Every finding on record at Lansing Care and Rehab

The facility documented a census of 52 residents. The sample included three residents. Based on observation, record review and interview, the facility failed to ensure a safe environment free from preventable accidents when staff turned cognitively impaired Resident (R) 1 and her wheelchair into her bed on 02/01/26, causing R1 to hit her left knee on the bed frame and R1 cried out in pain that staff broke her knee. The direct care staff decided to hug transfer R1 to bed without help from another direct care staff and R1 screamed they broke my [expletive] knee. R1 was dependent on staff for transfers and mobility in her wheelchair. The direct care staff informed the Nurse on 02/01/26 of the increased pain to R1's left lower extremity. On 02/03/26 the staff reported the bruising and an x-ray revealed R1 had an oblique fracture (a type of bone break where the fracture line runs at an angle, and are often caused by rotational force or sudden, direct force when the bone is hit from an angle) to her proximal tibia (the upper, wider end of the shinbone) and proximal fibula (the upper end of the bone located on the outer side of the lower leg), which was not present on R1's 10/20/25 left knee x-ray. The deficient practice caused R1 to have increased pain and discomfort, not fully addressed for two days (once bruising appeared), for a potentially pre-existing leg fracture for dependent resident R1.Findings included:- R1's Electronic Medical Record (EMR) documented diagnoses of unspecified dementia (progressive mental disorder characterized by failing memory, confusion), generalized muscle weakness, need for assistance with personal care, history of falling, and other reduced mobilitThe Quarterly Minimum Data Set (MDS) dated [DATE], documented R1 had a Brief Interview for Mental Status (BIMS) score of four which indicated severe cognitive impairment. The MDS documented R1 used a wheelchair and was dependent on staff to wheel at least 50 feet and make two turns. The MDS documented R1 had substantial to maximal assistance from staff for tub or shower transfers, toilet transfers, lying to sitting on side of bed, transition from sit to lying position, bed mobility, dressing, and personal hygiene. The MDS documented R1 was dependent on staff for toileting hygiene, showers and bathing, moving from seated to standing position, and chair to bed transfers.The Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) dated 09/21/25, documented R1 admitted to the facility for rehabilitation after a fall. The CAA documented R1 was alert with moderate episodes of confusion. The CAA documented R1 required staff assistance of one with Activities of Daily Living (ADL) but due to R1's advanced dementia, two staff provided care most of the time.R1's 09/22/25 Care Plan documented R1 had impaired cognitive function, dementia or impaired thought processes related to dementia. The Care Plan documented R1 required supervision and assistance with all decision making.R1's 09/17/25 Care Plan documented R1 had ADL self-care performance deficit related to fatigue, and impaired balance. The Care Plan documented the following interventions:09/17/25 - R1 required two staff participation to reposition and turn in bed.09/17/25 - R1 required skin inspection as ordered. The intervention directed staff to observe for redness, open areas, scratches, cuts, bruises and report changes to the nursA Nursing Progress Note dated 10/19/25 at 06:29 PM, documented R1's left knee appeared swollen. The note documented that R1's leg was not red or hot to touch. The note further documented R1 did complain of pain to the knee when bearing weight. The note documented NP was notified and staff received an order for a Medrol (medication used to treat various acute inflammation, and severe arthritis) dose pack and to obtain an x-ray.A Patient Report dated 10/20/25, documented the results of an x-ray which indicated no fracture to R1's left knee.A Nursing Progress Note entered by Licensed Nurse (LN) G was marked as a late entry, had an effective date of 02/01/26 at 09:00 PM and a created date of 02/04/26 at 10:22 AM. The note documented R1 refused all medication at that time, including pain medication. The note documented R1 stated she did not need it. The note documented that LN G educated R1 that her pain could increase if pain medication was not taken and encouraged R1 to take the medication. The note further documented R1 continued to refuse and stated if she was in pain in the morning she would take it.A Patient Report dated 02/03/26, documented the results of an x-ray of R1's left knee. The report documented R1 had an oblique fracture deformity of the proximal tibia and proximal fibula present. The report documented R1 had soft tissue swelling. The report documented R1 had age-indeterminate fractures involving the tibia and fibula proximalA Nursing Note dated 02/03/26, documented the facility received R1's x-ray results and sent the results to the NP. The note documented new orders for R1 for a lidocaine patch 4% (used to treat localized pain) applied daily and removed at night. The note further documented orders to immobilize R1's leg, change R1 to non-weight bearing, and directed staff to make a STAT (immediately) follow up appointment with orthopedic.A Nursing Progress Note dated 02/04/26 at 10:40 AM, documented the nurse contacted the nurse practitioner (NP) in relation to R1's increased pain to her bilateral lower extremity (BLE). The note documented an order to increase Tramadol (medication used to treat moderate to moderately severe pain) from 25 milligrams (mg) three times a day to Tramadol 50 mg three times a day for R1.A document from an orthopedic clinic with a handwritten date of 02/05/26, documented R1's reason for visit was left knee pain. The document recorded under findings R1's x-ray showed a nondisplaced (a fracture where the bones remain properly aligned and have not moved out of their normal position) tibial metaphysis (the narrow, neck-like region of a long bone) fracture with proximal fibula fracture. The document recorded under recommendations: pain control, ice and elevate left lower extremity, non-weight bearing left lower extremity, apply hinged knee brace