Every finding on record at Ignite Medical Resort Overland Park LLC

Based on observation, interview, and record review, the facility failed to provide sanitary conditions for food storage and preparation in the facility's one kitchen to prevent the spread of food borne illness. Findings included:- Initial tour of the kitchen on 07/27/2026 at 08:09 AM with Dietary Staff BB revealed the following areas of concern:Two small skillets and two small pots had black staining to the interior and exterior of the cookware.The small freezer at the entrance into the kitchen from the dining room had an open box of chocolate ice cream cups and an open box of vanilla ice cream with no open date.A small cart had a plastic bag of thawing, frozen, diced turkey dated 07/19.The pantry had one devil's food cake mix dated 06/05, an opened half full bag of devil's food cake mix opened 06/12, one yellow cake mix dated 07/02, one bag of fudge brownie mix dated June 2, four bags of fudge brownie mix dated 07/17 three bags of basic muffin mix dated 07/10, a large storage bin labeled flour and dated 05/12 and a large storage bin labeled sugar and dated 05/22, five bags of dry crispy cereal dated with 07/17, seven bags of frosted dry cereal dated 07/21, six bags of pancake/waffle mix dated 07/10, twelve containers of dry oatmeal dated 07/24, one open container of dry oatmeal dated 07/27, a large container of peanut butter with an open date of 06/02/1, five large containers of peanut butter dated 06/19, five large containers of salad dressing dated 07/07, two cartons of pineapple juice with an expiration date of 07/01/2026.The large cooler had an open carton of liquid egg on the bottom shelf dated 07/27, sitting below a turkey loaf wrapped in unsealed, partially open plastic wrap that was dripping liquid on the third rack above the open liquid egg and a partial crate of eggs on the bottom shelf.The food items had no documentation of the year listed with the dates marked on them.On 07/29/2026 at 12:03 PM, Dietary Staff BB reported that potentially hazardous foods should be stored separately to prevent cross-contamination and to prevent illness. Dietary Staff BB also reported that food should be dated with the month, day, and year.The facility's policy Dietary Food Storage, dated December 2020, with revision dates of 11/2021, 10/2022, and 04/2023 documented food and non-food supplies will be purchased, received, and stored under sanitary, safe, and secure conditions as required to meet federal, state, and local laws.

Based on observation, record review, and interview, the facility failed to ensure Resident (R)121's call light was within his reach to enable him to call for staff assistance. Findings included:- R121's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of paraplegia (paralysis characterized by motor or sensory loss in the lower limbs and trunk), left leg above the knee amputation (surgical removal of a body part), and right leg above the knee amputation. R121 was admitted on [DATE], and no Minimum Data Set (MDS) assessment had been completed at the time of the survey. R121's Baseline Care Plan dated 07/26/2026 documented that he was a fall risk and to anticipate and meet his needs. The plan documented that he did not have cognitive impairment. R121's Daily Skilled Note on 07/24/2026 documented that he had cognition to person, place, time, and situation, but required supervision for safety. Observed on 07/27/2026 at 09:45 AM, R121 laid in bed on a low air loss mattress with his breakfast tray on his table over the bed and a pencil and paper on the tray to fill out his menu. R121's call light was on the floor out of his reach. Observation on 07/28/2026 at 07:58 AM, R121 laid in his bed with the call light on the floor out of his reach. His oxygen tubing lay on his bed. During an interview on 07/27/2026 at 09:45 AM, R121 stated that he could not reach his call light because it was on the floor, so he could not call for help to fill out the menu as he could not write it. He stated that he could activate his call light when he could reach it. During an interview on 07/28/2026 at 07:58 AM, R121 stated he could not reach his call light to ask for help to put on his nasal cannula as he thought he was supposed to be wearing it. He stated that he had not had breakfast and was leaving at 09:00 AM for an appointment but could not use his call light to ask about breakfast. During an interview on 07/29/2026 at 07:36 AM, Licensed Nurse (LN) G stated that R121was able to use his call light and that he should have it on his bedside within his reach. During an interview on 07/29/2026 at 07:42 AM, Certified Nursing Aide (CNA) O stated that R121 was able to use his call light and should always have it within his reach. During an interview on 07/29/2026 at 12:44 PM, Administrative Nurse D stated that she expected that R121's call light should always be within his reach. She said if a resident was impaired or cognitively impaired, then the call light should be clipped on them and always within their reach. Policy for Call Light -Ability to Use dated 11/2018 revised 09/1019, 08/2020, 08/2021, 10/2022, 04/2023, 01/2024 documented that the call light system is provided as a tool for residents to communicate with staff and staff members will ensure that call lights are within reach of a resident who is able to cognitively use a call light each time they leave the room.

Based on observation, record review, and interview, the facility failed to ensure the Office of the Long Term Care Ombudsman was notified when Resident (R) 3 was transferred to the hospital. The facility failed to ensure R3, R4. and R8 and their representatives were provided with a bed hold policy that included their daily rate to hold the bed. The facility failed to ensure R3 and their representatives were provided with a written notification of transfer that included a statement of the right to appeal and the state ombudsman information, upon their transfer to the hospital as soon as practicable upon their transfer to the hospital. Findings included:- 1. R3's EMR documented a Discharge Minimum Data Set (MDS), dated 08/02/2025, for an unplanned discharge to an acute hospital with a return anticipated. R3's Entry MDS, dated 08/02/2025, documented a re-entry to the facility from an acute hospital.R3's Discharge MDS, dated 08/20/2025, documented an unplanned discharge to an acute hospital with a return anticipated.R3's Entry MDS, dated 08/26/2025, documented a re-entry to the facility from an acute hospital. R3's Discharge MDS, dated 03/05/2026, documented an unplanned discharge to an acute hospital with a return anticipated.R3's Entry MDS, dated 03/10/2026, documented a re-entry to the facility from an acute hospital. The facility lacked proof or documentation that R3 or his representative had been provided the bed hold information or the notice of transfer in writing for his transfers to the hospital on [DATE], 08/20/2025, and 03/05/2025. The facility lacked proof or documentation that the LTC ombudsman had been notified of R3's 03/05/2026 transfer to the hospital. The facility's Bed Hold Notice form documented the bed hold information, including the appeal rights and the LTC ombudsman information as well as the private and semi-private daily rates to hold the bed. The form also had an area for staff to document where the resident was transferred to, the reason for transfer, and the date of the transfer. On 07/29/2026 at 09:19 AM, Administrative Staff A stated that the nurses completed a bed hold assessment in the EMR that shows the information about the bed hold, and the representative was called to ask about the bed hold, but the actual paper form that was completed by staff was not scanned into the residents record. Administrative Staff A stated that the social worker submitted the transfers and discharges to the state ombudsman monthly and could not state why R3's transfer to the hospital had been omitted from the list.

Based on observations, interviews, and record reviews, the facility failed to ensure appropriate care and services were provided to promote wound healing (R)72 when staff failed to follow the physician's treatment order for leg wraps. Findings included:- R72's Electronic Health Record (EHR) documented diagnoses that included chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminishing lung capacity and difficulty or discomfort in breathing), elevated white blood cell count, kidney failure, sepsis (a life-threatening systemic reaction that develops due to infections that cause inflammation throughout the entire body), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), heart failure (HF-a condition with low heart output and the body becomes congested with fluid), lymphedema (swelling caused by an accumulation of protein-rich fluid), history of thrombosis (a clot that develops within a blood vessel) and embolism (an obstruction in a blood vessel due to a blood clot or other foreign matters that gets stuck while traveling through the bloodstream).R72's 07/20/2026 Quarterly Minimum Data Set (MDS) documented R72 had received an application of ointments or medications other than to the feet and documented R72 had a Brief Interview for Mental Status score of 15, which indicated intact cognitive function.R72's Care Plan documented R72 had actual impairment to her skin integrity and further documented staff should evaluate and treat per physician order.R72's Registered Dietitian Progress Note dated 07/12/2026 documented diagnoses including lymphedema, heart failure, and depression. R72 had a significant weight gain of 12 pounds (five percent) in 30 days, seventeen pounds and six ounces in 90 days. R72's physician's order dated 04/26/2026 documented nursing staff was to apply ace wrap for compression lightly to bilateral lower extremity up to the knee, every Wednesday and Saturday, and to change wrap on shower days scheduled on Wednesday and Saturday.R72's EHR documented a pulmonary follow up appointment on 07/23/2026 at 11:55 AM that documented R72 presented with swollen bilateral leg. The note documented that R72's legs were currently wrapped but had not been wrapped for several days prior.R72's electronic Medication Administration Report (MAR) documented hydrocodone-acetaminophen for pain was requested by R72 on 07/01/2026 with a reported pain level of 5, 07/04/2026 with a reported pain level of 5, 07/09/2026 with a reported pain level of 6, on 07/15/2026 with a reported pain level of 6, 07/19/2026 with a reported pain level of 5, 07/20/26 with a reported pain level of 4, and 07/23/2026 with a reported pain level of 6. R72's MAR dated July 2026 showed the order for ace wrap to bilateral lower extremity each day shift on Wednesday and Saturday. The MAR documented that the ace wraps were applied by nursing staff each Wednesday and Saturday between July 1, 2026, and July 25, 2026.R72's EHR lacked evidence that the resident refused the wraps.Observation on 07/27/26 at 09:13 AM showed R72 lying in bed. She reported she has leg wraps that were supposed to be done on Wednesday and Saturday, and this does not always get done. She stated she was there for help, and not receiving the help caused her to feel depressed and frustrated. R72's legs were visibly swollen, and she did not have ace wraps on her right or left leg.Observation on 07/28/2026 at 04:53 PM showed R72 sitting in her recliner with the footrest partially extended. R72 stated the wraps were still not on her legs. R72 reported the last time her wraps were on was last Saturday, 7/25/2026. R72's legs were visibly swollen, and she did not have ace wraps on her right or left leg.Observation on 07/29/2026 at 09:05 AM showed R72 lying in bed with breakfast on a tray on the bedside table over the bed. R72 reported the nurses had still not put the wraps on her legs, and she said she hoped that they would put them on after her shower that day. R72 reports it was hit or miss if the nurses put her leg wraps on. She used to ask them to please put them on but stopped asking because it did not do any good. On 07/29/2026 at 12:21 PM, Certified Nurse Aide (CNA) PP reported R72 had leg wraps, but the wraps were not on her legs about 60% of the time when CNA PP assisted R72 with her shower. On 07/29/2026 at 12:25 PM, Licensed Nurse (LN) J stated staff was to unwrap R72's legs before her shower. LN J stated she had never had to do that because the wraps were not on the resident's legs. LN J stated there was an order to wrap R72's legs with ace wraps after her shower, but it only got done about 25% of the time.On 07/29/2026 at 12:53 PM, Administrative Nurse D stated all nursing staff should follow and provide all treatments as ordered.

Based on observation, record review, and interview, the facility failed to provide an environment free from accident hazards for Resident (R) 121 when staff transferred R121 using the full body lift (Hoyer) and did not maintain direct contact to provide safety and stabilization during the transfer. Findings included:- R121's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of paraplegia (paralysis characterized by motor or sensory loss in the lower limbs and trunk), left leg above the knee amputation (surgical removal of a body part), and right leg above the knee amputation. R121 admitted on [DATE], and no Minimum Data Set (MDS) assessment had been completed at the time of the survey. R121's Baseline Care Plan, dated 07/26/2026, documented that he was a fall risk and to anticipate and meet his needs. The plan documented that he did not have cognitive impairment and he was a maximum assist for transfers. R121's Daily Skilled Note on 07/24/2026 documented that he had cognition to person, place, time, and situation, but required supervision for safety. Observed on 07/28/2026 at 09:07 AM, Certified Nurse Aide (CNA) M and CNA N placed the Hoyer lift sheet under the R121 and attached the lift sheet correctly to the Hoyer lift over. CNA M used the control on the Hoyer to lift to raise R121 into the air over the bed while CNA N held the Foley catheter (a tube inserted into the bladder to drain urine into a collection bag) urine collection bag in his hands and walked around the bed to the same side the Hoyer lift was on next to R121 as he was transferred from the bed to his wheelchair while suspended in the air. While R121 was lifted and transferred from the bed to the chair, and lowered into the chair, CNA M operated the lift while CNA N stood by holding the urine collection bag, he did not provide contact to R121 while he was transferred. While R121 was suspended in the air over the chair, there was a knock on the door and a staff member informed CNA M and CNA N that the call light was on. CNA M removed his hands from the Hoyer lift and turned the call light off while CNA N stood next to R121 holding his catheter bag. As R121 was lowered into his wheelchair, CNA N placed one hand on R121 to adjust him in the chair. On 07/28/2026 at 11:17 AM, CNA M stated that she would get a second person to help with the transfer when a Hoyer lift was used, as it required two staff members. She would place a clean lift sheet under the resident and use one staff member to operate the lift, and the other staff member was to keep their hands on the resident and guide them. CNA M said the resident should never be left suspended in the air without someone having hands on them during the transfer process. On 07/28/2026 at 11:33 AM, CNA N stated that the proper way to use a Hoyer lift was to place a clean lift sheet under the resident and to have one person hold R121's foley bag below the waist while one person guided the lift. He stated that one person should have had a hand on R121 while he was transferred. On 07/28/2026 at 11:41 AM, Licensed Nurse (LN)G stated that for Hoyer lift transfers there should have been two staff members for safety. One staff should have held the foley catheter bag and kept a hand on R121 to guide him for safety and reassurance, and the other staff member was to operate the lift. On 07/29/2026 at 12:44 PM, Administrative Nurse D stated that her expectation was that two staff members were to use the Hoyer lift correctly for patient safety by keeping their hand on the resident during the transfer and to never walk away during a transfer. The facility policy Hoyer Lift (Mechanical Lift), dated 03/2025, documented Resident's that required a Hoyer lift would be transferred and use approved mechanical lifting equipment by trained staff in accordance with the resident's care plan, manufacturer guidelines, and all applicable state and federal guidelines.

Based on observation, record review, and interview, the facility failed to provide adequate infection control practices related to utilization of Enhanced Barrier Precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms that employ targeted gown and glove use during high-contact care), Personal Protective Equipment (PPE), or proper hand hygiene, while providing direct care to Resident (R) 120 and R29. Additionally, the facility failed to implement adequate infection control practices related to sanitary storage of respiratory equipment for R41. Findings included:- 1. Observed on 07/27/2026 at 09:26 AM, R120 had EBP signage on his door that required staff to wear gloves and gown PPE when providing cares related to a wound on his backside and right lower leg, as reported by R120. Certified Nurse Aide (CNA) OO assisted R120 off the toilet and only wore gloves. R120 also reported that staff would only wear gloves when they provided care. Observed on 07/27/2026 at 04:34 PM, Certified Medication Aide (CMA) R answered R120's call light and assisted him to the bathroom while wearing only gloves. R120 stood up with gait belt assistance, and his pants and wheelchair cushion were wet. The dressing on R120's sacrum (large triangular bone/area between the two hip bones), dated 07/26/26, was peeling away from his skin. CMA R assisted R120 onto the toilet and removed his wet pants and then cleaned off the wheelchair cushion. CMA R then opened the closet door and removed a clean pair of pants for R120 without changing gloves or performing hand hygiene, then applied a new incontinence brief and the clean pants to his lower legs.On 07/27/2026 at 04:52 PM, CNA P reported that EBP was required for residents who had a wound, feeding tube (tube for introducing high-calorie fluids into the stomach), or a Foley catheter (a tube inserted into the bladder to drain urine into a collection bag). She then said that EBP meant that staff needed to wear a gown and gloves PPE.On 07/28/2026 at 01:55 PM, Licensed Nurse (LN) H reported the staff are required to wear the appropriate personal protective equipment (PPE- gowns, face shields and/or eyeglasses/goggles, and gloves) when a resident was on EBP when they were completing hands on care.On 07/28/2026 at 04:30 PM, CMA R reported that she did not notice that R120 had an EBP sign on his door frame when she assisted him with his toileting. CMA R reported she should have removed her gloves and performed hand hygiene before she started to gather the items she needed from his closet. On 07/29/2026 at 10:32 AM, Administrative Nurse K expected all staff to wear PPE when a resident required EBP. 2. 07/28/2026 at 09:37 AM CNA Q knocked on R29's room no hand hygiene performed. CNA Q just applied gloves, no gown was applied EBP sign and PPE was located outside R29's door. CNA Q then opened the closet in 29's room and removed a pad, wipes, and a brief as she was doing that R29 called out for help and had emesis twice. CNA Q cleaned R29's face, then CNA Q started to remove R29's brief. At 9:41 AM LN I knocked on R29s door to ask a question, CNA Q told LN I that R29 was throwing up. On 07/28/2026 at 9:51 AM LN I entered R29's room, CNA Q had a gown and gloves on while providing incontinent care to R29. CNA Q she cleansed bowel movement off R29's buttocks as R29 was sliding off the bed and CNA Q asked LN I to assist her. CNA Q removed her gloves and applied new gloves no hand hygiene performed. CNA Q continued to cleanse off R29's buttocks. CNA Q removed her gloves no hand hygiene performed, applied new gloves, and applied R29s brief. CNA Q and LN I adjusted R29's brief and gown and boosted her back up in bed. On 07/28/2026 at 04:05 PM, CNA Q reported she had forgotten to put on her gown when she started cares for R29 and did not know she had to wash her hands after she removed her gloves during care she said she thought she only had to do that at the end of all cares. On 07/28/2026 at 04:12 PM, LN I reported she noticed that CNA Q was not wearing a gown and reported she told CNA Q to apply a gown when proving hands on care to all the residents that have EBP. On 07/29/2026 at 10:32 AM, Administrative Nurse K expected all staff to wear PPE when a resident required EBP. Administrative Nurse K expected all staff to complete hand hygiene when they removed gloves before applying new gloves. 3. On 07/27/2026 at 11:23 AM, R41 was not in his room LN H reported that R41 was in therapy. Observed in R41's room a nebulizer mask attached to the machine laying in the drawer with clear fluid in the chamber and the call touch pad laid directly in the mask. On 07/27/2026 at 04:56 PM, R41 was in his bed watching television. R41's nebulizer mask remained in the drawer lying directly on items and clear fluid in the chamber. On 07/28/2026 at 07:54 AM, R41 was seated upright in his bed, he did the ok sign with his fingers. R41's nebulizer mask remained in the top drawer lying on items and had clear liquid in the chamber. On 07/28/2026 1:39 PM, LN H pulled R41s the nebulizer mask out of his drawer and squeezed the vial of albuterol (a medication that works by relaxing the muscles in the airways, leading to increased airflow to the lungs) into the chamber. R41 applied the mask to administer the breathing treatment. On 07/28/2026 at 01:55 PM, LN H reported there was a bag that the mask should be placed in when the treatment was finished. On 07/29/2026 at 10:32 AM, Administrative Nurse K expected the nebulizer equipment to be rinsed out after use, air dry, and placed in a bag when not in use. The facility's policy Enhanced Barrier Precautions dated 3/2024, documented on the recommendation and approval of the facility's Infection Preventionist in collaboration with the facility's Medical Director, Enhanced Barrier Precautions (EBP) are implemented as one intervention this facility uses to reducetransmission of resistant organisms that employs targeted Personal Protective Equipment (PPE) use during high contact resident care activities. Standard Precautions continue to apply to the care of all residents, regardless of suspected or confirmed infection or colonization status. EBP will be used for any residents in this facility who meet the stated criteria wherever the resident resides in the facility. Residents with the following conditions require EBP for all cares including wounds any skin opening requiring a dressing, Foley catheter (a tube inserted into the bladder to drain urine into a collection bag), and feeding tube. Contact precautions would be continued for infected or colonized residents in situations deemed necessary by the Infection Preventionist, the Infection Prevention Committee, the facility's Medical Director, and The State, and local health department, including but not limited to: C. difficileThe facility's policy Hand Hygiene dated 04/2023 documented indications for handwashing was before and after contact with inanimate objects including medical equipment in the immediate vicinity of the resident and after removing gloves.The facility's policy Respiratory Supplies dated May 2023 did not sanitary storage of nebulizer masks.

