) aspect of the distal (away from the farthest point of origin or attachment) elbow, and severe ecchymoses (bruising) and swelling about the elbow and forearm. Palpation (a technique used in physical examination in which the examiner feels the texture, size, consistency and location of certain body parts with his/her hands) of the elbow caused outward signs of pain. The assessment documented R1 had sustained a traumatic right elbow dislocation which was still dislocated, and the physician documented he had concerns about potential elder abuse in this situation. In addition, it documented a single x-ray view of the right elbow showed an anterior (front) dislocation of the elbow. In a signed Witness Statement dated 01/24/2021 CNA N documented at 10:00 AM she observed R1 out for breakfast in the dining room. R1 arms looked stretched out. At 01:00 PM CNA N documented bruising started, so she reported the bruising to the nurse. The notarized Witness Statement dated 01/25/2021 by Certified Medication Aide (CMA) R documented at 02:30 PM, three unidentified staff members placed ice on R1's right arm which was swollen and discolored at the elbow, both arms were extended which was abnormal. There was swelling at the left elbow as well, but much less discoloration that the right. R1 did not appear to be in pain except for when the unidentified staff member touched her elbow to place the ice. The Facility Investigation report, signed and dated on 01/29/21, recorded on 08:26 AM on 01/24/21, CNA M was observed on facility video entering R1's room alone with the Hoyer lift, and also was observed bringing the Hoyer out by himself and then bringing R1 out in her Broda chair without having anyone else in the room to assist with the Hoyer transfer. CNA M was in the room for six minutes and then was observed on camera to step to the doorway of R1's room. At that time CNA M spoke to Licensed Nurse (LN) H. He held his elbow and moved his arm around during the conversation. LN H entered the room, and exited approximately 30 seconds later. The Facility Investigation report, signed and dated on 01/29/21, under the Conclusion section documented the following: Based on investigation, statements gathered, video footage review, hospital and diagnostic reports and staff interviews, (CNA M) failed to follow the care plan and (facility) policy for safe mechanical lift transfers resulting in a major injury to (R1's) right arm. The Facility Investigation report, signed and dated on 01/29/21, recorded R1 transferred to the hospital to have her elbow reset and used an immobilizer afterwards. On 01/26/2021 at 11:25 AM Administrative Staff A stated that upon review of facility video footage, CNA M was the only staff member observed to leave R1's room when the Hoyer lift was brought out, and then again when R1 was brought out in her wheelchair. On 01/26/2021 at 11:26 AM Administrative Nurse D stated that the Hoyer lift required two staff members to operate and she did not see anyone else come out of R1's room. On 01/26/2021 at 12:12 PM Physician JJ stated that R1's injury to her right elbow was a high energy injury and was not something that would have happened without force. Physician JJ stated that he was told R1 received the injury during bathing, but the injury that he saw was not consistent with that type of injury. He further stated the injury had force behind it. On 1/26/2021 CNA M was unavailable for interview. On 01/26/2021 at 02:11 PM CNA P stated that upon hire, she received training to use the mechanical lifts and that it always required two staff members to use it. On 01/26/2021 at 02:30 PM Licensed Nurse (LN) G stated that it required two staff members to use a mechanical lift and R1 was easy to transfer with the Hoyer lift. On 01/26/2021 at 03:15 PM CNA O stated that she knew how to transfer residents by reading the care plans. The care plans told staff how to care for the residents. CNA O further stated she received training on the use of the Hoyer lift upon hire, and the mechanical lift required two staff members to use. She transferred R1 in the past and R1 required a two person assist with the Hoyer lift. The facility policy Use of a Mechanical Lift for Resident Transfers updated 04/19/2007 directed all mechanical transfers are to be conducted with two staff members. The facility failed to ensure was free from accidents and safety hazards when facility staff failed to transfer R1 with two staff members utilizing the Hoyer lift. This deficient practice caused actual harm to R1 when she sustained a dislocated right elbow, which required orthopedic intervention and evaluation at an acute care hospital.