with brace locked in extension, physical and occupation therapy, and follow up outpatient in two weeks for repeat x-ray.A Progress Notes entry dated 02/05/26 at 07:00 AM, documented R1 reported persistent left knee pain with inability to bear weight and significant limitation in mobility. The note documented the pain began several days prior and R1 had required ongoing analgesia. R1 continued to need staff assistance for repositioning of the left leg due to pain. The note further documented R1 was evaluated by orthopedics on 02/05/26 for further management of R1's known fracture. The note documented R1 had a fracture of the proximal left tibia and fibula, that was age indeterminate and confirmed on X-ray. The note further documented the fracture was likely contributing to acute pain and immobility. The note documented R1 had increased fracture risk given osteopenia (loss of bone density which weakens the bone) and osteoporosis (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk).A Nursing Progress Note dated 02/05/26, documented R1 arrived back from her orthopedic appointment for left knee due to pain and swelling. The note further documented the progress note received recorded the x-ray showed a nondisplaced metaphysis fracture with proximal fibula fracture.An investigation document provided by the facility, dated 02/06/26 with a CP number of 2735200, documented R1 admitted on [DATE] and had dementia and osteoarthritis (degenerative joint disease, primarily causing cartilage to break down, resulting in pain, swelling, and reduced mobility). The investigation documented R1 complained of increased pain to BLE on 02/03/26. The investigation further documented nursing assessed R1 and noted a slight darkening of the skin below R1's left knee, with resident responding with indications of pain to touch, equally on both extremities. The investigation documented an order for an x-ray with results of an oblique fracture, unable to determine age. The investigation documented Administrative Nurse E reported the location of the bruising was consistent with the height of R1's shins when R1 wheeled up to her bed. The investigation noted Administrative Nurse D reported she received a call from the orthopedic office and informed that the fracture was believed to be preexisting, not new in nature, and likely occurred as a result of a fall prior to the resident's admission to the facility.A notarized witness statement, dated 02/04/26, for LN H documented on 02/03/26 at approximately 08:00 AM she was notified by a Certified Nurse Aide (CNA) of a bruise to R1's lower leg. The statement documented LN H assessed R1 and observed bruising below R1's left knee. The witness statement further documented facial grimacing and yelling was observed upon palpation of R1's lower leg. LN H documented that she notified the NP in the facility about the bruise and increased pain. LN H's witness statement documented a verbal order was received from the NP for an x-ray of R1's left knee due to increased pain.A notarized witness statement, dated 02/06/26, for Administrative Nurse E documented R1's bed was at a consistent height with R1's shins when R1 wheeled up to her bed.A notarized witness statement, dated 02/06/26, for Administrative Nurse D documented R1 attended an ortho appointment in regard to the bruise to her LLE and follow up x-ray indicating a fracture. Administrative Nurse D's witness statement documented she received a phone call from the ortho office requesting further medical information and current medications. Administrative Nurse D documented during the discussion with the medical staff, she was informed they felt the fracture occurred during R1's fall just previous to her original admission to the hospital and the facility. Administrative Nurse D documented the ortho clinic staff did not feel the fracture was new. Administrative Nurse D further documented she was told a written explanation would be faxed to the facility in a few days. Administrative Nurse D further documented she spoke to the ortho clinic staff about pain control and a leg brace for R1 to wear for two weeks. Treatment plan would be reassessed at a follow up appointment.A notarized witness statement, dated 02/06/26, for CNA M documented she and CNA N were putting R1 into bed. CNA M documented R1 was resistant and hitting so they decided to arm and arm R1 while getting her in bed. CNA M documented the way R1's wheelchair was positioned; they could not get R1 in bed. CNA M documented CNA N swung R1's wheelchair toward R1's bed frame to turn her. She documented, while CNA N was turning the wheelchair, R1's left leg was stuck behind her right leg, and R1 hit her left knee on the bed frame. CNA M documented she told CNA N to hold on and they pulled R1 out and they repositioned R1's wheelchair into a better spot. CNA M documented CNA N decided to hug R1 and put R1 in bed without CNA M's help. CNA M documented R1 cried out after that they broke her [expletive] knee. CNA M documented they let the nurse know R1 had cried out in pain.On 02/16/26 at 05:15 PM R1 sat in a wheelchair, at a table in the dining room, eating dinner. R1's left leg was elevated out in front of her, in the wheelchair, and had a leg brace on her left leg.On 02/16/26 at 03:05 PM Administrative Nurse D stated R1 was sent out to an ortho (orthopedic/bone specialist) appointment due to the fracture. Administrative Nurse D stated she spoke to the nurse at the ortho clinic and was told the doctor felt it was an old fracture that had not healed well. She stated they recommended a brace for two weeks and R1 would follow up. She stated the facility was supposed to get a more detailed note saying as such, but the facility had not received it at this time. She stated one of the CNAs did come to report to her R1 hit her leg on the bed frame. She stated the CNAs did report to her about R1 bumping her leg after, and she told them to make sure to report instances like that in the future when they happen. Administrative Nurse D said she believed the oblique fracture was from twisting and said she thought it would have lined up more with R1's previous fall as well as the doctor reporting it may have been an older fracture. She stated R1 did have a fall prior to admission