Based on the record review and interview, the facility failed to conduct a thorough facility-wide assessment to determine the nursing staff resources necessary to care for residents competently during both day-to-day operations and emergencies. Findings Included:- An inspection of the Facility Assessment dated 03/22/2026 provided by the facility revealed the following: The assessment failed to identify the specific staffing levels needed for each unit and identify the number of Registered Nurses (RN), Licensed Nurses (LPN/LVN), Certified Medication Aides (CMA), and Certified Nurse Aides (CNA) needed for each unit, patient acuity, and census. The assessment lacked the staffing levels required for each daily shift and on weekends.On 07/29/2026 at 12:45 PM, Administrative Nurse D stated that the facility assessment should reflect the number of total hours for each nursing staff. Administrative Nurse D could not state for certain whether the facility assessment broke down each required nursing staff per shift.On 07/29/2026 at 01:09 PM, Administrative Staff A stated the Facility Assessment was reviewed annually, and information was included per the new guidelines. She was not aware that the staffing plan needed to be broken down for each category of nursing staff each shift and for each unit, including on the weekends. Administrative Staff stated she would make sure to review the facility assessment and revise it to reflect the needed information.The facility's Facility Assessment policy dated 08/01/2024 documented The Facility Assessment will address but is not limited to: the facility's resident population including, but not limited to: both the number of residents and the facility's resident capacity; the care required by the resident population, using evidence-based, data-driven methods that consider the types of diseases, conditions, physical and behavioral needs, cognitive disabilities, overall acuity, and any other pertinent facts that are present within the population, consistent with and informed by individual resident assessments as required by regulation; staff competencies and skill set that are necessary to provide the level and types of care needed for the resident population; the physical environment, equipment, services and other physical plant considerations that are necessary to care for this population; any ethnic, cultural or religious factors that may potentially affect the care provided by the facility including but not limited to activities and food and nutrition services. The facility's resources, including but not limited to: All buildings and/or other physical structures and vehicles; equipment (medical and non-medical); services provided, including but not limited to physical, occupations, speech skilled therapy, pharmacy consulting and dispensing services, behavioral health services, specific rehabilitation therapies such as respiratory therapy services; all personnel, including managers, nursing, and other direct care staff, both employees and those who provide services under contract, and volunteers, as well as those staff members' education and/or training and any competencies related to resident care; contracts, memorandums of understanding, or other agreements with third parties to provide services or equipment to the facility during both normal operations and during emergencies; and health information technology resources, such as systems for electronically managing resident records and electronically sharing information with other organizations. A facility-based and community-based risk assessment, utilizing an all-hazards approach as required in Federal regulations.

The facility identified a census of 110 residents. The sample included 20 residents with three residents reviewed for notification of roommate/room changes. Based on observation, record review, and interviews, the facility failed to provide written notice, including the reason for the change, to Resident (R) 1 and/or his representative before R1 received a roommate, R2. Findings included:- R1's Electronic Medical Record (EMR) documented diagnoses of generalized muscle weakness and dementia (a progressive mental disorder characterized by failing memory and confusion) with other behavioral disturbances. The Annual Minimum Data Set (MDS) dated 01/09/26, documented R1 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. The Activities of Daily Living (ADL) Functional/Rehabilitation Potential Care Area Assessment (CAA) dated 01/13/26, documented R1 was highly active in his ADLs and preferred to do what he could for himself. R1's Care Plan, dated 08/18/25, documented R1 had a behavior problem and directed staff to administer medications as ordered and monitor behavior episodes to determine their underlying cause. R1's EMR revealed a Social Service Note on 02/11/26 at 04:22 PM that staff notified R1 that he would be getting a roommate in the next couple of days. R1 verbalized understanding and agreed. Upon request, the facility provided a notice, dated 11/26/24, addressed to R1 and his representative that stated the facility wrote to the resident and their loved ones to inform them of an upcoming change that may affect the resident's living arrangements. The notice stated effective 01/01/25, the facility would be transitioning from private rooms to semi-private accommodations for some residents. The facility was not moving any residents out of their rooms, but were converting some rooms back to semi-private rooms. If the resident or their representative received the letter, that resident's room was one being converted. The notice did not inform R1 of when he would be receiving a roommate. Upon request, the facility was unable to provide a written notice for R1 prior to R1 getting a roommate on 02/13/26 when R2 admitted to the facility. On 03/17/26 at 12:34 PM, R1 sat in his wheelchair in his room. He stated he never received a written notice prior to R2 moving into his room. He stated the facility told him verbally that he would be getting a roommate. On 03/17/26 at 02:18 PM, Social Services X stated she went to the resident's room to tell them they were getting a roommate, then documented a note. She stated she did not give anything in written form, but stated the facility did send out a letter to residents that they might get a roommate at some point. On 03/17/26 at 03:15 PM, Administrative Staff A stated the facility let the resident know at least the day before that they were getting a roommate, but they did not give any written notice. She stated when the facility switched to semi-private rooms, the facility notified residents that they might get a roommate. The facility's Room Moves policy, revised January 2026, directed when the facility decided to change a resident room, Social Services informed the resident and family of the room move if time allowed. If time did not allow or the facility was unable to inform the resident or family, the facility informed the resident and family at the earliest possible availability. The policy did not address written notice of room or roommate changes.

The facility identified a census of 98 residents which included ten residents reviewed for transfers to another room in the facility for the convenience of staff. Based on observations, interviews, and record review, the facility failed to inform Residents (R) 1, R2, R3, R4, R5, R6, R7, R8, and R9 in writing of the impending room change in order to create a hall to group skilled residents. This placed the residents at risk for impaired resident rights and decreased psychosocial well-being. Findings included: - R9's Electronic Medical Record (EMR) recorded a Family Communication Note dated 07/23/24 at 11:10 AM that documented R9 (Brief Interview for Mental Status [BIMS] score of 15 which indicated intact cognition), discussed moving rooms on 07/33/24. R9 was agreeable to a new room. On 08/01/24 at 12:30 PM R9's Notification of Room Change located under the Evaluations tab documented the reason for the room change was a transfer from post-acute to long-term care. Administrative Staff C spoke with R9 and R9's family member on 07/22/24 regarding the move. R3's EMR recorded a Family Communication Note dated 07/23/24 at 12:53 PM that documented R3 (BIMS score of three which indicated severely impaired cognition) was spoken to on 07/23/24 related to changing rooms. R3 stated she was 'OK' with changing rooms if R3's representative was ok with the change. On 08/01/24 at 12:08 PM R3's Notification of Room Change located under the Evaluations tab documented the reason for the room change was R3 being transferred to long-term care from the post-acute unit. Administrative Staff C placed calls to R3's family member on 07/19/24 and 07/22/24 and finally spoke with R3's family member on 07/23/24 regarding the move. R2's EMR recorded a Family Communication Note dated 07/23/24 at 02:15 PM that documented R2 (BIMS score of one which indicated severely impaired cognition) was visited on 07/19/24 regarding changing rooms. R2's representative was also spoken with related to R2's room move and was agreeable to the room picked for R2. On 08/01/24 at 12:16 PM, R2's Notification of Room Change located under the Evaluations tab documented the reason for the room change was to transfer from the post-acute care to long-term care. Administrative Staff C spoke with R2 and R2's representative on 07/19/24 regarding the move. R5's EMR recorded a Family Communication Note dated 07/24/24 at 05:53 PM that documented R5's (BIMS score of 15) family member was given a compassionate ear related to R5's change in rooms. On 08/01/24 at 12:25 PM R5's Notification of Room Change located under the Evaluations tab documented the reason for the room change was to transfer from post-acute to long-term care. Administrative Staff C spoke with R5 and R5's family member on 07/19/24 regarding the move. R6's EMR recorded an Other Note dated 07/25/24 at 10:46 AM that documented R6 (BIMS score of 15) would be taken to see the room R6 would move into by unidentified administrative staff. On 08/01/24 at 12:33 PM R6's Notification of Room Change located under the Evaluations tab documented the reason for the room change was to transfer to long-term care from post-acute care. Administrative Staff C spoke with R6 on 07/19/24 regarding the move. R1's EMR documented a Notification of Room Change dated 08/01/24 at 12:41 PM that documented the reason for the room change was to transfer to long-term care from post-acute care. Administrative Staff C spoke with R1 and R1's family representative on 07/05/24 regarding the move. R7's EMR recorded a Notification of Room Change dated 08/02/24 at 12:37 PM that documented the reason for the room change was to transfer from the post-acute. R4's EMR noted a Notification of Room Change dated 08/05/24 at 12:20 PM, that documented the reason for the room change was to transfer from the post-acute care unit to long-term care. Administrative Staff B spoke with R4's family on 08/05/24 regarding the move. R8's EMR recorded a Notification of Room Change dated 08/05/24 at 12:53 PM that documented the reason for the room change was to transfer from the post-acute care unit to long-term care. Administrative Staff B spoke with R8's family representative and R8 regarding the move. The list of residents provided by the facility via electronic mail on 08/21/24 documented that were recently moved from P hall documented staff spoke with R1 regarding changing rooms and R1's family representative, R2 and R2's family representative, R3 and R3's family representative, R4's family representatives, R5 and R5's family representative, R6, R7 and R7's family representative, R8's family representative, and R9 and R9's family representative to move to a different room. On 08/28/24 at 12:48 PM R1 (BIMS score of 15) lay in his bed with his blankets up to his chest. R1 stated that he knew he was moved for a reason but R1 he could not remember why. On 08/28/24 at 01:40 PM, R6 sat in her wheelchair in her room painting on an easel. R6 stated she was not asked but was told she was moving and the room she was in would be used for dialysis (a procedure where impurities or wastes were removed from the blood). R6 further stated she did not want to move because she would lose her shower. R6 revealed that she had not gotten anything in writing and only remembered hearing about it through word of mouth. R6 revealed she was disappointed with the room move. On 08/28/24 at 02:12 PM, R5 appeared well-groomed and clean. R5 sat in her wheelchair watching the television. R5 stated she was told she had to move that the new owners wanted the hallway she used to live on for acute care and that everyone on that hall had to move. R5 revealed she had not received a letter about the move and was not told she could stay if she did not want to move. R5 stated she cried and felt very unhappy about the move. R5 stated she had lived in the facility for over two and a half years, and it was quite upsetting. On 08/29/24 at 03:09 PM, R9 lay in bed with a clean blanket draped over him up to his chest with his arms and hands laid on top of the blanket. R9 stated that he had no option to stay in his old room. R9 revealed that the room move was heard through word of mouth and that neither he nor his family member had received written notice of the room change. R9 stated that if he would thought he could have stayed in his old room, he would have fought it and put up a stink. R9 stated he felt like a number or an object and wished he could have stayed in his old room. On 08/28/24 at 01:15 PM, R1's representative stated neither he nor R1 had received written notification about the room move. R1's representative stated they were not given an option to stay in the room R1 had been in. R1's representative stated that R1 and he chose that room due to it being smaller and that way he would not end up with a roommate. R1's representative stated that the residents and residents' family members were fearful that the bigger rooms with be doubled up with more than one resident in the room. On 08/28/24 at 01:35 PM, R2's representative stated that he had been told that R2 needed to move rooms. R2's representative stated the facility had taken good care of R2 and R2 was not up out of bed so R2's representative had no concerns with the room move. R2's representative verified he had not been informed of the move in writing. On 08/28/24 at 02:10 PM, R7's representative stated she was told that R7's old room was going to be used for therapy. R7's representative stated it took multiple family members making numerous statements to get R7 moved to a room where R7's wheelchair would fit through the bathroom door. On 08/28/24 at 02:21 PM, R3's representative stated that she was told that R3 had to move and that the incoming company wanted everyone moved off of the hall that R3 was on, and the new company wanted to use that hall for rehabilitation. R3's representative stated that she had not received anything in writing explaining the room move, nor was R3 staying in the old room even an option. R3's representative stated if R3 could have stayed in the old room, R3's representative would have wanted that. On 08/29/24 at 02:29 PM, R8's representative stated that the room move happened and there was no choice to be able to stay in R8's current room. R8's representative further revealed that she had received nothing in writing related to the room move. R8's representative stated that R8's room was chosen because it is small because the family was fearful that the bigger rooms in the building were going to be doubled up. On 08/29/24 at 03:15 PM, Certified Nurse Aide (CNA) M stated that the room moves happened so that the P hallway where the resident previously lived, could be made into a rehabilitation hall. On 08/29/24 at 03:24 PM License Nurse (LN) G stated that the room moves occurred so that residents that were being skilled were all in one location. The facility's Room Moves policy revised in April 2024, documented that when it is decided by the facility administrator or per resident request of a room move, guest services/social services or designee would call the family and inform the resident of the room move if time allows. If time does not allow (urgent isolation need or new admission entered building early) or the facility is unable to inform the resident/family of the room move for any number of reasons (resident is on appointment, outside facility, in dialysis, etc.) facility would inform resident/family at earliest possible availability. If a resident is alert and oriented times three, the facility can notify the resident only. If a resident is not alert and oriented times three, then the facility should notify the Power of Attorney (POA) or representative. The facility failed to inform R1, R2, R3, R4, R5, R6, R7, R8, and R9 in writing of the impending room change in order to create a hall to group skilled residents. This placed the residents at risk for impaired resident rights and decreased psychosocial well-being.

The facility identified a census of 98 residents. The sample included three residents reviewed for weight loss. Based on record review, observation, and interview, the facility failed to monitor the effectiveness of weight loss interventions after a significant weight loss for Resident (R)1. This deficient practice placed R1 at risk for further loss and malnutrition. Findings included: - R1's Electronic Medical Record (EMR), under the Diagnosis tab documented diagnoses of need for assistance with personal care, difficulty in walking, dysphagia (swallowing difficulty), paralysis (the loss of muscle function, sensation, or both) of vocal cords and larynx, and iron deficiency. The Admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. R1 required setup or clean-up assistance with meals but was independent with eating. R1 weighed 173 pounds upon admission. The Five day Scheduled MDS dated [DATE] documented a BIMS score of 15 which indicated intact cognition. R1 required supervision or touching assistance on one staff providing verbal cues and or touching/steadying assistance with eating. R1 weighed 160 pounds. The Activity of Daily Living (ADL) Care Area Assessment (CAA) dated 06/20/24 documented R1 had weakness and required assistance with ADLs. Staff were directed to assist with R1's ADLs. R1 was able to feed himself. The Nutrition CAA dated 06/20/24 documented R1 had a therapeutic diet with no added salt. R1's Care Plan dated 07/22/24 documented R1 was able to feed himself after staff assistance setting his meal up. The plan documented R1 was offered the diet as prescribed to him and the registered dietitian (RD) would consult as needed. Staff were directed to monitor for changes in R1's intake pattern and report changes as needed. R1 was to be provided snacks and beverages during and in between meals. R1 was to be encouraged to weigh per facility protocols. Staff were directed to monitor for significant weight gain or loss and to notify the medical director. R1's Order Summary retrieved 08/28/24 recorded the following orders: Diet order for no added salt (NAS) diet, regular texture with thin consistency dated 07/30/24. Ensure Enlive (a liquid supplement designed to help rebuild strength and energy in patients recovering from illness, injury, and surgery) two times a day for a supplement dated 07/30/24 (discontinued on 08/01/24). Daily weights-notify provider for a gain of over three pounds in 24 hours or more than five pounds in seven days every dayshift dated 07/30/24. Review of R1's Tasks for snacks for the last 30 days documented snacks were given on 08/12/24, 08/16/24, 08/18/24, 08/19/24, 08/20/24, 08/25/24, and 08/26/24 with no other snack intakes documented during the last 30 days. Review of R1's Tasks for amount eaten for the last 30 days documented meals eaten for lunch and dinner on 08/12/24, breakfast and dinner on 08/16/24, dinner on 08/18/24, lunch on 08/19/24, lunch on 08/20/24, dinner on 08/22/24, lunch and dinner on 08/25/24, and lunch and dinner on 08/26/24 with no other meal intakes documented during the 30 days look back. R1's Nutrition Risk assessment dated [DATE] documented R1 reported a weight loss of 25 pounds from recent surgery and a previous liquid diet. R1 spoke of wanting a chocolate Ensure for a snack with breakfast. R1 reported he disliked breakfast compared to other meals and felt hungry. R1 was educated on weight gain, eating meals, and drinking water throughout the day. R1's EMR was documented on 06/21/24 at 05:15 PM the Behavioral Note documented R1 stated he wanted to start drinking Ensure twice a day at 10:00 AM and 02:00 PM and R1 only wanted chocolate shakes. At 10:00 AM staff attempted to give R1 his requested Ensure to which R1 refused stating he did not order it. R1 failed to recall he had seen his physician and requested the Ensure drinks and did not want them anymore. R1's Nutrition Risk assessment dated [DATE] documented R1 was at risk for malnutrition. R1 had supplemental Ensure Enlive twice a day at 10:00 AM and 02:00 PM. It was recommended R1 trial a Thrive (Gluten-free, protein-rich ice cream, packed with 24 vitamins and natural prebiotics) cup for weight maintenance. R1's August 2024 Medication Administration Record/Treatment Administration Record (MAR/TAR) documented R1 received Ensure Enlive twice daily but lacked a record of the intake amount of the supplement the resident consumed. A review of R1's Task: Snacks intake record for the last 30 days documented snacks were given on 08/12/24, 08/16/24, 08/18/24, 08/19/24, 08/20/24, 08/25/24, and 08/26/24 with no other snack intakes documented during the last 30 days. Review of R1's Task:Amount Eaten intake record for amount eaten for the last 30 days documented meals eaten for lunch and dinner on 08/12/24, breakfast and dinner on 08/16/24, dinner on 08/18/24, lunch on 08/19/24, lunch on 08/20/24, dinner on 08/22/24, lunch and dinner on 08/25/24, and lunch and dinner on 08/26/24 with no other meal intakes documented during the 30 days look back. On 08/28/24 at 12:48 PM R1 laid in his bed with his blankets up to his chest. R1 stated that lunch was ok, but the staff always took a long time to get him a beverage with his meal. R1 revealed that a lot of the time he had finished his meal before staff would bring him a beverage. On 08/29/24 at 12:56 PM, R1 lay in his bed visiting with his family. R1 reported that he had not received his lunch tray until after 12:30 and then when it had arrived it was a chicken burrito with beans. R1 stated he could not eat the chicken in the burrito or the beans due to both being too hard for him to chew. R1 revealed he was able to eat the burrito around the outside. R1 stated he was given a strawberry Ensure but he did not like it and could not consume it. R1 stated he had not seen the RD in quite a while. R1 went on to say that staff often left his tray of food on the bedside table when he was sleeping, and the staff did not attempt to alert him the food was there. R1 stated that staff often left the room without checking to see if he needed help cutting up his food or if he needed anything else. On 08/29/24 at 03:15 PM, Certified Nurse's Aide (CNA) M stated that that the CNA staff weighed residents, but she was unsure which residents were at risk for weight loss. CNA M stated staff charted the percentage eaten for the meals into the point of care charting system. On 08/29/24 at 03:24 PM Licensed Nurse (LN) G stated the MDS and plan of care informed the staff which residents needed assistance with eating and if the residents required assistance with meals, there was an assisted dining room set up where the staff assisted those residents. LN G stated that if a resident was triggering for weight loss, he would check with the physician to see if a resident needed a supplement or more assistance eating. The facility's Weight Change Investigation policy revised in May 2023 documented that weight change investigations would be initiated with the following: a significant weight change of 5% or more in one month. Once the weight change investigations were completed, the dietician and physician would be contacted for interventions. Interventions would be updated on the resident's chart if appropriate, and the resident or resident's representative would be notified of the interventions. The facility failed to consistently monitor the effectiveness of interventions, including intake amounts for meals, snacks, and nutritional supplements, after a significant weight loss for R1. This deficient practice placed R1 at risk for continued weight loss and malnutrition.