to the facility. She stated R1 has had pain in her legs since arriving in the facility. Administrative Nurse D further stated R1 reported pain in both legs when she went in to assess her and touched each one of them. She stated R1 did have some swelling in her legs and could not communicate well enough to say what was happening in detail.On 02/16/26 at 03:25 PM CNA M stated she was working with another CNA to help put R1 to bed on 02/01/26. She stated R1 was fighting with staff, she had CNA N come assist. She stated CNA N was usually good about calming R1 down when she was upset. CNA M stated R1 would not go for the attempt to calm her down, so they decided to try and move R1 into the bed. CNA M stated R1's wheelchair was in a weird position, so CNA N went to pull R1's wheelchair around and R1's knee bumped into the bed. CNA M stated R1's left leg was behind her right leg. CNA M demonstrated the seated position. CNA M's left foot and lower shin were placed at an angle behind her right lower leg. Her left knee leaned to the left side of her body. Her right foot was placed on the floor with her right knee pointing forward. This position placed CNA M 's left leg at an angle. As CNA M demonstrated the leg placement, she stated that was how R1's legs were placed when R1's left knee hit the bed. CNA M stated when R1's knee hit the bed, R1 screamed and hollered that staff broke her knee. She stated R1 yelled and cussed but did not scream out in pain until after she had hit her knee. CNA M stated it did not seem like R1 hit the bed very hard, and she stated there did not appear to be any ill intent from the staff. She stated R1's bed frame lined up with the area she had the bruise in. CNA M stated R1 had complained of pain in her legs before and her saying she had pain was not anything new for her. CNA M stated they told the nurse about R1's leg bumping into the bed and her reported pain. She stated R1 required staff assistance to propel in her wheelchair. She stated she has never known R1 to get around in her wheelchair on her own and has always required staff assistance to do so.On 02/16/26 at 05:39 PM LN G stated she was told on the morning of 02/02/26 that R1 had bumped her leg on the bed frame while staff attempted to assist her to bed. LN G stated the CNA she worked with that day had told her what had happened. LN G stated she went down to assess R1 and did not see any redness, or bruising at that time. LN G stated R1 was normally in pain but did not seem to be in any more pain than normal when she assessed her. Stated R1 does have a history of refusing pain medications 2-3 times per week. She stated nothing stood out as R1 being in worse condition when she saw her and thought R1 was at her baseline. LN G stated R1 was dependent on staff to get around in her wheelchair. She stated R1 could maybe move a couple of feet on her own, but could not move very far, in general, without staff assistance. She said she had witnessed R1 trying to pull or push herself from the dining room table, but she had never seen R1 try to get herself into bed or attempt to self-transfer. She stated she was unaware if R1 had received any x-rays in the past while in the facility related to her leg pain.On 02/16/26 at 06:11 PM conducted joint interview with Administrative Staff A, Administrative Nurse D, and Administrative Nurse E. Administrative Nurse E stated R1 had received an order for an x-ray for her left knee on 10/19/25. She stated there was no evidence of a fracture found in the results of that x-ray. Administrative Nurse E stated the recent x-ray did mention R1 had some demineralization and osteopenia. Administrative Nurse D stated the ortho doctor had stated the fracture likely may not have shown in the x-ray ordered on 10/19/25. The three stated R1 did not have increased pain but did have some bruising show up later. They stated the bruising was why they decided to get an order for the x-ray and not for increased pain. Administrative Nurse D stated she worked one night shift, after the resident's knee was bumped on the bed frame, from 02:00 AM to 06:00 AM and R1 did not report increased pain at that time. Administrative Nurse D stated since it was an oblique fracture, there was no way it was caused by R1 bumping her leg on the bed frame. She stated that was another reason why the facility believed it was an old fracture as well. Administrative Nurse D stated LN H found the bruising on 02/03/26 and that was when they decided to get an order for the x-ray. They stated they were waiting for a detailed report from the ortho doctor, but they did not have it at this time.On 02/18/26 at 03:55 PM, Administrative Nurse D provided an Orthopedic Clinic Note for R1 with an encounter date of 02/05/26. The note documented R1 presented to the clinic for evaluation of left knee pain. The note documented, under the plan section, the provider attempted to have a discussion with R1regarding her left knee pain, her x-ray findings, and her history. The note documented R1 seemed confused and was unclear whether this was her baseline or not. The note further documented the facility was contacted for further history, and although the exact mechanism and timing of the fracture was unclear, there were some acute findings visualized on the x-rays from 02/03/26 and the x-rays obtained today (02/05/26). The note documented the acute findings included well-defined fracture lines and notably absent evidence of healing. The note documented based on this, the clinic would treat the fracture as acute (a sudden broken or cracked bone resulting from a specific, immediate injury) versus subacute (a bone injury in the process of healing, typically occurring roughly five days to several weeks after the initial trauma). The facility's F 689 Accidents policy with an effective date of 10/2025, documented the facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Our resident-oriented approach to safety addresses safety and accident hazards for individual residents. The facility-oriented and resident-oriented approaches to safety are used together to implement a systems approach to safety, which considers the hazards identified in the environment and individual resident risk factors, and then adjusts interventions accordingly.