The facility identified a census of 93 residents. The sample included five residents reviewed for abuse. Based on record review, interviews, and observations, the facility failed to ensure an environment free from avoidable accidents for Resident (R) 72 when staff failed to apply wheelchair pedals to her chair when propelled by staff and failed to use the required amount of staff assistance for transfers to ensure safety. Subsequently, R72 sustained a comminuted (a type of broken bone that is broken in at least two places and are usually caused by severe trauma) distal (away from the farthest point of origin or attachment) left femur (the thigh bone) fracture. This also placed R72 at risk for increased pain and impaired well-being. Findings included: - R72's Electronic Medical Record (EMR), under the Diagnosis tab, recorded diagnoses of need for continuous supervision, aphasia (condition with disordered or absent language function) following cerebral infarction (CVA-stroke- sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain), gastroesophageal reflux (GERD-backflow of stomach contents to the esophagus), hypertension (HTN-high blood pressure), hyperlipidemia (HLD-high cholesterol), atrial fibrillation (Afib-condition with disordered or absent language function), malignant neoplasm (tumor) of skin, and anemia (an inadequate number of healthy red blood cells to carry adequate oxygen to body tissues). The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of zero which indicated severely impaired cognition. The MDS documented R72 had no impairment of upper and lower body extremities. R72 used a manual wheelchair and required substantial to maximal assistance where the staff did more than half the effort for lower body dressing, upper body dressing, putting on and taking off footwear, personal hygiene, toileting hygiene, and showering or bathing self. R72 was dependent on staff to assist with all transfers. The Activities of Daily Living [ADL] Functional/Rehabilitation Potential Care Area Assessment (CAA) dated 06/12/24 did not trigger. R72's Care Plan documented interventions dated 07/17/23 directing staff that R72 could not walk and needed a wheelchair to help her get around. R72 could propel her wheelchair but might need help with longer distances. An intervention dated 08/01/23 directed staff to ensure R72's bad foot was on the footrest as needed but lacked clarification as to which foot. The intervention dated 08/30/24 directed staff to use a sit-to-stand lift for transfers with the assistance of two staff members. R72's Care Plan dated 09/09/24 documented the resident had a diagnosis of CVA and a fracture of the left distal femur. The plan directed staff R72 could not walk and needed a Broda chair (specialized wheelchair with the ability to tilt and recline) to get around; staff were to assist with the Broda chair. The plan directed R72 required the assistance of two staff using a Hoyer (a full-body mechanical lift) for transfers. The undated Nursing Report A Hall document described R72's room location, how R72 was transferred, her toileting needs, her route of communication and understanding, and if R72 would use her call light. The document recorded R72 used the sit-to-stand lift for transfers but lacked the number of staff needed to provide this. R72's History and Physical dated 10/30/23 documented an assessment of Afib, GERD, anemia, HTN, HLD, major depressive disorder (MDD), and stroke with aphasia. The plan documented to continue the same medications, monitor for changes, infection, and weight, and provide a supportive environment for the resident. The document was electronically signed on 11/30/23 by Consultant GG. R72's Skin Observation dated 08/29/24 documented that R72 had a scabbed area on her forehead and no other concerns. R72's Nurse's Note dated 08/31/24 at 06:34 PM documented that at approximately 04:45 PM R72's representative arrived and stated that R72 was not lifting her leg to allow the representative to push R72 in her wheelchair. Staff notified Consultant GG who gave orders to send R72 out to the emergency room for evaluation and treatment. R72's Encounter Summary from the hospital documented H&P Notes dated 08/31/24 at 08:36 PM that recorded R72 admitted with a chief complaint of left leg weakness. The Physical Exam section noted R72 had + [positive] edema of the left knee. The summary listed an X-ray Knee 3-View Left section which documented a complete fracture was identified involving the distal femur. There was mild to moderate comminution. There was moderate needle displacement of the distal fracture fragment. There was displacement of approximately 2.5 centimeters (cm); the fracture extended to the knee arthroplasty (a surgical procedure that repairs or replaces a join), a joint effusion (presence of increased fluid in the joint), total knee arthroplasty was identified and vascular calcification (a condition where calcium deposits form in the walls of blood vessels). This was electronically signed by Physician II. The encounter documented an X-ray Femur Left section dated 08/31/24 that documented a distal fracture; no comparison was able to be done. The findings recorded an oblique fracture (a complete break in a bone at an angle) was noted in the distal femoral diaphysis (main or midsection of a long bone) above the knee prosthesis. There was cephalad an anatomical direction that refers to movement towards the head. It is often used in medical terminology to describe the location of body parts) overriding of the distal femur and medial (towards the middle or center) displacement. The section documented a finding of overriding medially displaced oblique fracture of the distal femoral diaphysis above the prosthetic (artificial body part) knee and was signed by Physician JJ. The encounter noted a section CT [computed tomography-a test that uses X-ray technology to make multiple cross-sectional views of organs, bone, soft tissue, and blood vessels] Knee Left without Contrast dated 08/31/24. The section noted the indication for the CT was a fracture. The findings documented there was a complete fracture identified involving the distal femur. The fracture demonstrated mild to moderate comminution. The fracture extended to a knee prosthesis. There was approximately 11 millimeters (mm) overriding of the fracture fragments. There was medial displacement of the distal fracture fragment. A left knee arthroplasty was present. The proximal (nearer to the center or point of attachment) tibia (larger of two bones of the lower leg) and fibula (smaller of two bones of the lower leg) were unremarkable for acute abnormality and there was a joint effusion. This was signed by Physician II. No other issues or abnormalities were documented on the left knee X-ray or CT findings. R72's Referral/Response Letter from Consultant GG's office documented an encounter dated 09/04/24. The documents recorded R72 was seen by Consultant Nurse Practitioner (NP) KK. The encounter recorded R72 returned from the hospital with a left femur fracture and a hospice consult. The assessment noted R72's left leg was in a brace. R72 had no skin tears, ecchymosis (redness), abrasions, hematomas (collection of blood outside of the blood vessels) or evidence of trauma on the knee or left and right lower extremities. The assessment recorded a left leg closed comminuted intra-articular (in the joint) fracture involving the distal femur extending to the knee prosthesis consistent with an osteoporotic fracture (fractures due to weakened bone density). The encounter listed other diagnoses of Afib, GERD, anemia, HTN, HLD, MDD, and stroke with aphasia. The assessment noted that Consultant NP KK discussed with staff R72's fracture was due to osteoporosis (a disease-causing bones to become porous and weak) because there was no history of a fall or trauma, no evidence of trauma on or fall based on the physical assessment and a history of osteoporosis. The plan directed to monitor for pain and reposition for comfort. The document noted the encounter had not yet been electronically signed. Review of additional Referral/Response Letter from Consultant GG's office documented encounters dated 09/10/24, 09/13/24, and 09/18/24. The assessment on all three encounters noted a left leg closed comminuted intra-articular fracture involving the distal femur extending to the knee prosthesis consistent with an osteoporotic fracture. The encounter listed other diagnoses of Afib, GERD, anemia, HTN, HLD, MDD, and stroke with aphasia. The assessment noted that Consultant NP KK discussed with staff R72's fracture was due to osteoporosis because there was no history of a fall or trauma, no evidence of trauma on or fall based on the physical assessment, and a history of osteoporosis. The plan on 09/10/24 directed to continue current care, monitor for swelling in the leg, and encouraged the family not to sit the resident in an upright position due to pressure on the femur. The plan for 09/13/24 directed to continue current care and monitor for swelling in the leg. The plan for 09/18/24 directed to continue to monitor for comfort, pain, and repositioning and continue with the plan of care. All three encounter visits noted the document had not yet been electronically signed. Licensed Nurse (LN) G's Notarized Witness Statement dated 09/06/24 documented on 08/31/24 at approximately 04:45 PM R72's representative approached the nurses' station and stated concerns related to R72 not lifting her left leg so she could be pushed in the wheelchair. LN G went to assess R72. R72 was wearing shorts and would not lift her left leg. R72's representative had placed a gait belt on R72's leg to attempt to lift R72's leg while a second family member attempted to push R72 in her wheelchair but was unable to. LN G documented that R72 had no visible injuries at that time as there was no bruising or swelling. Certified Nurse Aide (CNA) M's typed interview via phone call dated 09/09/24 at 12:35 PM documented CNA M assisted R72 out of bed and R72 ate breakfast in the dining room and then she went back to her room. R72 then had lunch in the dining room and R72's representative reported R72's leg was not acting normal. R72 was taken to her room and CNA M assisted in changing her clothes and then R72 was sent out [to the hospital]. The Facility's Investigation dated 09/10/24 documented that facility leadership was notified on 09/03/24 by the hospital that R72 had sustained a fracture to her left femur. R72 had no previous falls or incidents reported or noted in the resident's clinical record nor reported by initial staff interviews. The investigation documented the facility concluded the care plan was followed and no abuse had occurred. During an observation on 09/16/24 at 10:10 AM, R72 laid in her bed with her blanket pulled up to her chest. R72 manipulated her blankets but did not respond when her name was called. During an observation on 09/16/24 at 01:10 PM, R72 sat in her Broda chair (specialized wheelchair with the ability to tilt and recline), with her feet raised on the foot pedal, R72's back tilted back and a blanket covered her lap. R72 had her call light pad in her lap within reach. R72 fidgeted during interaction but was not vocal at all. R72 appeared sad and moved her right leg up and down on the foot pedal. During an interview on 09/16/24 at 12:45 PM, CNA N stated when she worked on 08/30/24, R72 appeared to have no concerns with her leg nor had any events that could have caused injury. CNA N stated that if a resident had a concern or if she had noticed R72's leg would not raise and was not acting normally, she would report it to the charge nurse. CNA N stated R72 had no foot pedals for her wheelchair, and when she propelled her on 08/30/24 to the dining room, no foot pedals were used. During an interview on 09/16/24 at 12:54 PM Licenses Nurse (LN) G reported that R72 never had wheelchair pedals for her wheelchair. LN G stated that R72's family reported a concern with her leg when her family arrived to visit R72. LN G further revealed that she received training in July of this year that directed staff that if a resident was going to be pushed by staff, foot pedals needed to be placed on the resident's wheelchair. During an interview on 09/16/24 at 02:27 PM, R72's representative stated R72 was seated in her wheelchair when she arrived to visit with R72. R72's representative stated foot pedals would have been helpful to move R72 safely, as typically R72 had to be asked to raise her feet when anyone pushed R72 in the wheelchair. R72's representative reported that at times R72 would act like her foot would not work and drop it to the floor. R72's representative stated when R72 did that, she would have to stop and talk to R72, and then R72 would raise her foot again. R72's representative stated on 08/31/24 that R72's foot was very strange. R72's representative described R72's left foot as turned in and like a limp wet noodle when she attempted to raise R72's leg. R72's representative revealed that R72's knee was also very swollen and R72's capri pants were not pulled down due to this and it looked like R72 had shorts on. R72's representative stated that R72 never had foot pedals for her wheelchair and R72's family representative had asked for some foot pedal multiple times, but none had ever been found that would fit. R72's representative stated in the past she told the facility when R72 was self-propelling, putting foot pedals on R72's wheelchair would hinder R72 from being mobile she had asked for foot pedals to be used when they visited and would propel R72 on walks outside and in the facility. R72's representative said foot pedals would have been very beneficial for R72. During an interview on 09/16/24 at 03:08 PM, CNA M stated that she worked on 08/31/24 with R72. CNA M reported that she got R72 up that day with the sit-to-stand lift by herself to go to breakfast. CNA M stated she noticed R72's leg did not work when she used the sit-to-stand lift but said had not received anything in report to know if anything had happened with R72 or if this was normal behavior. CNA M stated that R72 did not use foot pedals when R72 was in her wheelchair. CNA M could not recall R72's feet or legs getting caught up when she propelled R72 and said if that happened, she would have reported it to the nurse. CNA M revealed that 08/31/24 was the first day she worked at the facility and that when she came on duty, she was provided a nursing report sheet that told her who to get up and what care each resident needed. CNA M reported she worked on R72's hall by herself, which is why she did not have a second person with her when transferring R72 with the sit-to-stand lift. During an interview on 09/16/24 at 03:27 PM, LN H stated that the sit-to-stand transfer should be performed with two staff members, and if a second staff member is not present for the transfer, staff are to locate another staff member or get the nurse for the second staff member to safely perform the transfer. During an interview on 09/16/24 at 03:30 PM CNA O stated the sit-to-stand lift required two staff members for use and if he did not have someone present, CNA O would locate a second staff member to safely transfer the resident. During an interview on 09/16/24 at 03:35 PM Administrative Staff A stated if the resident's care plan called for two staff members for R72's transfer with the sit-to-stand lift, the transfer via lift should have been conducted with two staff members. Administrative Staff A stated CNA M should have had a second staff member present. Administrative Staff A stated if staff pushed a resident and the resident could hold up his or her legs, no foot pedals were needed. Administrative Staff A confirmed the facility had conducted recent audits as part of the corrective actions for the deficiency cited on the annual survey for the lack of foot pedals for R72. The facility's policy Incidents - Accidents dated November 18 documented all staff would be trained upon hire on proper usage of facility equipment. The policy directed that the facility would monitor the effectiveness of the interventions including adequate supervision consistent with the resident's needs, goals, plan of care, and current standards of practice to reduce the risk of an accident. The facility failed to ensure an environment free from avoidable accidents for R72 when staff failed to apply wheelchair pedals to her chair when propelled by staff and failed to use the required amount of staff assistance for transfers to ensure safety. Subsequently, R72 sustained a comminuted distal left femur fracture. This also placed R72 at risk for increased pain and impaired well-being.

The facility identified a census of 93 residents. The sample included five residents reviewed for abuse. Based on record review, interviews, and observations, the facility failed to ensure an environment free from avoidable accidents for Resident (R) 72 when staff failed to apply wheelchair pedals to her chair when propelled by staff and failed to use the required amount of staff assistance for transfers to ensure safety. Subsequently, R72 sustained a comminuted (a type of broken bone that is broken in at least two places and are usually caused by severe trauma) distal (away from the farthest point of origin or attachment) left femur (the thigh bone) fracture. This also placed R72 at risk for increased pain and impaired well-being. Findings included: - R72's Electronic Medical Record (EMR), under the Diagnosis tab, recorded diagnoses of need for continuous supervision, aphasia (condition with disordered or absent language function) following cerebral infarction (CVA-stroke- sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain), gastroesophageal reflux (GERD-backflow of stomach contents to the esophagus), hypertension (HTN-high blood pressure), hyperlipidemia (HLD-high cholesterol), atrial fibrillation (Afib-condition with disordered or absent language function), malignant neoplasm (tumor) of skin, and anemia (an inadequate number of healthy red blood cells to carry adequate oxygen to body tissues). The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of zero which indicated severely impaired cognition. The MDS documented R72 had no impairment of upper and lower body extremities. R72 used a manual wheelchair and required substantial to maximal assistance where the staff did more than half the effort for lower body dressing, upper body dressing, putting on and taking off footwear, personal hygiene, toileting hygiene, and showering or bathing self. R72 was dependent on staff to assist with all transfers. The Activities of Daily Living [ADL] Functional/Rehabilitation Potential Care Area Assessment (CAA) dated 06/12/24 did not trigger. R72's Care Plan documented interventions dated 07/17/23 directing staff that R72 could not walk and needed a wheelchair to help her get around. R72 could propel her wheelchair but might need help with longer distances. An intervention dated 08/01/23 directed staff to ensure R72's bad foot was on the footrest as needed but lacked clarification as to which foot. The intervention dated 08/30/24 directed staff to use a sit-to-stand lift for transfers with the assistance of two staff members. R72's Care Plan dated 09/09/24 documented the resident had a diagnosis of CVA and a fracture of the left distal femur. The plan directed staff R72 could not walk and needed a Broda chair (specialized wheelchair with the ability to tilt and recline) to get around; staff were to assist with the Broda chair. The plan directed R72 required the assistance of two staff using a Hoyer (a full-body mechanical lift) for transfers. The undated Nursing Report A Hall document described R72's room location, how R72 was transferred, her toileting needs, her route of communication and understanding, and if R72 would use her call light. The document recorded R72 used the sit-to-stand lift for transfers but lacked the number of staff needed to provide this. R72's History and Physical dated 10/30/23 documented an assessment of Afib, GERD, anemia, HTN, HLD, major depressive disorder (MDD), and stroke with aphasia. The plan documented to continue the same medications, monitor for changes, infection, and weight, and provide a supportive environment for the resident. The document was electronically signed on 11/30/23 by Consultant GG. R72's Skin Observation dated 08/29/24 documented that R72 had a scabbed area on her forehead and no other concerns. R72's Nurse's Note dated 08/31/24 at 06:34 PM documented that at approximately 04:45 PM R72's representative arrived and stated that R72 was not lifting her leg to allow the representative to push R72 in her wheelchair. Staff notified Consultant GG who gave orders to send R72 out to the emergency room for evaluation and treatment. R72's Encounter Summary from the hospital documented H&P Notes dated 08/31/24 at 08:36 PM that recorded R72 admitted with a chief complaint of left leg weakness. The Physical Exam section noted R72 had + [positive] edema of the left knee. The summary listed an X-ray Knee 3-View Left section which documented a complete fracture was identified involving the distal femur. There was mild to moderate comminution. There was moderate needle displacement of the distal fracture fragment. There was displacement of approximately 2.5 centimeters (cm); the fracture extended to the knee arthroplasty (a surgical procedure that repairs or replaces a join), a joint effusion (presence of increased fluid in the joint), total knee arthroplasty was identified and vascular calcification (a condition where calcium deposits form in the walls of blood vessels). This was electronically signed by Physician II. The encounter documented an X-ray Femur Left section dated 08/31/24 that documented a distal fracture; no comparison was able to be done. The findings recorded an oblique fracture (a complete break in a bone at an angle) was noted in the distal femoral diaphysis (main or midsection of a long bone) above the knee prosthesis. There was cephalad an anatomical direction that refers to movement towards the head. It is often used in medical terminology to describe the location of body parts) overriding of the distal femur and medial (towards the middle or center) displacement. The section documented a finding of overriding medially displaced oblique fracture of the distal femoral diaphysis above the prosthetic (artificial body part) knee and was signed by Physician JJ. The encounter noted a section CT [computed tomography-a test that uses X-ray technology to make multiple cross-sectional views of organs, bone, soft tissue, and blood vessels] Knee Left without Contrast dated 08/31/24. The section noted the indication for the CT was a fracture. The findings documented there was a complete fracture identified involving the distal femur. The fracture demonstrated mild to moderate comminution. The fracture extended to a knee prosthesis. There was approximately 11 millimeters (mm) overriding of the fracture fragments. There was medial displacement of the distal fracture fragment. A left knee arthroplasty was present. The proximal (nearer to the center or point of attachment) tibia (larger of two bones of the lower leg) and fibula (smaller of two bones of the lower leg) were unremarkable for acute abnormality and there was a joint effusion. This was signed by Physician II. No other issues or abnormalities were documented on the left knee X-ray or CT findings. R72's Referral/Response Letter from Consultant GG's office documented an encounter dated 09/04/24. The documents recorded R72 was seen by Consultant Nurse Practitioner (NP) KK. The encounter recorded R72 returned from the hospital with a left femur fracture and a hospice consult. The assessment noted R72's left leg was in a brace. R72 had no skin tears, ecchymosis (redness), abrasions, hematomas (collection of blood outside of the blood vessels) or evidence of trauma on the knee or left and right lower extremities. The assessment recorded a left leg closed comminuted intra-articular (in the joint) fracture involving the distal femur extending to the knee prosthesis consistent with an osteoporotic fracture (fractures due to weakened bone density). The encounter listed other diagnoses of Afib, GERD, anemia, HTN, HLD, MDD, and stroke with aphasia. The assessment noted that Consultant NP KK discussed with staff R72's fracture was due to osteoporosis (a disease-causing bones to become porous and weak) because there was no history of a fall or trauma, no evidence of trauma on or fall based on the physical assessment and a history of osteoporosis. The plan directed to monitor for pain and reposition for comfort. The document noted the encounter had not yet been electronically signed. Review of additional Referral/Response Letter from Consultant GG's office documented encounters dated 09/10/24, 09/13/24, and 09/18/24. The assessment on all three encounters noted a left leg closed comminuted intra-articular fracture involving the distal femur extending to the knee prosthesis consistent with an osteoporotic fracture. The encounter listed other diagnoses of Afib, GERD, anemia, HTN, HLD, MDD, and stroke with aphasia. The assessment noted that Consultant NP KK discussed with staff R72's fracture was due to osteoporosis because there was no history of a fall or trauma, no evidence of trauma on or fall based on the physical assessment, and a history of osteoporosis. The plan on 09/10/24 directed to continue current care, monitor for swelling in the leg, and encouraged the family not to sit the resident in an upright position due to pressure on the femur. The plan for 09/13/24 directed to continue current care and monitor for swelling in the leg. The plan for 09/18/24 directed to continue to monitor for comfort, pain, and repositioning and continue with the plan of care. All three encounter visits noted the document had not yet been electronically signed. Licensed Nurse (LN) G's Notarized Witness Statement dated 09/06/24 documented on 08/31/24 at approximately 04:45 PM R72's representative approached the nurses' station and stated concerns related to R72 not lifting her left leg so she could be pushed in the wheelchair. LN G went to assess R72. R72 was wearing shorts and would not lift her left leg. R72's representative had placed a gait belt on R72's leg to attempt to lift R72's leg while a second family member attempted to push R72 in her wheelchair but was unable to. LN G documented that R72 had no visible injuries at that time as there was no bruising or swelling. Certified Nurse Aide (CNA) M's typed interview via phone call dated 09/09/24 at 12:35 PM documented CNA M assisted R72 out of bed and R72 ate breakfast in the dining room and then she went back to her room. R72 then had lunch in the dining room and R72's representative reported R72's leg was not acting normal. R72 was taken to her room and CNA M assisted in changing her clothes and then R72 was sent out [to the hospital]. The Facility's Investigation dated 09/10/24 documented that facility leadership was notified on 09/03/24 by the hospital that R72 had sustained a fracture to her left femur. R72 had no previous falls or incidents reported or noted in the resident's clinical record nor reported by initial staff interviews. The investigation documented the facility concluded the care plan was followed and no abuse had occurred. During an observation on 09/16/24 at 10:10 AM, R72 laid in her bed with her blanket pulled up to her chest. R72 manipulated her blankets but did not respond when her name was called. During an observation on 09/16/24 at 01:10 PM, R72 sat in her Broda chair (specialized wheelchair with the ability to tilt and recline), with her feet raised on the foot pedal, R72's back tilted back and a blanket covered her lap. R72 had her call light pad in her lap within reach. R72 fidgeted during interaction but was not vocal at all. R72 appeared sad and moved her right leg up and down on the foot pedal. During an interview on 09/16/24 at 12:45 PM, CNA N stated when she worked on 08/30/24, R72 appeared to have no concerns with her leg nor had any events that could have caused injury. CNA N stated that if a resident had a concern or if she had noticed R72's leg would not raise and was not acting normally, she would report it to the charge nurse. CNA N stated R72 had no foot pedals for her wheelchair, and when she propelled her on 08/30/24 to the dining room, no foot pedals were used. During an interview on 09/16/24 at 12:54 PM Licenses Nurse (LN) G reported that R72 never had wheelchair pedals for her wheelchair. LN G stated that R72's family reported a concern with her leg when her family arrived to visit R72. LN G further revealed that she received training in July of this year that directed staff that if a resident was going to be pushed by staff, foot pedals needed to be placed on the resident's wheelchair. During an interview on 09/16/24 at 02:27 PM, R72's representative stated R72 was seated in her wheelchair when she arrived to visit with R72. R72's representative stated foot pedals would have been helpful to move R72 safely, as typically R72 had to be asked to raise her feet when anyone pushed R72 in the wheelchair. R72's representative reported that at times R72 would act like her foot would not work and drop it to the floor. R72's representative stated when R72 did that, she would have to stop and talk to R72, and then R72 would raise her foot again. R72's representative stated on 08/31/24 that R72's foot was very strange. R72's representative described R72's left foot as turned in and like a limp wet noodle when she attempted to raise R72's leg. R72's representative revealed that R72's knee was also very swollen and R72's capri pants were not pulled down due to this and it looked like R72 had shorts on. R72's representative stated that R72 never had foot pedals for her wheelchair and R72's family representative had asked for some foot pedal multiple times, but none had ever been found that would fit. R72's representative stated in the past she told the facility when R72 was self-propelling, putting foot pedals on R72's wheelchair would hinder R72 from being mobile she had asked for foot pedals to be used when they visited and would propel R72 on walks outside and in the facility. R72's representative said foot pedals would have been very beneficial for R72. During an interview on 09/16/24 at 03:08 PM, CNA M stated that she worked on 08/31/24 with R72. CNA M reported that she got R72 up that day with the sit-to-stand lift by herself to go to breakfast. CNA M stated she noticed R72's leg did not work when she used the sit-to-stand lift but said had not received anything in report to know if anything had happened with R72 or if this was normal behavior. CNA M stated that R72 did not use foot pedals when R72 was in her wheelchair. CNA M could not recall R72's feet or legs getting caught up when she propelled R72 and said if that happened, she would have reported it to the nurse. CNA M revealed that 08/31/24 was the first day she worked at the facility and that when she came on duty, she was provided a nursing report sheet that told her who to get up and what care each resident needed. CNA M reported she worked on R72's hall by herself, which is why she did not have a second person with her when transferring R72 with the sit-to-stand lift. During an interview on 09/16/24 at 03:27 PM, LN H stated that the sit-to-stand transfer should be performed with two staff members, and if a second staff member is not present for the transfer, staff are to locate another staff member or get the nurse for the second staff member to safely perform the transfer. During an interview on 09/16/24 at 03:30 PM CNA O stated the sit-to-stand lift required two staff members for use and if he did not have someone present, CNA O would locate a second staff member to safely transfer the resident. During an interview on 09/16/24 at 03:35 PM Administrative Staff A stated if the resident's care plan called for two staff members for R72's transfer with the sit-to-stand lift, the transfer via lift should have been conducted with two staff members. Administrative Staff A stated CNA M should have had a second staff member present. Administrative Staff A stated if staff pushed a resident and the resident could hold up his or her legs, no foot pedals were needed. Administrative Staff A confirmed the facility had conducted recent audits as part of the corrective actions for the deficiency cited on the annual survey for the lack of foot pedals for R72. The facility's policy Incidents - Accidents dated November 18 documented all staff would be trained upon hire on proper usage of facility equipment. The policy directed that the facility would monitor the effectiveness of the interventions including adequate supervision consistent with the resident's needs, goals, plan of care, and current standards of practice to reduce the risk of an accident. The facility failed to ensure an environment free from avoidable accidents for R72 when staff failed to apply wheelchair pedals to her chair when propelled by staff and failed to use the required amount of staff assistance for transfers to ensure safety. Subsequently, R72 sustained a comminuted distal left femur fracture. This also placed R72 at risk for increased pain and impaired well-being.

The facility identified a census of 83 residents. The sample included 18 residents with four residents sampled for reasonable accommodations of resident needs and preferences. Based on observation, record review, and interview, the facility failed to ensure that Resident (R)11, R43, and R80 had call lights to call for assistance. The facility further failed to provide footrests for R72's wheelchair. This deficient practice left these residents at risk for impaired care due to unmet care needs. Findings included: - On 07/15/24 at 09:33 AM, R80's call light lay in the middle of her bed. R80 sat in her recliner and the call light was out of her reach. On 07/15/24 at 09:45 AM R43's call light was wrapped around her bed rail, R43 was in her Broda chair (specialized wheelchair with the ability to tilt and recline). R43's call light was out of her reach. On 07/16/24 at 12:09 PM, R11's call light was wrapped around his bed rail. R11 was in his wheelchair eating lunch. R11's call light was out of his reach. On 07/15/24 at 11:48 AM R72 was pushed to the dining room without foot pedals, R72 was pushed fast and her heels hit the floor and bounced back up before staff parked her wheelchair at the dining room table. On 07/16/24 at 11:05 PM, Certified Nurse's Aide (CNA) N stated pedals should be placed on wheelchairs if staff is going to propel the chairs. CNA N stated all call lights should be either on the resident or within the resident's reach. On 07/17/24 at 11:15 PM, Licensed Nurse (LN) I stated all residents should have their pedals on their wheelchairs if staff were pushing them. LN I stated all staff were responsible for call lights being placed where the residents can reach them. On 07/10/24 at 12:29 PM in an interview, Administrative Nurse D stated staff should never push residents without pedals, and call lights should always be within the residents' reach. The facility's Accommodation of Needs policy revised on 12/2017 documented the community's environment and staff behaviors are directed toward assisting the resident in maintaining and or achieving independent functioning, dignity, and well-being. The facility failed to ensure R11, R43, and R80 had call lights for use and failed to provide footrests for R72's wheelchair. This deficient practice placed the residents at risk for impaired care due to unmet care needs.

The facility identified a census of 83 residents. The sample included 18 residents with five reviewed for range of motion (ROM) and positioning. Based on observation, record review, and interviews, the facility failed to ensure Residents(R)73 and R44's care planned arm bolsters (specialized devices used for positioning and support) were utilized on their Broda chairs (specialized wheelchair with the ability to tilt and recline). The facility additionally failed to ensure R75 and R11's hand splints were implemented as ordered. This deficient practice placed the residents at risk for a decline in ROM and contractures (abnormal permanent fixation of a joint). Findings Included: -The Medical Diagnosis section within R73's Electronic Medical Records (EMR) included diagnoses of major depressive disorder (major mood disorder), osteoporosis (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk), hypertension (high blood pressure), and dementia (a progressive mental disorder characterized by failing memory, confusion). A review of R73's Annual Minimum Data Set (MDS) completed 05/08/24 noted a Brief Interview for Mental Status (BIMS) score of four indicating severe cognitive impairment. The MDS indicated she was dependent on staff assistance for toileting, bathing, transfers, bed mobility, dressing, and personal hygiene. The MDS indicated she required staff assistance with meal set-up and clean up. R73's Dementia Care Area Assessment (CAA) completed 05/16/24 indicated she had memory impairment related to her cognitive loss. The CAA noted she had difficulty hearing but could make her needs known. R73's Pressure Injury CAA completed 05/16/24 indicated she was at risk for skin breakdown. The CAA noted she required turning and repositioning every two hours. The CAA noted she used a pressure reduction mattress and wheelchair seat cushion. R73's Care Plan initiated on 06/04/24 indicated she had impaired memory, decision-making, and comprehension related to her dementia diagnoses. The plan indicated she required a Hoyer lift (full-body mechanical lift) and two staff for transfers. The plan noted she required staff assistance with bed mobility, toileting, dressing, and personal hygiene. The plan indicated she used a Broda chair for comfort and positioning. The plan indicated her Broda chair had arm bolsters for positioning. The plan indicated R73 had fragile skin and bruised easily. R73's EMR under Physician's Order revealed no orders related to her arm bolsters. R73's EMR under physical or occupational therapy notes lacked documentation related to her arm bolsters. On 07/15/24 at 07:13 AM R73 was wheeled into the E Hall dining room. R73 was positioned at the rear table facing the empty kitchenette. R73 had geri-sleeves (sleeves placed over arms and legs to protect from injuries) on but her Broda lacked the arm bolsters. On 07/17/24 at 10:03 AM R73 sat in her Broda chair. R73's Broda chair lacked the arm bolsters. On 07/17/24 at 10:05 AM Certified Nurse's Aide (CNA) O stated she had been in the facility for almost a year and R73's chairs had been switched out. She stated she was not sure what arm bolsters were. She stated didn't remember her having arm bolsters attached to her chair. She stated all staff had access to the care plans and could review the preventative interventions. She stated she would report issues or concerns to the nurse for clarification. She stated she would place pillows, cushions, or apply splints if she was aware that the resident required the supportive devices. On 07/17/24 at 10:25 AM Licensed Nurse (LN) J stated the direct care staff or nurses could apply the bolster directly to the chairs based on the orders from the Treatment Administration Report (TAR). She stated she was not sure about R73's arm bolsters. On 07/17/24 at 12:28 PM, Administrative Nurse D stated she expected supportive devices to be listed on the Medication Administration Record (MAR) or the Treatment Administration Record (TAR) for the nurse to sign off and be responsible for the application or placement of the devices. The facility's Accommodation of Needs policy the facility will ensure the availability and appropriate placement of assistive devices that promote positioning, safety, independence, and dignity. The policy indicated the individual needs and preferences of each resident will be accommodated while maintaining health and safety. The facility failed to implement R73's arm bolsters to her Broda chair as care planned. This deficient practice placed R73 at risk for a decline in ROM and contractures. 41037 - R44's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of cerebral infarction (stroke - the sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), dysphagia (swallowing difficulty), Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), major depressive disorder (major mood disorder which causes persistent feelings of sadness), and severe protein-calorie malnutrition. The Significant Change Minimum Data Set (MDS) dated [DATE] documented R44 had severely impaired cognition. The MDS documented R44 was dependent on staff assistance for positioning. The Quarterly MDS dated [DATE] documented R44 had severely impaired cognition. The MDS documented that R44 was dependent on staff assistance for positioning. R44's Pressure Ulcer Care Area Assessment (CAA) dated 01/09/24 documented she required repositioning. R44's Care Plan dated 12/13/23 documented that staff would reposition R44 as needed when up in her Broda chair (specialized wheelchair with the ability to tilt and recline). The plan of care documented that staff would place arm bolsters (specialized devices used for positioning and support) in her Broda chair for positioning. On 07/15/24 at 08:10 AM R44 sat upright in her Broda chair. R44's chair did not have arm bolsters. On 07/15/24 at 11:48 AM Certified Nurse Aide (CNA) O pushed R44 into the dining room in her Broda chair. The chair did not have arm bolsters in place. On 07/16/24 at 07:50 AM R44 sat in her Broda chair at the dining room table. R44 did not have arm bolsters on her Broda chair. On 07/17/24 at 10:05 AM, Certified Nurse Aide (CNA) O stated she would place pillows, cushions, or apply splints if she was aware that the resident required supportive devices. CNA O stated she was not sure what arm bolsters were. CNA O stated she was not aware of R44's need for arm bolsters. CNA O stated she had not seen any bolsters for R44 in the past four months that she had taken care of R44. On 07/17/24 at 10:16 AM, agency Licensed Nurse (LN) J stated she was not aware that R44 was care planned to have an arm bolster in her Broda chair for support and positioning. On 07/17/24 at 12:28 PM, Administrative Nurse D stated she expected supportive devices to be listed on the Medication Administration Record (MAR) or the Treatment Administration Record (TAR) for the nurse to sign off and be responsible for the application or placement of the devices. The facility's Accommodation of Needs policy last revised 12/2017 documented the facility would ensure the availability and appropriate placement of assistive devices that promote positioning, safety, independence, and dignity. The policy indicated the individual needs and preferences of each resident would be accommodated while maintaining health and safety. The facility failed to ensure R44's supportive devices were provided for positioning. This deficient practice left R44 at risk for discomfort and a decrease in mobility. - R75's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of hemiplegia (paralysis of one side of the body) affecting the right side, chronic pain, and lack of coordination. The Significant Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of one which indicated severely impaired cognition. The MDS documented R75 was dependent on staff assistant for dressing, transfers, and mobility. The MDS documented R75 had functional limitations of range of motion (ROM- the full movement potential of a joint, usually its range of flexion and extension) of her upper and lower extremities on one side. The Quarterly MDS dated ,d+[DATE] documented a BIMS score of four which indicated severely impaired cognition. The MDS documented that R75 had functional limitations of ROM of her upper and lower extremities on one side. The MDS documented R75 was dependent on staff assistance for her activities of daily living. R75's Pressure Ulcer Care Area Assessment (CAA) dated 12/29/23 documented she required the assistance of the staff for repositioning. R75's Care Plan dated 03/26/24 documented that staff would ensure the hand splint was on her right hand at all times except for showers and hand hygiene for contractures. R75's EMR under the Orders tab revealed the following physician orders: Right-hand splint on at all times, except for shower and hand hygiene per therapy dated 03/26/24. A review of R75's Treatment Administration Record from 07/01/24 to 07/15/24 documented she had her right-hand splint in place 27 out of 30 opportunities including the morning and evening of 07/15/24. On 07/15/24 at 11:13 AM R75 sat in her high back wheelchair asleep in the common area. R75's right lacked a right-hand splint, her right-hand fingers were bent inward, and her right arm rested tightly across her chest area. On 07/16/24 at 07:24 AM R75 sat in her high-back wheelchair in the common area asleep. R75's right hand lacked her hand splint. On 07/16/24 at 01:00 PM, Certified Nurse Aide (CNA) P stated R75 had not worn her right-hand splint at least for the past three months. CNA P stated the splint had caused bruises and discomfort for R75. On 07/16/24 at 01:06 PM, Licensed Nurse (LN) G stated R75 had refused her right-hand splint a few times in the past two or three weeks. LN G stated therapy was aware that R75 had refused to wear her splint. On 07/17/24 at 12:29 PM, Administrative Nurse D stated the splints or device should be on the Medication Administration Record (MAR), or the Treatment Administration Record (TAR), and nursing staff were responsible for ensuring they were applied as ordered or care planned. The facility's Restorative Nursing-Range of Motion Program policy revised 12/17 documented the residents who have or were at risk of having difficulty with ROM were assessed by nursing or therapy for a restorative nursing range of motion program to promote independence and quality of life by improving or maintaining functional ROM. The facility failed to ensure R75 received services and treatment for her multiple contractures to prevent an avoidable reduction of ROM and/or mobility. This deficient practice left R75 at risk for further decline and decreased ROM. 49634 - R11's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of hemiparesis (muscular weakness of one half of the body) with cerebrovascular accident (CVA-stroke- sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), hypertension (HTN-elevated blood pressure, and obesity. The Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of nine which indicated moderately impaired cognition. The MDS documented R11had an impairment to one side. The MDS indicated R11 had therapy during the observation period. R11's Functional/Rehabilitation Potential Care Area Assessment (CAA) dated 11/29/23 documented R11 had right-sided hemiparesis. R11 required extensive to total staff assistance with dressing, bathing, grooming, personal hygiene, and oral care. R11's Care Plan dated 05/01/24 documented staff to keep R11's fingernails trimmed and the palm of his right hand clean. The plan of care documented staff was to apply a rolled washcloth in R11's right hand as needed. R11's plan of care dated 06/06/24 documented that staff was to apply the right resting hand splint in the morning for approximately eight hours, staff may remove the splint for showers and hand hygiene, then reapply at nighttime. On 07/16/24 at 08:34 AM R11 was sitting up in a reclined wheelchair. R11 was eating breakfast with his left hand, which consisted of hot cereal and mandarin oranges. R11 did not have a splint on his right hand or a rolled washcloth in his right hand. On 07/17/24 at 08:22 AM R11 sat in his reclined wheelchair watching TV. R11 did not have a rolled washcloth in his right hand, or a splint on his right hand. On 07/17/24 at 11:05 AM, Certified Nurse's Aide (CNA) M stated she was not able to see what the plan of care for R11 was and said she was trained by a staff CNA. CNA M stated she was an agency and had been logged out of the facility's system. CNA M stated she had not taken the time to get a new login. CNA M stated she would put the rolled washcloth in R11's right hand. On 07/17/24 at 11:36 AM Licensed Nurse (LN) I stated she was able to see the plan of care for all residents. LN I stated all splints should be applied. On 07/17/24 at 12:29 PM, Administrative Nurse D stated the splints or devise should be on the Medication Administration Record (MAR), or the Treatment Administration Record (TAR), and nursing staff were responsible for ensuring they were applied as ordered or care planned. The facility's Restorative Nursing-Range of Motion Program policy revised 12/17 documented the residents who have or were at risk of having difficulty with ROM were assessed by nursing or therapy for a restorative nursing range of motion program to promote independence and quality of life by improving or maintaining functional ROM. The facility failed to ensure R11's right hand splint or a rolled washcloth was placed in R11's right hand, to prevent his contractures from worsening. This deficient practice left R11 at risk for further decline and decreased range of motion ROM or mobility.