The facility identified a census of 58 residents. The facility identified nine residents 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) and one resident on contact precautions (safeguards designed to reduce the risk of transmission of microorganisms by direct or indirect contact). Based on observations, interviews, and record review, the facility failed to ensure Resident (R) 62's continuous positive airway pressure (CPAP- ventilation device that blows a gentle stream of air into the nose to keep the airway open during sleep) mask was stored in a sanitary manner, and further failed to develop, implement, and maintain a water management program to reduce the risk of Legionella (Legionella is a bacterium which can cause pneumonia in vulnerable populations) and other waterborne pathogens. Findings included:- On 09/22/25 at 08:13 AM, R62 sat in her recliner, waiting for breakfast. R62's unbagged CPAP mask rested directly on her bedside table. There was no bag visible for storing the CPAP mask. R62 stated the mask was usually not stored in a bag and normally laid on her bedside table. She stated she did not have a bag for her CPAP mask. On 09/22/25 at 02:10 PM, Administrative Staff A brought a binder with printed directions on monitoring for Legionella. The notebook contained documentation of Legionella testing, the last test completed on 06/2025, and information provided by the Centers for Medicare & Medicaid Services (CMS) on how to track Legionella. The documentation was not specific to the facility. The facility lacked documentation of a risk assessment and evidence of monitoring to identify potential sources of Legionella growth. On 09/24/25 at 11:36 AM, Certified Medication Aide (CMA) R stated that the respiratory mask should be in a dated bag. She stated that the night shift ensured there was a bag in the room, and the day shift ensured the respiratory mask was placed in the bag when not in use.On 09/24/25 at 11:45 AM, Licensed Nurse (LN) G stated that the night shift changes out the bags on Sundays, and any staff member can put the respiratory mask in the bag when they find the mask unbagged. On 09/24/25 at 11:55 AM, Administrative Nurse D stated all respiratory equipment should be placed in a dated bag if the mask was not in use. On 09/24/25 at 12:09 PM, Maintenance U stated he did not have a diagram or text to flow. He stated the rooms are usually full. He stated that housekeeping cleans the rooms even if the resident did not use the restroom. He stated the only control measure he knew of was the testing that was done on 06/2025. The facility's Cleaning, Disinfection, Testing, or Resident Care Items and Equipment policy, revised 11/2024, documents residents' care equipment, including reusable items and durable medical equipment, would be cleaned and disinfected according to Centers for Disease Control and Prevention (CDC) standards.The facility's Water Management, Legionella Testing policy, revised 10/2022, documented that the facility handled and maintained water supply in accordance with recommendations of the Centers for Disease Control and Prevention (CDC), the Healthcare Advisory Committee, and the Food and Drug Administration (FDA). The community would demonstrate measures to minimize their risk of Legionella and other opportunistic pathogens in the building water system through a documented water management program.

The facility identified a census of 58 residents. The sample included 16 residents, with one medication room, three medication carts, and two treatment carts. Based on observation, interviews, and record review, the facility failed to appropriately store medications and biologicals when staff failed to ensure the medication carts were always locked when the cart was not within the nurses' line of sight. Findings included:- On 09/22/25 at 07:33 AM, the treatment cart containing residents' treatment supplies, as-needed (PRN) creams, and insulin (hormone medication used to lower blood glucose) pens was unlocked. The cart was in the 200 Hall, and the Administrative Nurse E locked the medication cart. On 09/24/25 at 11:45 AM, Licensed Nurse (LN) G stated that medication carts and treatment carts should be locked if the staff have stepped away and were out of their visual sight. On 09/24/25 at 11:55 AM, Administrative Nurse D stated that medication carts and treatment carts should be locked if the LN or Certified Medication Aide (CMA) could not see the cart.The facility's Storage of Medication policy, revised 10/2024, documented that the facility would store all drugs and biologicals in a safe, secure, and orderly manner.

The facility identified a census of 58 residents. The sample included 16 residents, with three reviewed for dignity and respect. Based on observation, record review, and interviews, the facility failed to provide a dignified care environment for Residents (R) 21 and R18. Findings Included:- R21's Electronic Medical Records (EMR) included diagnoses of quadriplegia (inability to move the arms, legs, and trunk of the body below the level of an associated injury to the spinal cord), type two diabetes mellitus (DM- when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and major depressive disorder (major mood disorder). R21's Quarterly Minimum Data Set (MDS) completed 08/19/25 indicated a Brief interview for Mental Status (BIMS) score of 15 (intact cognition). The MDS noted bilateral upper or lower extremity impairments. The MDS noted she used a wheelchair for mobility. The MDS noted she was dependent on staff assistance with toileting, bathing, transfers, bed mobility, personal hygiene, and dressing. The MDS noted no behavioral concerns. R21's Functional Abilities Care Area Assessment (CAA) completed 05/28/25 indicated she required total staff dependence for her activities of daily living (ADL). The CAA noted she was at risk for falls, skin breakdown, impaired nutrition, and pain related to her medical diagnoses. The CAA noted that a care plan was implemented to minimize her risks. R21's Care Plan initiated 06/24/24 indicated she required staff assistance with her ADLs. The plan noted she needed substantial to maximal assistance with bathing, toileting, dressing, personal hygiene, and transfers. The plan indicated she required at least two staff members in her room for any interactions due to the potential for false statements by other staff. The plan noted she had a history of making allegations towards staff (09/27/24). The Facility Incident Report #1090 completed on 09/23/25 indicated Certified Nurse's Aide (CNA) N entered R21's room on 09/18/25. The report indicated R21 asked CNA N why he was in her room. R21 stated in the report, CNA N replied, It's none of your fucking business. The report indicated CNA N was immediately suspended (pending investigation). The report indicated R10 (R21's roommate) witnessed the incident but denied that CNA N used abusive language. The report indicated that CNA N admitted to saying, it's none of your business upon talking to both residents. The report indicated CNA N was provided training related to resident rights, communication, and abuse prevention. On 09/24/25 at 11:36 AM, Certified Medication Aide (CMA) R stated that staff were expected to knock and introduce themselves before entering the resident's rooms. CMA R stated staff should never just enter a room without the resident's permission. She stated that staff were to always speak in a respectful manner. On 09/24/25 at 12:36 PM, Administrative Nurse D stated that staff were expected to always be respectful and provide care that promoted dignity to all residents. She stated that all staff are trained on dementia care, resident rights, and abuse. The facility's Resident Rights policy, revised 10/2022, indicated the facility was to ensure all residents were treated in a dignified manner. The policy indicated the facility was to provide ongoing education and In-service. - R18's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of hypertension (HTN- elevated blood pressure), hyperlipidemia (condition of elevated blood lipid levels), 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), fracture of left pubic ramus fracture (a break or crack in the pelvis bones), diabetes mellitus (DM- when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), dysphagia (swallowing difficulty), and aphasia (condition with disordered or absent language function). The Quarterly 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 that R18 was rarely or never understood. The MDS documented R18 was dependent on all activities of daily living (ADL) except eating. R18 needed substantial to maximal assistance from staff. R18's Nutritional Status Care Area Assessment (CAA) dated 12/12/24 documented R18 was a long-term guest at the facility. The CAA documented R18 had diagnoses of stroke, DM, aphasia, and HTN. The CAA documented R18 was alert to himself and did not speak much, and would sometimes answer yes or no to the appropriate question. The CAA documented R18 was incontinent of bowel and bladder. The CAA documented R18 was dependent on staff for all ADLs and utilized a staff-propelled Broda chair (specialized wheelchair with the ability to tilt and recline) for locomotion. The CAA documented R18 had contractures (abnormal permanent fixation of a joint or muscle) in his bilateral lower extremities, and does not participate in facility activities, nor does he socialize with anyone. The CAA documented R18 would sleep most of the day, and he had a fall during the lookback period without injury. R18's Care Plan was revised on 09/15/25. R18's plan of care had nutritional risks related to swallowing difficulty and self-feeding difficulty. R18's plan of care documented that the staff were to provide adaptive equipment. R18's plan of care documented staff would utilize a plate guard or divided plate and built-up silverware during mealtimes as needed. The plan of care for R18 documented staff would provide set-up and assistance with meals and snacks. The plan of care for R18 documented R18's abilities would vary regarding his feeding himself; staff were to put food on his spoon, and he would generally feed himself. The plan of care for R18 documented that the staff were to give encouragement to R18, and he would feed himself. On 09/22/25 at 08:33 AM, R18 sat at the breakfast table with his peers. Certified Nurse's Aide (CNA) E stood over R18 and gave him a spoonful of his ground meat. R18's bare abdomen and right side were visible to his peers. On 09/23/25 at 08:47 PM, R18 sat at the breakfast table with his peers. Administrative Staff F stood over R18, feeding him his breakfast. On 09/24/25 at 11:36 AM, CNA R stated staff should sit by the resident and never tower over a resident when assisting the resident with eating. She stated that residents' skin should be covered when the residents were in the dining area. On 09/24/25 at 11:45 AM, Licensed Nurse G stated staff should sit by the resident, converse with the resident, offer the resident drinks between bites, but never stand to assist a resident with eating. She stated all residents should have their skin covered when in the dining room. On 09/24/25 at 11:55 AM, Administrative Nurse D stated that staff should sit by the resident, never stand while assisting the resident with eating. She stated that a resident's abdomen should be covered while in the dining room. The facility's Respect and Dignity policy, revised 10/2022, documented that residents have the right to be treated with respect and dignity, including the right to retain and use personal possessions, including furnishing and clothing, as space permits, unless to do so would infringe upon the rights and safety of other residents. Residents' possessions, regardless of their apparent value to others, would be treated with respect.

The facility identified a census of 58 residents. The sample included 16 residents, with two reviewed for abuse and neglect. Based on observation, interview, and record review, the facility failed to prevent staff-to-resident verbal and emotional abuse of Resident (R) 44. Findings Included:- R44's Electronic Medical Records (EMR) included diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), muscle weakness, repeated falls, and the need for assistance with personal care. R44's Quarterly Minimum Data Set (MDS) completed 06/14/25 indicated a Brief interview for Mental Status (BIMS) score of zero (severe cognitive impairment). The MDS noted bilateral upper or lower extremity impairments. The MDS noted she used a wheelchair for mobility. The MDS noted she was dependent on staff assistance for toileting, bathing, transfers, bed mobility, personal hygiene, and dressing. The MDS noted no behavioral concerns. R44's Functional Abilities Care Area Assessment (CAA) completed 12/21/24 indicated she required staff assistance to complete her activities of daily living (ADL). The CAA noted she could verbalize her needs and answer yes and no questions. The CAA noted she displayed behaviors of yelling out and withdrawing from social activities. The CAA noted that a care plan was implemented to minimize risks.R44's Care Plan initiated 09/24/24 indicated she required staff assistance with her ADLs. The plan noted she was dependent on staff assistance with bed mobility, bathing, toileting, dressing, personal hygiene, and transfers. The plan indicated R44 was dependent on staff for activities, cognitive stimulation, and social interactions. The plan instructed staff to provide activities that were compatible with her mental and physical capabilities. The plan instructed staff to provide structured daily routines and familiarity. The plan instructed staff to provide positive feedback and emphasize her positive behavior aspects. The Facility Incident Report #8280 completed on 08/12/25 indicated Certified Nurse's Aide (CNA) O observed CNA P use abusive language towards R44. The report indicated that on 08/12/25, around 05:00 PM, CNA P told R44 Let go of the bear dummy, as she took R44's bear away from R44 against her wishes. The report indicated CNA P then told R44, You ripped it, dummy, after pulling it away from her. The report indicated that CNA O reported the incident, and CNA P was immediately suspended and terminated. The report indicated R44 was immediately assessed with no injury or change in mood. The report indicated R44's bear was her coping mechanism for calming down. On 09/23/25 at 09:45 AM, R44 sat in the day room area. She was clean and well-groomed. On 09/24/25 at 11:36 AM, Certified Medication Aide (CMA) R stated that staff were expected to treat all residents in a kind and respectful manner. She stated that staff were expected to work toward comforting and caring for the residents in their care. She stated the facility provided frequent training related to abuse, resident rights, and communication. On 09/24/25 at 12:36 PM, Administrative Nurse D stated that staff were expected to always be respectful and provide care that promoted dignity to all residents. She stated that all staff are trained on dementia care, resident rights, and abuse.The facility's Abuse, Neglect, and Exploitation policy, revised 08/2024, documented that the resident has a right to be free from verbal, sexual, physical, and mental abuse and involuntary seclusion. The policy indicated it was the responsibility of the facility to treat each resident with respect, kindness, dignity, and care, to keep them free from abuse and neglect, and to take swift action to investigate and adjudicate alleged resident abuse and neglect. Mental abuse includes, but is not limited to, verbal or non-verbal conduct which causes or has the potential to cause humiliation, intimidation, fear, shame, agitation, degradation, harassment, or threats of punishment or deprivation. The policy indicated that all staff were to be educated to identify, prevent, and intervene when potential abuse was identified. The facility identified, implemented, and completed the following corrective actions related to the incident:The facility screened all the affected residents on 08/12/25. The facility assessed R44 for psychosocial trauma from the incident on 08/12/25. CNA P was immediately suspended, terminated, and reported to the investigative agencies on 08/12/25. All staff were educated on Abuse, Neglect, and Exploitation on 08/30/25.The facility will monitor and provide ongoing education through the Quality Assurance and Performance Improvement program (QAPI) team. This deficient practice was deemed past non-compliance when the facility completed the corrective actions on 08/30/25, prior to the surveyor entering the facility.