The facility identified a census of 83 residents. The sample included 18 residents with eight medication carts, four treatment carts, and three medication rooms. Based on observation, record review, and interviews, the facility failed to properly store medications in seven of the eight medication carts and four of the four treatment carts. This placed the residents at risk for adverse outcomes or ineffective medication regimens. Findings included: - On 07/15/24 at 07:12 AM the medication cart on C-hall was unlocked and unattended in the hallway. The medication cart contained plastic cups in the top drawer with unlabeled pills in the cups. On 07/15/24 at 07:16 AM the medication cart on B-hall was unlocked and unattended in the hallway. On 07/15/24 at 07:20 AM the treatment carts on F-hallway and G-hall were unlocked and unattended in the hallway. On 07/15/24 at 07:20 AM the medication cart on G-Hall was unlocked and unattended in the hallway. On 07/15/24 at 07:21 AM the treatment cart on E hall was unlocked and unattended in the hallway. On 07/15/24 at 07:22 AM the mediation cart on C-hall was unlocked and unattended in the hallway. On 07/16/24 at 07:12 AM the medication cart and the treatment cart on E-hall were unlocked and unattended in the hallway. On 07/16/24 at 07:34 AM the treatment cart on A-hall was unlocked and unattended in the hallway. On 07/16/24 at 06:50 AM the treatment cart on P-hall was unlocked and unattended in the hallway. On 07/17/24 at 07:37 AM the medication cart on A-hall was unlocked and unattended in the hallway. On 07/15/24 at 07:20 AM, agency Licensed Nurse (LN) K stated the medication carts should stay locked unless the cart was in view. On 07/15/24 at 07:22 AM LN H stated the carts should be locked at all times, and the computer should be off when not in use. On 07/16/24 at 07:12 AM LN J stated the medication cart and the treatment cart should always be locked when not in use. On 07/17/24 at 12:28 PM, Administrative Nurse D stated she expected the nurses to keep the medication carts and the treatment carts locked when not in use. The facility's Storage of Medications policy last reviewed 01/2024 documented the facility would store all drugs and biological in a safe, secure, and orderly manner. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes.) containing drugs and biologicals would be locked when not in use, and trays or carts used to transport such items would not be left unattended if open or otherwise potentially available to others. The facility failed to properly store medications which could potentially cause adverse consequences or ineffective treatment to the affected residents.

The facility identified a census of 83 residents and 13 residents who were on Enhanced Barrier Precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms which employ targeted gown and glove use during high contact care). Based on record review, observations, and interviews, the facility failed to follow sanitary infection control standards related to the handling of soiled laundry, storage of oxygen tubing while not in use, and hand hygiene during catheter (a tube inserted into the bladder to drain urine) care. The facility further failed to follow EBP. These deficient practices placed the residents at risk for infectious diseases. Included Findings: - On 07/15/ 24 at 07:40 AM Resident (R) 51 had a portable oxygen tank with a nasal cannula (a hollow tube used to deliver supplemental oxygen) that was not in use near the entrance of her room. The nasal cannula hung over the portable oxygen tank, there was not a sanitary container for storage of the cannula. On 07/15/24 at 09:07 AM R33's nasal cannula was wrapped around the arm of the wheelchair in her room. The nasal cannula was not stored in a sanitary container. On 07/15/24 at 09:46 AM, an unidentified staff member walked off the E-hallway with unbagged linens pressed up against her upper body. On 07/16/24 at 03:38 PM, a dirty tub of white clothing was in a yellow tub marked dirty laundry. The yellow tub of soiled clothing sat next to clean laundry that was hanging on a rack and hung partly into the soiled bin in the washing area of the laundry room. 0n 07/17/24 at 08:15 AM R11 laid in his bed. Certified Nurse Aid (CNA) M donned two pairs of gloves, preparing to get R11 up in his wheelchair for breakfast. CNA M placed R11's catheter bag and tubing on his bed. CNA M did not don her gown for the EBP nor perform any hand hygiene prior to donning the gloves. CNA M rolled R11 to the wall, removed his brief, and there was bowel movement in the brief. CNA M wiped R11's backside with wipes. Wearing the same gloves, CNA M used a wet soapy washcloth to finish cleaning R11 and dried R11's backside with a towel. CNA M doffed her gloves, did not perform hand hygiene, and donned a clean pair of gloves. CNA M washed R11's front peri area with a wipe and used the same towel to try R11's front peri/catheter area. CNA M rolled R11 from side to side, securing clothing and Hoyer (total body mechanical lift) sling. CNA M doffed her gloves and left the room to get help with R11s transfer. Administrative Nurse E arrived at R11's room to help with the transfer using the Hoyer. Administrative Nurse E and CNA M donned gloves but neither Administrative Nurse E nor CNA M performed hand hygiene before donning gloves and neither wore a gown for EBP. Administrative Nurse E held R11's catheter bag, and CNA M transferred R11. CNA M pushed the Hoyer to the hallway without sanitizing it and walked away. On 07/17/24 at 02:19 PM a laundry tub marked dirty laundry sat in the dirty part of the laundry room without a lid. There was clothing hanging on top of the basket. Dietary Staff BB stated the clothes hanging were clothing that was going to be given away. He stated the facility had nowhere else to store the clothing. Dietary Staff BB stated the dirty clothes tubs should have had lids. On 07/17/24 at 12:29 PM Administrative Nurse D stated staff are trained on hand hygiene when they are hired, and agency staff have a check-off sheet when they come aboard that includes hand hygiene. She stated oxygen tubing should always be stored in a container when not in use. Administrative D stated staff would know what PPE to wear when taking care of a resident, by the guide provided to them inside the resident's room, with the PPE. The facility's policy for Peri Care, Enhanced Barrier Precautions, and Laundry and Linen documented, that the facility was to provide cleanliness and comfort to the resident to prevent infections skin irritation, and to observe the resident's skin condition. The enhanced barrier precautions documented the community will fully implement the precautions during high-contact resident care activities when caring for residents at risk. The laundry and linen policy directs to separate soiled and clean linen and perform hand hygiene after handling soiled linen and before handling clean linen. The facility failed to follow sanitary infection control standards related to the handling of soiled laundry, hand hygiene storage of oxygen tubing while not in use, catheter care, and EBP. These deficient practices placed the residents at risk for infectious diseases.

The facility identified a census of 83 residents. The sample included 18 residents with one reviewed for self-administration of medications. Based on observation, record review, and interviews, the facility failed to ensure Resident (R)53 was safe to self-administer her medications. This deficient practice placed R53 at risk for unidentified medication complications and administration errors. Findings Included: -The Medical Diagnosis section within R53's Electronic Medical Records (EMR) included diagnoses of multiple sclerosis (MS- progressive disease of the nerve fibers of the brain and spinal cord), paraplegia (paralysis characterized by motor or sensory loss in the lower limbs and trunk), and obstructive uropathy (structural blockage within the urinary tract blocking urine flow). R53's Quarterly Minimum Data Set (MDS) completed 06/07/24 noted a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The MDS indicated she was dependent on staff assistance for toileting, bathing, transfers, bed mobility, dressing, and personal hygiene. The MDS indicated she had an indwelling urinary catheter (a tube inserted into the bladder to drain urine). R53's Urinary Catheter Care Area Assessment (CAA) completed 08/17/23 indicated she had a suprapubic urinary catheter (a catheter that enters the bladder through a surgically created hole in the abdomen) related to obstructive uropathy. The plan noted she required staff monitoring for the catheter ostomy site. The CAA instructed staff to provide catheter care and monitor her for urinary tract infections. R53's Functional Abilities CAA completed 08/17/23 revealed she required total staff assistance for bathing, dressing, grooming, personal hygiene, toileting, transfers, and bed mobility. R53's Care Plan initiated 06/04/24 indicated she required assistance with her daily activities of daily living (ADLs). The plan indicated she required staff assistance for toileting, bathing, transfers, bed mobility, and dressing. The plan indicated she had impaired memory, decision-making, and comprehension. The plan lacked documentation indicating she could self-administer her medication safely. R53's EMR under Physician's Orders lacked an order related to medication self-administration. On 07/17/24 at 11:30 AM, upon request, the facility provided a Medication Self-Administration Evaluation completed on 04/09/24. The evaluation noted R53 was deemed unable to safely self-administer her medications. On 07/15/24 at 08:01 AM, R53 sat upward in her bed. Her bed was elevated to the highest position. R53's bedside table was pulled over her lap. Her table contained a cup of water, and two small plastic pill cups filled with numerous medications. She stated she was taking her morning pills. Staff were not present in the room. On 07/17/24 at 10:20 AM Licensed Nurse (LN) J stated R53 should not be taking her medications unsupervised. She stated some residents prefer to eat their meals before taking the medications, but the medication should not left in the room unsupervised. On 07/17/24 at 12:20 PM Administrative Nurse D stated no residents in the facility were currently able to self-administer their own medications. She stated R53 needed supervision while taking her medications and staff were expected to remove the medication from the room upon leaving. The facility's Self-Administration of Medications policy revised 12/2017 indicated the facility will ensure each resident's safety related to the administration of medication. The policy indicated the facility will complete ongoing assessments of individuals identified as safe for self-administration. The policy indicated care planned interventions will be provided to identify the appropriate education and supervision for the administration. The facility failed to ensure R53 was safe to self-administer her medications. This deficient practice placed R53 at risk for unidentified medication complications and administration errors.

The facility identified a census of 83 residents with 18 residents included in the sample. Based on interview and record review the facility failed to issue Center for Medicare/Medicaid Services (CMS) Notification of Medicare Non-Coverage Form 10123 (NOMNC- the form used to notify Medicare A participants of their rights to appeal and the last covered date of participants of potential financial liability when a Medicare Part A episode ends) with the required information for Resident (R)139. This failure placed the resident at risk for decreased autonomy and impaired decision-making. Findings included: - A review of R139's Electronic Medical Record (EMR) documented that the Medicare Part A episode began on 04/10/24 and ended on 04/27/24. R139 did not remain in the facility for custodial care. R139's clinical record lacked evidence of a NOMNC issued for this Medicare Part A episode. On 07/16/24 at 11:40 AM AM Administrative Staff A stated the facility was unable to find the NOMNC issued to R139. The facility did not provide a policy for beneficiary notification. The facility failed to ensure a NOMNC was provided at the end of skilled services for R139. This failure placed the residents at risk for decreased autonomy and impaired decision-making.

The facility identified a census of 83 residents. The sample included 18 residents with four residents sampled for transfer and discharge. Based on observations, record review, and interview the facility failed to provide a written notice of transfer as soon as practicable to Resident (R) 13 and R56 or their representative for their facility-initiated transfers. This deficient practice had the risk of miscommunication between the facility and resident/family and possible missed opportunities for healthcare service for R13 and R56. Findings included: - The electronic medical record (EMR) for R13 documented diagnoses of congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), and dementia (progressive mental disorder characterized by failing memory, confusion). The Significant Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of five which indicated severely impaired cognition. R13 required extensive assistance from two staff for activities of daily living (ADLs). The Quarterly MDS dated [DATE] for R13 documented a BIMS score of eight that indicated moderately impaired cognition. R13 utilized a walker and a wheelchair for mobility. R13 required partial to moderate assistance with upper body dressing and substantial to maximal assistance with toileting, bathing, lower body dressing, and personal hygiene. The Discharge MDS dated [DATE] for R13 documented a discharge to an acute hospital with a return anticipated. An Entry MDS dated [DATE] for R13 documented a reentry from an acute hospital. The Discharge MDS dated [DATE] for R13 documented a discharge to an acute hospital with a return anticipated. The Entry MDS dated [DATE] documented a reentry to the facility from an acute hospital. The Discharge MDS dated [DATE] for R13 documented a discharge to an acute hospital with a return anticipated. The Entry MDS dated [DATE] for R13 documented a reentry to the facility from an acute hospital. The ADL Care Area assessment dated [DATE] for R13 documented he was alert and oriented with episodes of confusion. R13 was able to communicate his needs. R13 needed assistance with ADLs. R13 was able to walk with a walker but would forget it at times. R13 had lower extremity weakness and was at risk for falls. R13's Care Plan dated 04/19/24 directed staff would support R13's plan to stay long term. Staff was directed to assist R13 with adjustments to the facility and routines. A Nursing Note dated 08/18/23 at 03:28 PM for R13 documented him having increased thirst and shortness of air. Staff called R13's physician who ordered the resident to be sent out to the hospital for evaluation. R13's Nurse's Progress Note dated 03/09/24 at 05:27 PM documented R13 was observed in the recliner shaking and trembling. R13 stated he was cold. R13 stated he was not hungry. R13 was noted to be responding to staff inappropriately to questions. Staff called R13's physician and notified him of R13's symptoms and received orders to send R13 to the hospital for evaluation. R13's family was called and notified of the transfer. R13's Nurse's Progress Note dated 04/16/24 at 05:32 PM documented R13 was noted to be shaking. The nurse obtained his vital signs with a noted oxygen saturation of 87 percent (%). At 05:00 PM R13 was noted to be vomiting. R13's physician was notified, and an order was received to send the resident out for evaluation at the hospital. R13's family was notified. R13's Nurse's Progress Note dated 04/16/24 at 07:09 PM documented R13 was admitted to the hospital for aspiration pneumonia (an inflammatory condition of the lungs caused by inhaling foreign material or vomit). The facility was unable to provide, as requested, the required written notification of transfer or discharge for R13's facility-initiated discharge to the hospital on 08/18/23, 03/09/24, or 04/16/23. On 07/15/24 at 11:50 AM R13 propelled himself in his wheelchair to the dining area and visited with other residents in the area. On 07/16/24 at 01:41 PM, R13 rested in a recliner in the commons area with a blanket covering his body and head. On 07/16/24 at 03:22 PM Administrative Staff A stated that only nursing notes had documentation of the discharge. Administrative Staff A stated that the nurses were responsible for notifying the family when a resident was sent out the to hospital but could not state for fact if a written notification or transfer was sent to the resident's representative. On 07/17/24 at 12:27 PM Administrative Nurse D stated that the floor nurses were responsible for notifying the family representative when a resident was sent to the hospital. Administrative Nurse D stated to her knowledge a formal written notification of transfer was not sent to the representative and that the representative would only receive a phone call when a resident was sent out to the hospital. The facility did not have a policy regarding written notification of transfer and or discharge. The facility failed to provide written notice of transfer as soon as practicable to R13 or their representative for their facility-initiated transfers. This deficient practice had the risk of miscommunication between the facility and resident/family and possible missed opportunity for healthcare service for R13. - The electronic medical record (EMR) for R56 documented diagnoses of diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), dementia (progressive mental disorder characterized by failing memory, confusion), atrial fibrillation (a rapid, irregular heartbeat), and cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain). The Significant Change Minimum Data Set (MDS) for R56 dated 05/23/24 documented a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. R56 had impairment on one side of his upper and lower extremities. R56 used a walker to assist with mobility. R56 required partial to moderate assistance from staff for functional abilities. R56 had a history of falls. The Discharge MDS dated [DATE] for R56 documented a discharge to an acute hospital with a return anticipated. The Discharge MDS dated [DATE] for R56 documented a discharge to an acute hospital with a return anticipated. The Entry MDS dated [DATE] for R56 documented a reentry to the facility from an acute hospital. The Discharge MDS dated [DATE] for R56 documented a discharge to an acute hospital with a return anticipated. The Discharge MDS dated [DATE] for R56 documented a discharge to an acute hospital with a return anticipated. The Entry MDS dated [DATE] for R56 documented a reentry to the facility from an acute hospital. The Discharge MDS dated [DATE] for R56 documented a discharge to an acute hospital with a return anticipated. The Entry MDS dated [DATE] for R56 documented a reentry to the facility from an acute hospital. R56's Functional Abilities Care Area Assessment (CAA) dated 05/28/24 documented R56 sustained recent fractures to the face and leg and required assistance with activities of daily living (ADLS). R56 was able to feed himself with setup assistance. R56 was at risk for future falls. R56's Care Plan dated 05/16/24 directed staff that R56 planned to make the community a long-term home through the next review period. Staff was to support R56's plan to stay long-term. Staff was directed to assist R56 with referrals, as needed, to meet goals for discharge. R56's Nurse's Progress Note dated 11/25/23 at 11:03 AM documented the resident was assessed by the physician in the facility at that time due to tremors and delayed responses. R56's physician ordered R56 to be sent out to the hospital for evaluation. Staff called R56's daughter to notify her of the transfer. R56's Nurse's Progress Note dated 01/15/24 at 12:02 PM documented R56 complained of a headache and requested Imitrex (a medication used to treat migraines and cluster headaches). Staff notified R56's physician of his condition. R56 requested staff to call his daughter to notify her of his condition, and R56's daughter requested that R56 go to the hospital to be evaluated. R56's physician was notified, and the resident was transferred to the hospital. R56's Nurse's Progress Note dated 02/18/24 at 02:44 PM documented that staff noted R56 presented with some confusion and had put his shirt on inside out and on backward. Staff was called by R56's daughter and she requested that the nurse see R56 due to him being confused when she had called him. Staff checked on R56 again noting R56 with his arms and leg frequently jerking. R56 was unaware of the time. Staff called the on-call practitioner, and an order was received to send the resident to be evaluated at the hospital. R56's daughter was called and notified of the transfer. R56's 04/06/24 at 05:16 PM Nurse's Progress Note documented staff noted R56 to be confused and very disoriented. R56's family requested resident be sent out to the hospital. Staff called the on-call doctor, and an order was received to send the resident out to the hospital. R56's 05/02/24 at 06:04 PM Nurse's Progress Note documented R56's daughter had called the facility to notify staff that R56 was on the floor. Staff went to R56's and entered his room and found the resident on the floor in front of his dresser. R56 had noted blood coming from his nose and around his head. Staff immediately called 911. R56 stated he had turned his call light on for the staff to come get his dinner tray. R56 stated he got up from his recliner when the call light had not been answered and walked with the tray to a chair, then walked back to his recliner and attempted to turn around and fell . Emergency medical services (EMS)personnel arrived at the facility and assessed R56. R56 was transported out to the hospital. The facility was unable to provide as requested the required written notification of transfer/discharge for R56's discharges on 11/25/23, 01/15/24, 02/18/24, 04/06/24, and 05/02/24. On 07/16/24 at 08:45 AM R56 sat in the main lobby of the facility with his walker in front of him. R56 stated he was just waiting to go to his appointment this morning. On 07/16/24 at 03:22 PM Administrative Staff A stated that only nursing notes had documentation of the discharge. Administrative Staff A stated that the nurses were responsible for notifying the family when a resident was sent out to the hospital but could not state for fact if a written notification or transfer was sent to the resident's representative. On 07/17/24 at 12:27 PM Administrative Nurse D stated that the floor nurses were responsible for notifying the family representative when a resident was sent to the hospital. Administrative Nurse D stated to her knowledge a formal written notification of transfer was not sent to the representative and that the representative would only receive a phone call when a resident was sent out to the hospital. The facility did not have a policy regarding written notification of transfer and or discharge. The facility failed to provide written notice of transfer as soon as practicable to R56 or their representative for their facility-initiated transfers. This deficient practice had the risk of miscommunication between the facility and resident/family and possible missed opportunity for healthcare service for R56.

The facility identified a census of 83 residents. The sample included 18 residents with four residents sampled for transfer and discharge. Based on observations, record review, and interview the facility failed to provide a bed hold notice with the required information to Resident (R) 13 and R56 and/or to their family representative when transferred to the hospital. This deficient practice placed R13 and R56 at risk for impaired ability to return to the facility or his same room. Findings included: - The electronic medical record (EMR) for R13 documented diagnoses of congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), and dementia (progressive mental disorder characterized by failing memory, confusion). The Significant Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of five which indicated severely impaired cognition. R13 required extensive assistance from two staff for activities of daily living (ADLs). The Quarterly MDS dated [DATE] for R13 documented a BIMS score of eight that indicated moderately impaired cognition. R13 utilized a walker and a wheelchair for mobility. R13 required partial to moderate assistance with upper body dressing and substantial to maximal assistance with toileting, bathing, lower body dressing, and personal hygiene. The Discharge MDS dated [DATE] for R13 documented a discharge to an acute hospital with a return anticipated. An Entry MDS dated [DATE] for R13 documented a reentry from an acute hospital. The Discharge MDS dated [DATE] for R13 documented a discharge to an acute hospital with a return anticipated. The Entry MDS dated [DATE] documented a reentry to the facility from an acute hospital. The Discharge MDS dated [DATE] for R13 documented a discharge to an acute hospital with a return anticipated. The Entry MDS dated [DATE] for R13 documented a reentry to the facility from an acute hospital. The ADL Care Area assessment dated [DATE] for R13 documented he was alert and oriented with episodes of confusion. R13 was able to communicate his needs. R13 needed assistance with ADLs. R13 was able to walk with a walker but would forget it at times. R13 had lower extremity weakness and was at risk for falls. R13's Care Plan dated 04/19/24 directed staff would support R13's plan to stay long term. Staff was directed to assist R13 with adjustments to the facility and routines. A Nursing Note dated 08/18/23 at 03:28 PM for R13 documented him having increased thirst and shortness of air. Staff called R13's physician who ordered the resident to be sent out to the hospital for evaluation. R13's Nurse's Progress Note dated 03/09/24 at 05:27 PM documented R13 was observed in the recliner shaking and trembling. R13 stated he was cold. R13 stated he was not hungry. R13 was noted to be responding to staff inappropriately to questions. Staff called R13's physician and notified him of R13's symptoms and received orders to send R13 to the hospital for evaluation. R13's family was called and notified of the transfer. R13's Nurse's Progress Note dated 04/16/24 at 05:32 PM documented R13 was noted to be shaking. The nurse obtained his vital signs with a noted oxygen saturation of 87 percent (%). At 05:00 PM R13 was noted to be vomiting. R13's physician was notified, and an order was received to send the resident out for evaluation at the hospital. R13's family was notified. R13's Nurse's Progress Note dated 04/16/24 at 07:09 PM documented R13 was admitted to the hospital for aspiration pneumonia (an inflammatory condition of the lungs caused by inhaling foreign material or vomit). The facility was unable to provide, as requested, evidence a bed hold notice was provided to R13 when he was discharged to the hospital on 08/18/23, 03/09/24, or 04/16/23. On 07/15/24 at 11:50 AM R13 propelled himself in his wheelchair to the dining area and visited with other residents in the area. On 07/16/24 at 01:41 PM, R13 rested in a recliner in the commons area with a blanket covering his body and head. On 07/16/24 at 03:22 PM Administrative Staff A stated that the social worker had been typically responsible for providing the bed hold to the resident and the representative. Administrative Staff A stated that the facility had not had a social worker for nearly a month, but he had not been able to find any record of bed holds for R13's hospitalization s. The facility policy Bed- Holds and Returns last revised in December 2017 documented at the time of transfer for hospitalization , the nursing facility must provide to the residents and or resident representatives a written notice which specifies the duration for the bed hold. Residents may return to and resume residence in the community after hospitalization . Prior to a transfer, written information would be given to the residents and the resident's representative that explained in detail the duration of the bed hold. The reserve bed payment policy as indicated by the state plan and the details of the transfer (per the Notice of Transfer). The facility failed to provide a bed hold notice to R13 and his representative when transferred to the hospital. This deficient practice placed R13 at risk for impaired ability to return to the facility or his same room. - The electronic medical record (EMR) for R56 documented diagnoses of diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), dementia (progressive mental disorder characterized by failing memory, confusion), atrial fibrillation (a rapid, irregular heartbeat), and cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain). The Significant Change Minimum Data Set (MDS) for R56 dated 05/23/24 documented a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. R56 had impairment on one side of his upper and lower extremities. R56 used a walker to assist with mobility. R56 required partial to moderate assistance from staff for functional abilities. R56 had a history of falls. The Discharge MDS dated [DATE] for R56 documented a discharge to an acute hospital with a return anticipated. The Discharge MDS dated [DATE] for R56 documented a discharge to an acute hospital with a return anticipated. The Entry MDS dated [DATE] for R56 documented a reentry to the facility from an acute hospital. The Discharge MDS dated [DATE] for R56 documented a discharge to an acute hospital with a return anticipated. The Discharge MDS dated [DATE] for R56 documented a discharge to an acute hospital with a return anticipated. The Entry MDS dated [DATE] for R56 documented a reentry to the facility from an acute hospital. The Discharge MDS dated [DATE] for R56 documented a discharge to an acute hospital with a return anticipated. The Entry MDS dated [DATE] for R56 documented a reentry to the facility from an acute hospital. R56's Functional Abilities Care Area Assessment (CAA) dated 05/28/24 documented R56 sustained recent fractures to the face and leg and required assistance with activities of daily living (ADLS). R56 was able to feed himself with setup assistance. R56 was at risk for future falls. R56's Care Plan dated 05/16/24 directed staff that R56 planned to make the community a long-term home through the next review period. Staff was to support R56's plan to stay long-term. Staff was directed to assist R56 with referrals, as needed, to meet goals for discharge. R56's Nurse's Progress Note dated 11/25/23 at 11:03 AM documented the resident was assessed by the physician in the facility at that time due to tremors and delayed responses. R56's physician ordered R56 to be sent out to the hospital for evaluation. Staff called R56's daughter to notify her of the transfer. R56's Nurse's Progress Note dated 01/15/24 at 12:02 PM documented R56 complained of a headache and requested Imitrex (a medication used to treat migraines and cluster headaches). Staff notified R56's physician of his condition. R56 requested staff to call his daughter to notify her of his condition, and R56's daughter requested that R56 go to the hospital to be evaluated. R56's physician was notified, and the resident was transferred to the hospital. R56's Nurse's Progress Note dated 02/18/24 at 02:44 PM documented that staff noted R56 presented with some confusion and had put his shirt on inside out and on backward. Staff was called by R56's daughter and she requested that the nurse see R56 due to him being confused when she had called him. Staff checked on R56 again noting R56 with his arms and leg frequently jerking. R56 was unaware of the time. Staff called the on-call practitioner, and an order was received to send the resident to be evaluated at the hospital. R56's daughter was called and notified of the transfer. R56's 04/06/24 at 05:16 PM Nurse's Progress Note documented staff noted R56 to be confused and very disoriented. R56's family requested resident be sent out to the hospital. Staff called the on-call doctor, and an order was received to send the resident out to the hospital. R56's 05/02/24 at 06:04 PM Nurse's Progress Note documented R56's daughter had called the facility to notify staff that R56 was on the floor. Staff entered R56's room and found the resident on the floor in front of his dresser. R56 had noted blood coming from his nose and around his head. Staff immediately called 911. R56 stated he had turned his call light on for the staff to come get his dinner tray. R56 stated he got up from his recliner when the call light had not been answered and walked with the tray to a chair, then walked back to his recliner and attempted to turn around and fell . Emergency medical services (EMS)personnel arrived at the facility and assessed R56. R56 was transported out to the hospital. The facility was unable to provide, as requested, evidence a bed hold notice was provided to R56 when he was discharged to the hospital on 11/25/23, 01/15/24, 02/18/24, 04/06/24, and 05/02/24. On 07/16/24 at 08:45 AM R56 sat in the main lobby of the facility with his walker in front of him. R56 stated he was just waiting to go to his appointment this morning. On 07/16/24 at 03:22 PM Administrative Staff A stated that the social worker had been typically responsible for providing the bed hold to the resident and the representative. Administrative Staff A stated that the facility had not had a social worker for nearly a month, but he had not been able to find any record of bed holds for R5613's hospitalization s. The facility policy Bed- Holds and Returns last revised in December 2017 documented at the time of transfer for hospitalization , the nursing facility must provide to the residents and or resident representatives a written notice which specifies the duration for the bed hold. Residents may return to and resume residence in the community after hospitalization . Prior to a transfer, written information would be given to the residents and the resident's representative that explained in detail the duration of the bed hold. The reserve bed payment policy as indicated by the state plan and the details of the transfer (per the Notice of Transfer). The facility failed to provide a bed hold notice to R56 and his representative when transferred to the hospital. This deficient practice placed R56 at risk for impaired ability to return to the facility or his same room.

The facility identified a census of 86 residents. The sample included one resident reviewed for accidents. Based on record review, interview, and observations, the facility failed to provide adequate assistance during transfer to prevent injury from avoidable accidents for Resident (R)1, who required assistance of one staff member with the use of a gait belt (belt used to help transfer or stabilize during activity) during transfers. As a result, R1 sustained a medial (towards the middle) and lateral (pertaining to the side, away from the middle) tibial (bone of the lower leg) plateau (an elevated and usually flat area) fracture as well as an associated fibular (one of the two bones of the lower leg) fracture and increased pain. Findings included: - R1's Electronic Medical Record (EMR), under the Diagnosis tab, recorded diagnoses of osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain), morbid obesity, pain in left hip, and hypertension (elevated blood pressure). The Significant Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. R1 required set up assistance with transfers and bed mobility. The Activities of Daily Living (ADL) Care Area Assessment (CAA) dated 01/11/23 documented R1 needed set up to limited assistance with dressing but needed more help with bed mobility and had a left enabler bar to help her. R1 was non ambulatory and transferred herself most of the time but had a history of falls and was encouraged to ask for help. The Falls CAA dated 01/11/23 documented R1 would sometimes ask for help and other times transferred herself and was non-ambulatory. R1 had a history of falls and was encouraged to ask for help. R1's fall risk assessment score was a six on a scale of one to nine, which indicated R1 was a high risk for falls. The Quarterly MDS dated [DATE] documented a BIMS score of 15 which indicated intact cognition. R1 required partial to moderate assistance from staff for transfers. R1's Care Plan for ADLs initiated on 01/24/23 documented R1 had left extremity weakness and needed assistance with daily ADL cares. R1 needed staff assistance with transfers using a gait belt. R1's Care Plan for falls directed staff to the ADL care plan for mobility and transfer assistance directions. R1's Care Plan lacked any directives related to refusals to use the gait belt or directions for alternative safe transfers for R1 if she refused the gait belt. The Fall Risk [NAME] Fall Risk assessment dated [DATE] documented R1 scored 25 which indicated moderate risk for falls. The Nurse's Progress Note dated 10/30/23 at 07:46 AM, correction/addendum dated 11/06/23 at 06:24 AM, documented R1 had a witnessed fall from the bed to the wheelchair, while being assisted by Certified Nurse Aide (CNA) M. R1 stated she stood too long before moving to the wheelchair and her knees started to buckle. CNA M assisted R1 to sit on the floor. R1 sat on the floor, her right hand holding the wheelchair arm rest, and her left hand on the bed rail. R1's back leaned against the bed. R1 reported that her leg bent when she sat down. R1 stated she had pain in her left knee and requested pain medication. Staff assessed R1 for injuries with none noted; there was no swelling, bruising, lacerations, or skin tears, no limb shortening or abduction (the movement of a limb or other part away from the midline of the body). Active range of motion (AROM) was present with no limitations. The Physician Communication Note dated 10/30/23 at 11:43 AM documented a new order for a two-view X-ray to the left knee, related to the fall. R1's X-ray Report dated 10/30/23 documented R1 had no fracture or prominent degenerative changes noted. The Nurse's Progress Note dated 10/31/23 at 03:23 AM documented R1 had pain eight out of ten to her left knee two times on the night shift. R1 received her as needed pain medication, which was effective. The Physician Communication Note dated 10/31/23 at 11:13 AM documented an order for a venous doppler (a diagnostic test used to check the circulation in the large veins in the legs or arms) to R1's left lower extremity due to pain at the calf area. The Fall Documentation Note dated 10/31/23 at 11:14 AM documented R1 was anxious with cares, which was a noted change from R1's baseline. R1 had anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) related to the new onset of pain to her left lower extremity. R1 had full range of motion with no difference noted between both sides of R1's body. R1 made statements of pain with range of motion. The Follow Up Note dated 11/01/23 at 05:46 PM documented R1 denied pain with range of motion and continued to have no injuries noted from the previous fall. The fall interventions for R1 included physical therapy and occupational therapy related to R1's fall. The Nurse's Progress Note dated 11/02/23 at 05:00 AM documented at 03:30 PM R1 transferred to the hospital due to pain, discoloration, and swelling on her left leg. R1's Progress Notes reviewed from 09/01/23 to 11/20/23 lacked documentation indicating staff offered R1 a gait belt, that R1 refused to wear a gait belt, or that staff educated R1 on the risk of not wearing a gait belt or following R1's care plan. Review of the hospital Readmission Packet dated 11/03/23 documented multiple views of the left knee demonstrated a medial and lateral tibial plateau fracture as well as an associated fibular neck fracture. R1 also had significant osteoarthritis of the left knee. The Notarized Witness Statement dated 11/08/23 signed by Administrative Nurse D documented CNA M's interview on 11/03/23. CNA M stated R1 transferred from the bed to R1's wheelchair. CNA M noted during the transfer, R1's legs buckled, and CNA M assisted R1 to the floor. CNA M then proceeded to get Licensed Nurse (LN) G. The Notarized Witness Statement dated 11/08/23 by LN G documented that on 10/30/23 CNA M summoned LN G to R1's room. CNA M stated R1 was assisted to sit on the floor. LN G stated that upon entering the room, R1 sat on the floor with her back against the bed. R1 had her right hand holding her wheelchair arm and her left hand on the bed rail. R1 stated she had stood too long before moving to the wheelchair and her knees buckled. R1 complained of pain on the left knee and stated her leg bent when she sat down. LN G documented R1 had no swelling, bruising, lacerations, or skin tears. Staff assisted R1 to bed using a Hoyer (total body mechanical lift) lift with four staff members. The facility investigation and witness statements lacked documentation that staff offered R1 a gait belt or that R1 refused to wear a gait belt. On 11/20/23 at 12:43 PM R1 sat in her wheelchair with her left leg raised on the wheelchair pedal; she had a blanket draped on her lap covering her left leg. R1 stated the day that she fell , staff stood behind her wheelchair to hold it in place while R1 pulled herself to a standing position and attempted to pivot into her wheelchair. R1 stated she was not wearing a gait belt and that staff were behind her wheelchair. R1 stated when she attempted to step and then pivot, she stepped too wide and placed too much weight on her left leg, which gave way and buckled. R1 said she sat onto her left leg, and it was underneath her with the right leg out in front of her. R1 revealed that she attempted to lean to her right and straighten her left leg but was unable to and there was a lot of pain when she attempted this. R1 further stated that after the fall happened, she had pain in her left knee constantly. The pain medication helped but the pain never left completely. On 11/20/23 at 01:50 PM CNA N stated prior to the fall, R1 would stand and pivot for transfers. CNA N revealed that R1 allowed her to use a gait belt when she assisted R1 with transfers. CNA N further revealed that CNA N learned of R1's transfer assistance through verbal report at the start of CNA N's shift. CNA N stated that if a resident's level of assistance with transfers was unknown, she would speak to the charge nurse assigned to the hall she was working. On 11/20/23 at 01:58 PM LN H stated prior to the fall with the fracture, R1 transferred with assistance of one staff member with the gait belt. LN H revealed R1, at times, refused to use the gait belt but would also ask that a gait belt be used. LN H further revealed if there were questions on a resident's level of assistance with transfers, LN H looked in the care plan. LN H stated that if a CNA asked how a resident was cared for, LN H would print out that resident's care plan for the CNA to reference. On 11/20/23 at 02:40 PM Administrative Nurse D stated R1's fall investigation revealed the care plan was not followed. Administrative Nurse D further stated therapy was consulted regarding R1's transfers and the therapy department noted R1 refused to use the gait belt. Administrative Nurse D revealed when a resident chose not to use the gait belt, it made it hard for the nursing staff to do their jobs, but that was the resident's preference. Administrative Nurse D acknowledged the care plan did not indicate R1 refused to use the gait belt, or that R1's care plan included an alternative way to safely transfer R1. The Facility Falls Prevention Policy revised 07/2023 documented the purposes of this policy was to provide an environment that is free from accidental hazards, over which there is control, and provide supervision and interventions to residents to prevent avoidable accidents. The facility failed to follow R1's care plan for transfers which resulted in a fall. R1 sustained a fractured tibia and fibula as a result of the deficient practice.