The facility identified a census of 58 residents. The sample included 16 residents, with six residents reviewed for unnecessary medications. Based on observation, interviews, and record review, the facility failed to ensure an appropriate indication, or a documented physician rationale which included the multiple unsuccessful attempts for nonpharmacological symptom management and risk versus benefits for the continued use of an antipsychotic (class of medications used to treat mental disorder characterized by a gross impairment in reality testing) for Resident (R) 27, who had a diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion). Findings included:- R27's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of dementia, repeated falls, muscle weakness, and Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness). The Significant Change Minimum Data Set (MDS) dated 09/20/24 documented she had severely impaired cognition. The MDS documented R27 had received a diuretic (a medication to promote the formation and excretion of urine) medication, antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medication, antidepressant (a class of medications used to treat mood disorders) medication, and antianxiety (a class of medications that calm and relax people) medication during the observation period. The Quarterly MDS dated [DATE] documented she had severely impaired cognition. The MDS documented that R27 received antipsychotic medication and antidepressant medication during the observation period. R27's Psychotropic Drug Use Care Area Assessment (CAA) dated 10/08/25 documented she received antipsychotic medications. The plan of care documented R27's medication was reviewed monthly by the pharmacist, and the physician reviewed any recommendations made by the pharmacist. R27's Care Plan, dated 03/27/21, documented the nursing staff would administer her medications as ordered. R27's EMR under the Orders tab revealed the following physician orders:Haloperidol (antipsychotic) oral tablet 1 milligram (mg), give one tablet by mouth in the afternoon for auditory and visual hallucinations, dated 02/18/25. Seroquel (antipsychotic) oral tablet 50 mg (Quetiapine Fumarate), give 1.5 tablets by mouth two times a day for anxiousness, dated 05/29/25. The facility provided an unsigned Consent for Use of Psychoactive Medication Therapy form, which lacked the physician documentation for the physician's rationale, which included the multiple unsuccessful attempts for nonpharmacological symptom management and risk versus benefits for the continued use of an antipsychotic medication for R27, who had a diagnosis of dementia. The facility was unable to provide physician documentation upon request. On 09/23/25 at 11:11 AM, R27 sat in her wheelchair in her room. R27's eyes were closed. On 09/24/25 at 11:55 AM, Administrative Nurse D stated the facility had purchased the preprinted consent forms. Administrative Nurse D stated R27 was on hospice services, and the family wanted her to continue to receive the antipsychotic medication. The facility's Use of Psychotropic Drugs policy, last revised 04/2025, documented residents would only receive psychotropic or other approved medications that have an effect on brain activity when necessary to treat specific conditions for which they are indicated and effective, and would not be used for discipline or the convenience of the staff. Residents and/or their representative have the right to refuse such treatment.

The facility identified a census of 58 residents. The sample included 16 residents, with three residents reviewed for hospice. Based on observation, interviews, and record review, the facility failed to complete a significant change in the physical condition and complete a comprehensive Significant Change Minimum Data Set (MDS) for Resident (R) 22 with the addition of hospice services. Findings included:- R22's Electronic Medical Record (EMR) from the Diagnosis tab 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 is made, or the body cannot respond to the insulin), and gastroesophageal reflux (GERD- backflow of stomach contents to the esophagus). The Significant Change MDS initiated on 08/28/25 was not completed for R22's admission on to hospice services. R22 was admitted to hospice services on 08/15/25. R22's Care Area Assessment (CAA) was not completed in the 14 days required after the Significant Change MDS was started on 08/25/25. R22's Care Plan dated 08/28/25 documented the facility would consult with the physician and social services to have hospice care for R22 in the facility. The plan of care documented the hospice provider would provide nurse services two times a week and a certified nurse aide two times a week. R22's EMR lacked an order for admission for hospice services. The facility provided an order printed on the hospice provider's certification form dated 05/15/25. On 09/23/2025 at 02:56 PM, R22 propelled her wheelchair down the hallway from her room to the common area. On 09/24/25 at 09:54 AM, Administrative Nurse F stated she had not completed the Significant Change MDS related to R22's admission on to hospice services. Administrative Nurse F stated she was behind in completed the MDS because she provides care for the residents. On 09/24/25 at 11:55 AM, Administrative Nurse D stated Administrative Staff A and the corporate office staff in charge of MDS's were responsible to ensure the MDS were completed as required by Centers for Medicare & Medicaid Services (CMS). The facility was unable to provide a policy related to the required timing for MDS completion upon request on 09/24/25.

The facility identified a census of 58 residents. The sample included 16 residents. One resident was sampled for accidents and hazards. Based on observation, interviews, and record review, the facility failed to provide Resident (R) 18's fall interventions as directed by his care plan. Findings included:- R18's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of hypertension (HTN- high blood pressure), hyperlipidemia (condition of elevated blood lipid levels), 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), fracture of left pubic ramus fracture (a break or crack in the pelvis bones), diabetes mellitus (DM- when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), dysphagia (swallowing difficulty), and aphasia (condition with disordered or absent language function). The Quarterly 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 that R18 was rarely or never understood. The MDS documented R18 was dependent on all activities of daily living (ADL) except eating and needed substantial/maximal assistance from staff. The MDS documented R18 had no falls during the observation period.R18's Falls Care Area Assessment (CAA) dated 12/12/24 documented that R18 was alert to himself and did not speak much, and would sometimes answer yes or no to the appropriate question. The CAA documented R18 was incontinent of bowel and bladder. The CAA documented R18 was dependent on staff for all ADLs and utilized a staff-propelled Broda chair (specialized wheelchair with the ability to tilt and recline) for locomotion. The CAA documented R18 had contracture (abnormal permanent fixation of a joint or muscle) in his bilateral lower extremities, and did not participate in facility activities, nor did he socialize with anyone. The CAA documented R18 would sleep most of the day, and he had a fall during the lookback period without injury. R18's CAA documented he was at risk for further cognitive deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness) decline, decline in ADL function, isolation, depression, falls, fall-related injuries, weight loss/gain, impaired skin integrity, and unmanaged pain. The CAA for R18 documented staff would care plan R18's risks.R18's Care Plan dated 02/23/23 documented R18 was at risk for falls, due to gait/balance problems, incontinence, and unaware of safety needs. R18's plan of care dated 01/31/24 documented a larger bed was provided to provide more comfort and a larger surface area. The plan of care for R18 documented staff were to ensure the floor next to his bed was free from clutter and objects that may cause injury. R18's plan of care dated 04/29/25 documented staff would place additional pillows in R18's room to assist with more comfortable positioning. R18's plan of care dated 10/13/24 documented that the staff were to place R18's bed in the lowest position, and staff were to ensure a fall mat was in place, next to R18's bed. On 09/22/25 at 07:39 AM, R18 laid in bed on his back. R18's pancake call light laid at the bottom of his bed. R18's call light was out of his reach.On 09/23/25 at 09:37 AM, R18 laid in his bed, which was at the lowest position. R18's floor mat was folded up next to his Broda chair. R18's fall mat was not next to his bed. On 09/24/25 at 11:36 AM, Certified Medication Aide (CMA) R stated that call lights were placed within reach of the residents, and mats should be applied to the floor when the residents were laid down after breakfast.On 09/24/25 at 11:45 AM, Licensed Nurse (LN) G stated that call lights should be placed where the resident can reach them. She stated if a resident needed a floor mat, it should be placed beside the bed. On 09/24/25 at 11:55 AM, Administrative Nurse D stated that call lights should be within the reach of the resident, and the fall mats should be placed by the bed as ordered. The facility's Accidents policy, revised 08/22, documented the facility strived to make the environment as free from accident hazards as possible. Resident safety, supervision, and assistance to prevent accidents were facility-wide priorities.

The facility identified a census of 58 residents. The sample included 16 residents, with six residents reviewed for unnecessary medications. Based on observation, interviews, and record review, the facility failed to ensure the Consultant Pharmacist (CP) had identified and reported irregularities for Resident (R) 22. Findings included:- R22's Electronic Medical Record (EMR) from the Diagnosis tab 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 is made, or the body cannot respond to the insulin), and gastroesophageal reflux (GERD- backflow of stomach contents to the esophagus). The Annual Minimum Data Set (MDS) dated 12/21/24 documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS documented R22 had received insulin (medication to regulate blood sugar), a diuretic (a medication to promote the formation and excretion of urine), and an antidepressant (a class of medications used to treat mood disorders) during the observation period. The Quarterly MDS dated [DATE] documented a BIMS score of 15, which indicated intact cognition. The MDS documented that R22 had received insulin, diuretic medication, and antidepressant medication during the observation period. R22's Psychotropic Drug Use Care Area Assessment (CAA) dated 01/07/25 documented she had received antidepressant medication for mood management. R22's medication would be followed by the pharmacist monthly, and the recommendations would be reviewed by the physician for further review. R22's Care Plan dated 01/23/24 documented the facility would administer her medication as ordered by the physician. The plan of care documented the facility would monitor R22 for side effects and document the effectiveness. R22's EMR under the Orders tab revealed the following physician orders:Reglan (antiemetic-prevents vomiting) tablet, five milligrams (mg) (Metoclopramide HCl), give one tablet by mouth before meals for nausea, dated 08/15/25. Review of the Monthly Medication Review (MMR) from August 2025 and September 2025 lacked documentation of the recommendations for an Abnormal Involuntary Movement Scale (AIMS) test to monitor for adverse effects from Reglan. The facility was unable to provide an AIMS test upon request. On 09/23/25 at 02:56 PM, R22 propelled her wheelchair down the hallway from her room to the common area. On 09/24/25 at 11:45 AM, Licensed Nurse (LN) G stated the administrative nurse would take care of the MMRs. LN G stated she did complete AIMS testing for the residents. LN G stated a User-Defined Assessment (UDA) would pop up in the resident's EMR when that assessment was due. On 09/24/25 at 11:55 AM, Administrative Nurse D stated the CP would email the MMRs to her and the unit manager monthly. Administrative Nurse D stated the CP should have identified R22's lack of an AIMS test. Administrative Nurse D stated she had notified the CP that R22 should have had an AIMS test completed related to the medication Reglan. Administrative Nurse D stated she had notified their corporate office to initiate a UDA to trigger to be completed as needed. The facility's Consultant Pharmacist Services policy last revised 06/01/24 documented the facility would provide the pharmacy with adequate workspace, access to the residents' complete medical records (including electronic health records, if used), ability to enter documentation/progress notes in the resident's medical record (including electronic health records) when deemed as an expectation by facility, an appropriate environment for resident and family interviews, and important resident information.