The facility identified a census of 95 residents, with 3 residents included in the sample. Based on observations, record review, and interviews, the facility failed to ensure Resident (R) 1, who was dependent upon staff assistance for transfers and locomotion, remained free of accidents and related injuries when facility staff failed to use foot pedals with R1's wheelchair. This deficient practice resulted in a fracture of R1's left ankle/distal (away from the farthest point of origin or attachment) fibula (one of the two bones of the lower leg). Findings included: - R1's Electronic Medical Record (EMR) documented diagnoses of [CONDITION(S)] (paralysis of one side of the body) following cerebral infarction ([CONDITION(S)]/stroke- sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain) affecting left nondominant side, generalized muscle weakness, [CONDITION(S)] (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain) without behavioral disturbance, and need for assistance with personal care. The Annual Minimum Data Set (MDS) dated [DATE], documented R1 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated moderate cognitive impairment. R1 required extensive physical assistance with two staff for bed mobility and toileting; extensive physical assistance with one staff for dressing and personal hygiene; total physical assistance with two staff for transfers; and total physical assistance with one staff for locomotion. The Quarterly MDS dated [DATE], documented R1 had a BIMS score of ten, which indicated moderate cognitive impairment. R1 required extensive physical assistance with one staff for bed mobility and personal hygiene; extensive physical assistance with two staff for dressing; total physical assistance with one staff for toileting; transfers and locomotion did not occur during assessment period. The Cognitive Loss/Dementia Care Area Assessment (CAA) dated 12/13/21, documented R1 had mild cognitive impairment. The Activities of Daily Living (ADL) Functional/Rehabilitation Potential CAA dated 12/21/21 documented R1 used a wheelchair to get around and propelled the wheelchair with staff assistance as needed. The ADL Functional/Rehab Potential Care Plan dated 12/21/21, documented R1 had a [CONDITION(S)] with left [CONDITION(S)] (muscular weakness of one half of the body) and needed assistance with daily ADL care. R1 was bedfast most of the time per his choice. The Care Plan directed staff to assist him with transfers using a Hoyer lift (total body mechanical lift used to transfer residents) and two staff assistance if/when he agreed to get up. R1 could not walk and needed a wheelchair to get around and staff kept a foot pedal on the left side of the wheelchair when up. The Orthopedic [field of medicine concerned with the study and treatment of the musculoskeletal system] Conditions Care Plan dated 05/23/22, documented R1 had a fractured left ankle/distal fibula fracture with risk for pain/complications and directed staff to monitor for complaints of pain and administer pain medications as ordered by the medical doctor. R1's EMR revealed a Nurse's Progress Note on 05/20/22 at 07:17 PM that documented the Nurse Practitioner (NP) was in the facility that morning and assessed R1 related to notification that his ankle hurt during transport to an appointment yesterday. R1 complained of pain to the overnight shift. Staff received orders to obtain a three-view x-ray of the left ankle and foot. R1 voiced pain with movement, but denied need for pain medication. R1's had some increased swelling. Results of the x-ray were negative. R1's EMR revealed a Nurse's Progress Note on 05/21/22 at 03:05 PM that documented R1 continued to report pain in the left ankle when he moved it. Staff called the doctor and received a new order to send to the emergency room (ER) for further evaluation.Staff sent R1 to the ER via emergency medical services (EMS). The X-Ray Exam of Ankle Left results on 05/21/22 documented R1 had a nondisplaced oblique (neither perpendicular nor parallel) fracture through the distal fibular metaphysis (trumpet-shaped end of long bones) extending to the level of the syndesmosis (joint in which two adjacent bones are linked by a strong membrane or ligament). R1's EMR revealed a Follow-up Note on 05/21/22 at 09:29 PM that documented R1 returned from the ER, accompanied by two staff, on a stretcher. Staff received report that R1 had an ankle/distal fibula fracture and was to follow up with the doctor. R1 had a splint to the left ankle at that time. The facility's Investigation dated 05/25/22, documented R1 complained of pain to his left ankle on 05/19/22. He stated his ankle was hit on the doorway as he exited his room in his wheelchair. R1 voiced complaints of ankle pain to the night shift nurse. The night nurse passed on that information to the day nurse and the NP in morning for follow up on 05/20/22. The NP ordered a three-view x-ray, a two-view x-ray completed per report as R1's leg/foot contracture (abnormal permanent fixation of a joint) caused limited view angles. The day nurse notified Administrative Nurse D nurse who notified the Director of Nursing (DON), Assistant DON (ADON), and Administrator. Administrative Nurse D and the interdisciplinary team (IDT) called the nurse that was on duty who stated that R1 had complaints of pain before the transfer and that she did not know of any statement that he hit his ankle. In-house x-ray returned and noted negative by Administrative Nurse D and IDT. Administrative Nurse D inspected R1 with Certified Medication Aide (CMA) present. Administrative Nurse D noted no visual bruising, trauma, open areas, or skin changes to leg, ankle, or foot; small area of swelling noted to the top of R1's foot. On 05/21/22, R1 continued to complain of pain, staff notified the physician of continued pain and ordered R1 to be sent to ER for evaluation. The ER notified the facility of R1's ankle fracture and he returned back to facility the same day with an ankle splint. Staff were contacted that worked with R1 on 05/19/22. In a Witness Statement dated 05/22/22, Certified Nurse Aide (CNA) M stated she was sent to get R1 for his eye appointment. She and the Licensed Nurse (LN) G got R1 up using a Hoyer lift. Once he was up, she continued to dress him and wash his face. CNA N came into the room and propelled him out of the room in his wheelchair, to his appointment. R1 stated ow. CNA M stated R1 did not have foot pedals on his wheelchair. The pedals to the wheelchair were missing. CNA M reported R1 did not have his own wheelchair, so the staff borrowed a wheelchair from another resident and the wheelchair did not have pedals. CNA M stated both CNAs looked for the foot pedals, but could not find them. CNA M stated she lifted R1's legs while the CNA N pushed the wheelchair. They propelled the wheelchair backwards down the hallway to his appointment since the wheelchair did not have foot pedals. In a Witness Statement dated 05/23/22, LN G stated on 05/19/22 she assisted CNA M in getting R1 up into the wheelchair to see the eye doctor with a Hoyer lift. After R1 was in the wheelchair, she left the room. CNA M assisted R1 out of the room with CNA N. She stated while R1 was in wheelchair, he asked her to reposition his feet, especially the left one, his left side was affected by a stroke and was flaccid (weak, soft and flabby). She repositioned R1's feet several times without complaints of increased pain or discomfort. After R1's appointment, she and CNA O assisted R1 back to bed using a Hoyer lift. On 06/01/22 at 12:39 PM, R1 laid in bed with his head of bed elevated. He appeared comfortable and without signs of discomfort or distress. There was a sheet on top of R1's body and unable to visualize left ankle/leg. R1 stated on 05/19/22, he did not have a wheelchair and had to use another resident's wheelchair. He stated staff hit his left foot on the doorframe when exiting his room and he still had pain in his left ankle that was being treated with medication. On 06/01/22 at 12:33 PM, CNA N stated R1 did not get out of bed, but when he did they used a Hoyer lift with assistance of two people. CNA N stated she worked on 05/19/22, but was not R1's aide. She said staff borrowed a wheelchair from another resident and it did not have foot pedals. On 06/01/22 at 12:41 PM, LN G stated on 05/19/22, the eye doctor was at the facility. CNA M grabbed a wheelchair from another resident and cleaned it for R1 to use. She and CNA M used the Hoyer lift to transfer R1 from bed to wheelchair. Another CNA came into R1's room and LN G left the room. When R1 was in line at the eye doctor, he asked LN G to reposition his legs and feet, but he never voiced pain in feet/ankles. LN G stated after his appointment, staff propelled R1 backwards because there were no foot pedals on the wheelchair, and she held his legs up while the CNA O propelled the wheelchair. Staff transferred R1 back to bed with the Hoyer lift, R1 did not complain of any increased or unusual pain from his general aches/pains. On 06/01/22 at 01:40 PM, Administrative Nurse D stated on 05/19/22, R1 was to get up for the eye doctor in the facility. CNA M and LN G transferred the resident with a Hoyer lift to a wheelchair. The wheelchair did not have foot pedals which were needed for wheelchair use. The staff tried to find foot pedals, but did not find any that fit onto the wheelchair so staff propelled R1 without foot pedals. Administrative Nurse D stated R1 did not normally get out of bed, so he did not have his own wheelchair. She stated one staff pushed the wheelchair while another held his legs since he did not have foot pedals. Staff were to notify their clinical manager if equipment was not available or not able to be found. Administrative Nurse D stated R1 had not complained of pain, but sometime during the wheelchair transfer, he stated ouch you bumped my leg. She stated LN G reported R1 went to the eye doctor and staff brought him back to his room the same way they propelled him, one staff pushed the wheelchair while another staff held his legs. She stated staff transferred him back in bed and that night, R1 complained about his ankle hurting and was seen by the provider the next day. Administrative Nurse D stated there was a little bit of swelling on top of R1's foot, but no redness or warmth. The provider ordered an x-ray which showed no acute fracture. She stated R1 continued to complain of pain the next day, staff notified the physician, and orders were received to send R1 to ER for more in-depth evaluation. When R1 returned to facility, ER reported he had a fracture. The facility's Equipment- General Use for All Residents policy, last revised December 2017, directed the facility provided routine equipment for the general use of the resident population; wheelchairs were maintained by facility for the general use of residents. The facility failed to ensure R1, who had a diagnosis of [CONDITION(S)] following cerebral infarction affecting left nondominant side, remained free of accidents when facility staff failed to use foot pedals with wheelchair use. This deficient practice resulted in a fracture to R1's left ankle/distal fibula. On 5/24/22 the facility completed the following corrections: In-service was provided to staff regarding use of proper equipment for resident safety during locomotion/mobility. Policy review and education regarding facility policy Using the Care Plan. Occupational therapy (OT) evaluated R1 for wheelchair positioning. R1 was ordered a new wheelchair with appropriate foot pedals/safety devices as determined by OT. This deficient practice was cited as past non-compliance.

The facility identified a census of 95 residents. The sample included three residents reviewed for medications. Based on interview, record review, and observation, the facility failed to prevent a significant medication error when a nurse failed to accurately transcribe MEDICATION ORDERS FOR [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 had a documented allergy to ACE inhibitors. The transcription error was not identified by nursing, pharmacy services, or the physician that electronically signed the contraindicated medication entered into the medical record. As a result, R1 received eight doses of the medication which contained an ACE inhibitor and R1 developed an adverse reaction of severe tongue and facial swelling. R1 was sent emergently to an acute care facility, intubated in order to maintain a patent airway, and admitted to the intensive care unit (ICU). The deficient practice placed R1 in immediate jeopardy . Findings included: - R1's Electronic Medical Record (EMR) documented the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . The Five Day Minimum Data Set (MDS), dated [DATE], documented a Brief Interview Mental Status (BIMS) score of 15 which indicated intact cognition. The Care Plan dated 04/21/21 documented R1 had diseases and conditions, which were treated with medications. Medications were overseen and managed by the nurse and physician team during the stay. Review of the Face Sheet in the EMR noted allergies listed for R1 included ACE Inhibitors, activated on 04/21/2021 at 12:02 PM. Review of the Transfer/Discharge Report, dated 04/19/21, scanned in R1's EMR under Attachments, documented R1 had an allergy to ACE Inhibitors, sulfa antibiotics, and lactose intolerance. R1's admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The EMR documented the discharge packet which contained the Order Summary and the Transfer/Discharge Report was uploaded into the system on 04/21/21 at 01:38 PM. Review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The order was signed electronically by Consultant HH on 04/22/21 at 12:43 PM. The Pharmacist Note dated 04/25/2021 at 11:50 PM documented the new admission medication regimen review (MRR) was completed, and no clinically significant medication issues were identified. The Pharmacist Note dated 04/29/2021 at 11:08 PM documented MRR completed, and no duplicate therapy or irregularities noted. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 also received the medication [MEDICATION(S)] 10mg-[MEDICATION(S)] 20 mg on 4/23/21, 4/24/21, 4/25/21, 4/26/21, 4/27/21, 4/28/21, and 4/29/21. The Interdisciplinary (ID) Note dated 04/30/21 at 08:36 AM documented R1 laid on her left side and drooled. Her tongue stuck out and was unusually large. R1 was unable to speak. R1's left cheek was swollen in addition. Staff notified Consultant HH and received an order to send R1 out to the emergency department for evaluation and treatment. The ID Note dated 04/30/21 at 03:41 PM by Administrative Nurse F documented on the morning of 04/30/21 the night shift nurse attempted to administer R1's medicine. R1 had significant tongue swelling and left cheek swelling. R1 was assessed by Licensed Nurse (LN) H, Administrative Nurse F, and another nurse. The note recorded R1 was able to breathe and denied difficulty breathing. Administrative Nurse F documented in R1's EMR R1's allergies were reviewed she hasn't had any ACE Inhibitors, Sulf [sic] ABT or lactolose recently. There hasn't been any other changes that would be indicitive [sic] of an allergic/swelling response. The note further recorded at 12:15 PM Administrative Nurse F found out R1 had been admitted to the ICU with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 05/11/21 at 12:25 PM LN H stated the EMR system alerted the individual entering the order if the resident had an allergy to the medication. The individual entering the order had to check that the order entered was correct before the system would allow that individual to continue entering orders. On 05/11/21 at 12:45 PM Administrative Nurse F stated the nurse on duty at the time of the admission received the discharge orders from the facility and called the doctor to verify the orders over the phone. The nurse then faxed the orders received from the discharging facility to the pharmacy. The orders were entered into the EMR system by the nurse on duty. Administrative Nurse F confirmed [MEDICATION(S)] and [MEDICATION(S)]-[MEDICATION(S)] were two different medications and that the charge nurse had entered the [MEDICATION(S)]-[MEDICATION(S)] order into the EMR. Administrative Nurse F further stated she was not sure how the ACE Inhibitor was missed when the medications were later reviewed. Administrative Nurse F stated the physician signed the orders electronically, so facility administrative staff felt there was no medication error. She further revealed she expected the pharmacy to have identified the contraindicated medication when the orders were reviewed. Administrative Nurse F stated she just assumed responsibility for the reconciliation of medications because the previous individual assigned to perform the task had not completed it. On 05/11/21 01:15 PM Consultant HH stated he did not always get to do a reconciliation on the medications as soon as a resident admitted . Consultant HH revealed for late admissions, staff called and verbally reviewed the medications which were on the list and he would give verbal approval to use the medications. He would then review the orders the following day. Consultant HH stated he was not able to compare medications ordered on the discharge/transfer orders with the medications entered in the EMR side by side due to how the EMR functioned. Consultant HH reported the orders were scanned into the system after he reviewed the medications. Consultant HH felt the pharmacy should have identified the allergy to the [MEDICATION(S)]. He also stated he would not have ordered an ACE inhibitor for R1 due her allergy to ACE Inhibitors. On 05/11/21 at 02:05 PM LN G stated she entered the medications into the EMR for R1. LN G stated she contacted Consultant HH and notified him of R1's arrival to the facility and received a verbal order for the medications on the Order Summary. LN G revealed she had been trained on medication reconciliation and order entry, but it have been a while ago. On 05/11/21 at 02:07 PM LN G demonstrated order entry in the EMR. She typed in [MEDICATION(S)] and multiple selections pulled up, but [MEDICATION(S)] was not an option listed. On 05/11/21 at 02:07 PM LN G stated if a medication was not listed in the system, the person entering the order would have to call the pharmacy. LN G stated she did not call the pharmacy and further stated she did not know why she choose [MEDICATION(S)] [MEDICATION(S)] from the system uploaded mediation list. On 05/12/21 at 10:15 AM Administrative Nurse E stated when a resident admitted to the facility the medications were supposed to be reviewed within 24 hours and entered correctly into the EMR. Administrative Nurse E stated she was generally responsible to audit the orders. She revealed there is a form in the EMR that asked if allergies were entered and if the medications had been reconciled, but the form did not ask if the resident had any allergies to medications ordered. Administrative Nurse E stated when she spoke with the pharmacy, the [MEDICATION(S)] [MEDICATION(S)] was not questioned because the pharmacy assumed the doctor had approved it. So, the medication was not flagged by the pharmacy. Administrative Nurse E stated when a new resident admitted to the facility the pharmacist reviewed orders within the first day or two and emailed her if there were any questions about the medications. She further stated the review done by the pharmacist was documented in the progress notes. On 05/12/21 at 10:36 AM Consultant Pharmacist (CP) GG stated she logged into the EMR and pulled up the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . CP GG revealed she trusted that the medications entered in the EMR had been looked at and screened. She further revealed that she had not screened for allergies as it never occurred to her to monitor for allergies. CP GG stated occasionally medication errors occurred from staff hand typing the medication in and not using the uploaded medication selection list already in the system. She checked this for R1 and the ordered [MEDICATION(S)] [MEDICATION(S)], and noted that it was selected from the list and not hand typed in. The Adverse Effects and Medication Errors policy revised 12/2019 documented associates and the Health Care Provider shall strive to minimize adverse effects by determining that the resident has no know allergies to a medication. The Medication Regimen Reviews policy revised 07/2020 documented reviews for short stay residents (those who are expected to stay 30 days or less) will be done as needed to identify individuals with high-risk medications and those who may be experiencing adverse consequences from their medications. The MRR would include a review of the resident's medical record in order to prevent, identify, report, and resolve medication-related concerns, medication errors, or other irregularities. As part of the MRR, the consultant pharmacist will identify medication errors, including those related to documentation or order transcription. The Physician Services policy revised 12/2017 documented the medical care of each resident is under the supervision of a Licensed Physician and prescribe the appropriate medical regimen. The Pharmacy Services Overview policy revised 10/2017 documented the facility shall contract with a licensed Pharmacist to give feedback about performance and practices related to medication administration and medication errors. Also documented to help develop a process for receiving, transcribing, and recapitulating medication orders. The facility failed prevent a significant medication error when a nurse failed to accurately transcribe MEDICATION ORDERS FOR [MEDICAL RECORD OR PHYSICIAN ORDER] . The transcription error was not identified by nursing, pharmacy services, or the physician that electronically signed for the contraindicated medication. R1 received eight doses of the medication and developed an adverse reaction of severe tongue and facial swelling. R1 was sent emergently to an acute care facility, intubated in order to maintain a patent airway and admitted to the intensive care unit (ICU). The deficient practice placed R1 in immediate jeopardy. The immediate jeopardy was abated when the facility completed the following corrections on 05/12/21 at 8:50 PM. Documented education and counseling completed with the nurse who entered in the incorrect medication. Proof of notification to pharmacy which included a pharmacy plan of correction. Re-education completed for all nurses on medication transcription. Completed a review of all current residents' medications against any known drug allergies. The scope and severity remained at a G.

The facility identified a census of 71 residents. The sample included three residents. Based on observation, interview, and record review, the facility failed to provide the necessary care and services, adequately assess, and monitor the blood sugar for one (#1) of three residents who required hospitalization for a change in level of consciousness, elevated glucose, and decreased blood pressure. These deficient practices placed resident #1 in immediate jeopardy. Findings included: - The clinical record documented resident #1 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission Minimum Data Set ((MDS) dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 3, which indicated severely impaired cognition. He/she required extensive assistance of one staff for activities of daily living (ADLs) and supervision with setup help for eating. The resident did not receive insulin. The admission MDS dated [DATE] documented the resident had a BIMS score of 3, which indicated severely impaired cognition. He/she required extensive assistance of two staff for ADLs and supervision with staff assistance for eating. The resident did not receive insulin. The Care Area assessment dated [DATE] for [MEDICAL CONDITION] drug use documented the resident received medications that had a black box warning (a warning issued by the U.S. Food and Drug Administration of serious or life-threatening risks located on the label of a prescription drug), including [MEDICATION NAME] (a medication used to treat diabetes), which indicated lactic acidosis (a medical condition characterized by the buildup of [MEDICATION NAME] in the body, which causes symptoms such as abdominal discomfort, decreased appetite, fast, shallow breathing, muscle pain or cramping, and unusual sleepiness, tiredness, or weakness) was a rare, but potentially severe consequence of therapy. The care plan for diabetes dated [DATE] directed staff to perform finger stick blood sugars per physician's orders [REDACTED]. [REDACTED]. The care plan further directed staff to administer medications per physician's orders [REDACTED]. A physician's orders [REDACTED]. The order lacked blood glucose parameters of when to notify the physician, and clarification of whether the blood sugar should be checked twice daily or four times daily. Review of the [DATE] Medication Administration Record [REDACTED]. A physician's orders [REDACTED]. Review of the [DATE] MAR indicated [REDACTED]. Review of the resident's clinical record documented he/she discharged from the facility on [DATE] and was readmitted to the facility from home on [DATE]. A physician's orders [REDACTED]. The physician's history and physical dated [DATE] documented the resident returned to the facility from the hospital for weakness. It documented medications and orders were per the hospital transfer records, and no hospital records were available. The clinical record dated [DATE] through [DATE] lacked physician's orders [REDACTED]. A progress note dated [DATE] at 2:32 P.M. by licensed nursing staff E documented the resident complained of pain and discomfort in his/her knees. (The progress note was incomplete and lacked further documentation.) A progress note dated [DATE] at 5:36 P.M. by licensed nursing staff F documented at 3:00 P.M., the resident sat at the nurses' desk and was lethargic. A nurse's aide reported the resident pocketed food at lunch, was sleepy, and was placed in bed. The resident's blood pressure was ,[DATE] (normal range ,[DATE]), heart rate was 51 (normal range ,[DATE] beats per minute), and oxygen saturation was ,[DATE]% (normal range above 94%). Staff notified consultant staff KK, called for an ambulance, and obtained a physician's orders [REDACTED]. Review of the clinical record lacked further progress notes between [DATE] and [DATE] regarding the resident's status and care that was provided by staff. Review of the Transfer Form dated [DATE] by licensed nursing staff F lacked documentation. The form was blank with the exception of the pre-populated physician's and spouse's phone numbers. Review of the Prehospital Care Report dated [DATE] documented emergency personnel were dispatched to the facility for the resident, who had a change in responsiveness. The resident's spouse reported the resident had a gradual decline over the previous two to three days. The resident responded to deep painful stimuli, but did not open his/her eyes and he/she had a weak pulse. The facility nurse reported to the emergency personnel the resident was diabetic, but did not have a physician's orders [REDACTED]. The emergency personnel were unable to obtain a blood pressure reading or oxygen saturation reading while in the resident's room due to the resident's [MEDICAL CONDITION] (low blood pressure) and cold extremities. The emergency personnel checked the resident's blood sugar, which resulted in a HI result on the glucometer. According to www.myfreestyle.com, the glucometer user's manual documented a reading of HI indicated severe high blood glucose (higher than 500 milligrams (mg) per deciliter (dL)) and to contact a healthcare professional immediately. An observation of the resident on [DATE] was not available as he/she no longer resided in the facility and expired at the hospital on [DATE]. On [DATE] at 9:22 A.M., family member JJ stated the resident was diabetic. The resident's blood sugar was checked daily at home, and his/her blood sugar was controlled with a carbohydrate-controlled diet and the use of [MEDICATION NAME] (an oral medication used to treat diabetes). Family member JJ stated on [DATE], he/she reported to an unidentified staff member that the resident appeared different. The resident was not smiling, complained of leg pain, and was withdrawn. On [DATE], the resident appeared the same way he/she had the day before ([DATE]), but an unidentified staff member indicated the resident did not have a fever. Family member JJ stated on [DATE] at approximately 3:00 P.M., the nurse called the ambulance because the resident was very lethargic and appeared to be in a coma. When the ambulance staff arrived, they were upset with the nurse because the resident's blood sugar had not been checked. On [DATE] at 10:20 A.M., licensed nursing staff H stated the physician's history and physical and orders regarding diabetic monitoring and blood sugars should have been clarified by nursing staff. On [DATE] at 10:58 A.M., administrative nursing staff D stated on [DATE], licensed nursing staff F reported to emergency personnel the resident did not have a physician's orders [REDACTED]. Administrative nursing staff D confirmed the resident's clinical record lacked documentation of an assessment and stated he/she did not complete an investigation of the incident. On [DATE] at 12:27 P.M., consultant physician KK was not available for an interview. On [DATE] at 12:30 P.M., direct care staff O stated on when he/she arrived to work on [DATE], the resident sat in his/her wheelchair at the nurse's station and appeared to be sleeping. Direct care staff O stated the resident's skin color appeared pale and he/she felt alarmed because the resident was normally very happy and always smiled. He/she asked another staff to help lay the resident in bed. Direct care staff O stated when they transferred the resident to the bed, the resident never opened his/her eyes and his/her arms and chest felt clammy or sweaty. Direct care staff O stated he/she obtained the resident's vital signs, but the blood pressure was very low, so he/she attempted to obtain a second blood pressure but could not obtain a reading on the vital signs machine. He/she immediately notified licensed nursing staff F of the resident's low blood pressure, asked the nurse to check on the resident, and then returned to the resident's bedside. Direct care staff O stated licensed nursing staff F entered the resident's room, stated that the vital signs machine was not accurate, and then went back to the nurse's station. Direct care staff O stated he/she remained in the resident's room until the ambulance staff arrived, and stated at no time did licensed nursing staff F assess the resident, use a stethoscope on the resident, or check the resident's vital signs and blood sugar. He/she stated when the ambulance staff arrived, they asked him/her when the resident's blood sugar had last been checked. Direct care staff O stated he/she left the room to ask the nurse, but licensed nursing staff F stated the resident was not on the list to have his/her blood sugar checked, so it had not been checked while he/she resided at the facility. Direct care staff O stated the ambulance staff checked the resident's blood sugar and informed the resident's spouse the reading was extremely high and they transported him/her to the hospital. On [DATE] at 12:58 P.M., licensed nursing staff G stated on [DATE], administrative nursing staff D asked him/her to help licensed nursing staff F print forms needed from the electronic medical record to transfer the resident to the hospital. Licensed nursing staff G stated he/she did not have knowledge of the resident's incident and had not been asked by licensed nursing staff F to assist, assess, or provide care to the resident. Licensed nursing staff G stated when a resident had a change of condition, the nurse should call another licensed nursing staff on duty to help assess the resident, notify the director of nursing and physician of the change, and try to determine a root cause for what led to the change of condition. He/she stated the licensed nurse should document a change of condition progress note and a transfer form to document a timeline of events that led up to the resident's change of condition. On [DATE] at 1:10 P.M., administrative nursing staff D stated the facility did not track or audit the nursing documentation of the transfer form when a resident was sent to the hospital or when the staff called for an ambulance. He/she reviewed the resident's clinical record and confirmed the transfer form was blank and lacked documentation of the events on [DATE]. On [DATE] at 1:20 P.M., licensed nursing staff F confirmed he/she worked at the facility on [DATE], but stated he/she was not familiar with the residents. Licensed nursing staff F stated after lunch, an unidentified direct care staff indicated the resident did not appear to be his/her normal self and was asleep in his/her wheelchair. Licensed nursing staff F stated he/she checked the resident's blood pressure after lunch, and found it to be within the normal range. He/she stated direct care staff O laid the resident in bed and reported to him/her the resident's blood pressure was very low. Licensed nursing staff F stated he/she assessed the resident prior to when he/she administered an as-needed medication after lunch, and auscultated (listened to) the resident's lungs, heart, and bowel sounds. He/she stated the resident was diabetic, but did not have a physician's orders [REDACTED]. Licensed nursing staff F stated he/she was not aware of the facility's diabetes management policies or protocols and confirmed he/she did not monitor the resident's blood sugar. Licensed nursing staff F stated he/she called the physician who instructed him/her to call for an ambulance and transfer the resident to the hospital for evaluation. This interview on [DATE] from licensed nursing staff F conflicted with the review of the clinical record dated [DATE], which lacked documentation of his/her assessment of the resident and lacked evidence of vital signs charted after [DATE]. On [DATE] at 1:39 P.M., consultant emergency staff II stated on [DATE], he/she entered the resident's room and observed him/her lying in bed, responsive only to painful stimuli. The resident had a weak, thready pulse, dry mucous membranes, and poor skin turgor. He/she stated emergency staff were unable to obtain a blood pressure reading on the resident and the emergency personnel's glucometer indicated the resident's blood sugar level was HI, which indicated a blood sugar level great than 600 mg/dL. Emergency staff II stated the resident's spouse verbalized the resident had a marked decline over the past two to three days, but indicated facility staff told him/her the resident was fine. Emergency staff II stated while emergency personnel attended to the resident, the facility's nurse did not enter the resident's room, and licensed nursing staff F confirmed to emergency personnel the resident's blood sugar had not been checked since his/her re-admission on [DATE]. On [DATE] at 3:30 P.M., administrative nursing staff B stated when the resident was admitted to the facility on [DATE] from home, nursing staff should have clarified the physician's orders [REDACTED]. The facility's Nursing Care of the Resident with Diabetes Mellitus policy, dated [DATE], documented early signs of [MEDICAL CONDITION] (elevated blood sugar) included increased thirst, dry mouth, increased urination, headache, lethargy, restlessness, and loss of appetite. The policy documented diabetic ketoacidosis (a serious diabetes complication where the body produces excess blood acids, or [MEDICATION NAME]) was a life-threatening emergency that required immediate medical attention and included symptoms of high blood sugar, [MEDICATION NAME] in the urine, nausea and/or vomiting, lethargy, weakness, short, labored, rapid respirations, abdominal pain, dehydration, decreased urine output, sweet or fruity odor of the breath, dry and/or flushed skin, decreased awareness, loss of consciousness, and/or coma. The policy further documented the management of individuals with diabetes mellitus should follow relevant protocols and guidelines: the nurse would closely monitor the diabetes management of cognitively impaired residents, and the normal range of blood sugar was defined as 80 to 130 mg/dL before meals and less than 180 mg/dL after meals. The policy lacked documentation regarding management of [MEDICAL CONDITION], including direction to staff for checking the blood sugar of a diabetic resident as needed in emergent situations. The facility failed to assess and monitor the blood sugar of this cognitively impaired, diabetic resident, which resulted in the hospitalization and expiration of this resident. This deficient practice placed resident #1 in immediate jeopardy. The facility abated the immediate jeopardy on [DATE] at 7:00 P.M. by initiating the following: current residing residents with the confirmed [DIAGNOSES REDACTED]. If no routine glucose monitoring was in place for a resident with diabetes, the physician would be notified for clarification of the type of glucose monitoring to implement. The current policy for care of residents with diabetes would be reviewed and updated to support initial care for symptoms indicated low and high blood sugar. When new admissions arrive to the facility, the nurse would evaluate for a confirmed [DIAGNOSES REDACTED]. Education would be provided to licensed nurses including the policy update, expectation for monitoring residents with a confirmed [DIAGNOSES REDACTED]. The process would be monitored by the director of nursing or designee on a weekly basis for all current residents and would be reviewed within 72 hours on all new admissions. The corrective process would be monitored for a duration of three months. The results of monitoring would be reviewed at the monthly QA meeting and after a three-month duration, further determination would be made for continued monitoring. The deficient practice remained at a scope and severity of G.

The facility identified a census of 98 residents with 24 residents sampled. Based on observation, interview and record review, the facility failed to provide appropriate pain management interventions to 2 dependent sampled residents (#124, #165) identified with pain. Resident #165 that experienced unrelieved pain that affected his/her ability and/or desire to eat, participate with the skilled therapy program, and psychosocial well-being. Resident #124 that reported pain and the staff failed to administer any ordered pain medications. Findings included: - The facility admitted resident #165 on 9/23/10 with [DIAGNOSES REDACTED]. Review of the admission 14-day Minimum Data Assessment 3.0 dated 10/6/10 revealed the resident required extensive assistance from staff for all activities of daily living, experienced frequent pain during the last 5 days of the assessment period and rated the pain at a 4 (on a scale of 0-10, zero being none and 10 the worst). Review of the Care Area Assessment Summary for pain dated 10/6/10, recorded the resident with chronic pain in his/her left leg/knee, low back pain, received pain medication, experienced increased pain in his/her left leg after a fall on 10/3/10, and planned to go back to his/her home after the completion of skilled therapy. Review of the resident's plan of care dated 10/6/10 recorded the resident was forgetful at times, on a pain management program for chronic pain and directed staff to -administer scheduled pain medication as ordered -monitor for complaints of breakthrough pain -administer as needed (PRN) pain medication as ordered, help reposition the resident for better comfort, assess the residents pain level after 20-30 minutes to see if the pain has resolved or decreased to an acceptable level -monitor the resident for increased complaints of pain each day as needed, consult with the physician about further pain management if the pain was not relieved or decreased to a pain intensity that the resident could tolerate (as necessary) -complete pain interview according to Resident Assessment Instrument instructions, comprehensive pain assessment at least quarterly and PRN -utilize the pain management flow sheet to assess the intensity of pain or discomfort indicators after giving PRN medication During an interview on 10/20/10 at 9:45 A.M., Licensed Nursing Staff C revealed that the facility's pain management program consisted of administration of scheduled medications. During an interview on 10/19/10 at 10:00 A.M., Licensed Nursing Staff B revealed staff do not document on pain monitoring sheets for scheduled pain administration. Licensed Nursing Staff B confirmed the clinical record lacked evidence of monitoring the assessment of scheduled pain medications. Review of the physician telephone orders documented the following on: 10/3/10 x-ray to left knee 10/4/10 [MEDICATION NAME] 5% (for pain) 10/7/10 Schedule Tylenol 1000 milligrams three times daily ([MEDICATION NAME]), stop PRN (as needed) Tylenol. [MEDICATION NAME] 25 milligram daily for leg pain 10/13/10 [MEDICATION NAME] 25 milligrams orally three times daily for pain. 10/14/10 Discontinue [MEDICATION NAME] 10/14/10 Discontinue scheduled Tylenol 10/14/10 Arterial Doppler to legs, Magnetic resonance imaging (MRI) lumber-5 spine, pelvic x-ray 10/15/10 Venous Doppler to bilateral lower extremities Review of the resident's current Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED].M., 2:00 P.M., and 8:00 P.M.) three times daily (ordered 10/14/10) and [MEDICATION NAME] 5% applied to the left knee and back daily (ordered 9/23/10) Review of nursing notes dated 10/15/10 through 10/18/10 recorded the resident with moderate pain and staff administered scheduled pain medication. Nursing notes dated 10/19/10 timed 2:00 P.M. documented the resident was uncooperative with therapy, required assistance of two staff members for transfers and all cares. Nursing notes dated 10/20/10 timed 10:30 A.M. documented the resident as alert with confusion, able to make his/her needs known, complained of lower back and buttocks pain, had difficulty sitting straight up in the wheelchair and more difficulty working with physical therapy. During observation on 10/18/10 at 10:53 A.M., the resident lay in bed rubbing his/her left leg, moved his/her legs around on the bed and reported, "I have pain all the time." On 10/19/10 at 9:03 A.M., the resident lay in a recliner in his/her room, furrowed brow, grabbed and squeezed the surveyor ' s hand and tearfully whispered, "I am begging and begging for pain medication and they won't give me anything." On 10/20/10 at 8:30 A.M., direct care staff B pushed the resident down the hallway in a wheelchair as the resident grimaced, pushed up with the left arm on the wheelchair arm and lifted his/her left buttock out of the wheelchair seat and leaned to the right side. On 10/20/10 at 10:00 A.M., Licensed nursing staff B reported the resident was not eating orally now because of the pain and staff followed physician orders [REDACTED]. On 10/20/10 at 1:00 P.M., the resident reported when seated in the wheelchair or working with therapy, his/her pain level rated a "10" the worst and when in bed or in the recliner his/her pain level was tolerable at a "4-5" on a scale of 0-10. The resident described the pressure of sitting resulted in pain in his/her buttocks. The resident continued that he/she lacked the means to stay at the facility if he/she was unable to continue with the therapy because of the intolerable pain and begged the surveyor to help with the pain not to forget about him/her. An interview on 10/19/10 at 2:40 P.M. with Licensed Nursing Staff B revealed the resident had a lot of pain, medications and treatments had changed and all the x-rays and tests failed to reveal a cause for the resident's continued pain. Review of a physician's progress note dated 10/14/10 documented the resident with low back pain that was impairing his/her ability to participate in therapy. Review of the resident's active clinical record lacked a radiology report for the MRI Lumbar-5 spine ordered by the physician on 10/14/10. An interview with Licensed Nursing Staff B on 10/20/10 at 1:00 P.M. revealed the MRI Lumbar-5 spine ordered by the physician on 10/14/10 was not done and the facility scheduled to do the testing reported waiting on precertification from insurance. Licensed Nursing Staff B acknowledged that the primary physician saw the resident on 10/14/10 and reported that the staff would notify the physician about the resident's continued pain and delayed testing when the physician made rounds on 10/21/10. The clinical record lacked documentation of any notification of the physician for the resident's continued debilitating pain. The clinical record lacked any documentation regarding the delay for the physician ordered MRI. An interview with Administrative Staff B on 10/20/10 at 11:50 A.M. revealed the resident expressed the desire to return home, lacked motivation to work with therapy and when staff transferred the resident to the bed or recliner ceased the complaints of pain. Review of the therapy progress note dated 10/14/10, recorded the resident with a pain rating of 8 (on a scale of 0-10 with zero as no pain), unbearable located in low back, left hip going down to the left knee and the resident described the pain as "achy, then shooting at times and frequently the pain is constant". Review of the facility provided policy for Pain Management dated 8/28/06 directed "The intent of this requirement is that the facility assists each resident with pain management maintain or achieve the highest practicable level of well-being and functionally by: -Screening to determine if the resident is or has been experiencing pain -Performing a comprehensive pain assessment -Identifying circumstances when pain can be anticipated -Developing and implementing a plan using pharmacological approach and/or preventing the pain consistent with the resident's goals. The policy directs the purpose was to "identify, assess, treat, and effectively manage the pain of residents a Villa Saint Joseph and recorded that assessment was the first key to treating pain." The facility failed to assess the effectiveness of scheduled pain medication, failed to evaluate interventions for pain management and failed to ensure an ongoing program for assessments of pain. The facility further failed to provide the necessary care and services to ensure that this resident identified with pain, admitted for skilled services could participate in therapy and reach the highest practicable physical level and mental well-being. This deficient practice also affected resident #124, a cognitively dependent resident that reported the complaint of pain to nursing staff and staff failed to administer any medication as ordered when requested by the resident.