The facility identified a census of 58 residents. The sample included 16 residents, with six residents reviewed for unnecessary medications. Based on observation, interviews, and record review, the facility failed to ensure an Abnormal Involuntary Movement Scale (AIMS) test to monitor for adverse effects from the medication Reglan (antiemetic-prevents vomiting) for Resident (R) 22. Findings included:- R22's Electronic Medical Record (EMR) from the Diagnosis tab 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 is made, or the body cannot respond to the insulin), and gastroesophageal reflux (GERD- backflow of stomach contents to the esophagus). The Annual Minimum Data Set (MDS) dated 12/21/24 documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS documented R22 had received insulin (medication to regulate blood sugar), a diuretic (a medication to promote the formation and excretion of urine), and an antidepressant (a class of medications used to treat mood disorders) during the observation period. The Quarterly MDS dated [DATE] documented a BIMS score of 15, which indicated intact cognition. The MDS documented that R22 had received insulin, diuretic medication, and antidepressant medication during the observation period. R22's Psychotropic Drug Use Care Area Assessment (CAA) dated 01/07/25 documented she had received antidepressant medication for mood management. R22's medication would be followed by the pharmacist monthly, and the recommendations would be reviewed by the physician for further review. R22's Care Plan dated 01/23/24 documented the facility would administer her medication as ordered by the physician. The plan of care documented the facility would monitor R22 for side effects and document the effectiveness. R22's EMR under the Orders tab revealed the following physician orders:Reglan (antiemetic) tablet, five milligrams (mg) (Metoclopramide HCl), give one tablet by mouth before meals for nausea, dated 08/15/25. The facility was unable to provide an AIMS test or any other method of monitoring for side effects upon request. On 09/23/2025 at 02:56 PM, R22 propelled her wheelchair down the hallway from her room to the common area. On 09/24/25 at 11:45 AM, Licensed Nurse (LN) G stated the administrative nurse would take care of the MMRs. LN G stated she did complete AIMS testing for the residents. LN G stated a User-Defined Assessment (UDA) would pop up in the resident's EMR when that assessment was due. On 09/24/25 at 11:55 AM, Administrative Nurse D stated she had notified their corporate office to initiate a UDA to trigger to be completed as needed. Administrative Nurse D stated the AIMS test did not trigger for R22's Reglan because it did not fall under the psychotropic medication class. The facility was unable to provide a policy related to monitoring medication side effects upon request on 09/24/25.

The facility identified a census of 58 residents. The sample included 16 residents, with three residents reviewed for hospice services. Based on observation, interviews, and record review, the facility failed to provide a description of the medication and equipment provided to Resident (R) 22 by hospice. Findings included:- R22's Electronic Medical Record (EMR) from the Diagnosis tab 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 is made, or the body cannot respond to the insulin), and gastroesophageal reflux (GERD- backflow of stomach contents to the esophagus).The Significant Change Minimum Data Set (MDS) initiated on 08/28/25 was not completed for R22's admission into hospice services. R22 was admitted to hospice services on 08/15/25.R22's Care Area Assessment (CAA) was not completed in the 14 days required after the Significant Change MDS was started on 08/25/25. R22's Care Plan dated 08/28/25 documented the facility would consult with the physician and social services to have hospice care for R22 in the facility. The plan of care documented the hospice provider would provide nurse services two times a week and a certified nurse aide two times a week. The plan of care lacked the equipment provided by the hospice services and the medication that would be covered by the hospice services.R22's EMR lacked an order for admission for hospice services. The facility provided an order printed on the hospice provider's certification form dated 05/15/25.On 09/23/25 at 02:56 PM, R22 propelled her wheelchair down the hallway from her room to the common area.On 09/24/25 at 11:37 AM, Certified Medication Aide (CMA) R stated everyone had access to the resident's care plans and their Kardex (nursing tool that gives a brief overview of the care needs of each resident). CMA R stated the staff would refer to the residents' care plan or their Kardex to find out if the resident was on hospice services. CMA R stated the care plan or Kardex should have what the hospice provided for the resident.On 09/24/25 at 11:45 AM, Licensed Nurse (LN) G stated all the staff had access to the resident's care plans and their Kardex. LN G stated hospice information could be found on the care plan and Kardex. LN G stated the resident's care plan should have the hospice information, which included the equipment, medications, and all the services provided by the hospice provider. LN G stated there should be an order from the physician to admit to hospice, which included the terminal diagnosis. On 09/24/25 at 11:55 AM, Administrative Nurse D stated the resident care plan should have the frequency of visits provided by hospice. Administrative Nurse D stated the facility had never obtained a physician order to admit a resident onto hospice after the evaluation from hospice that included the terminal diagnosis. Administrative Nurse D stated the facility had never care planned the equipment, medications, or all the services provided by the hospice provider. The facility's Hospice Program policy, reviewed 10/2024, documented the community would contract for hospice services for residents who wish to participate in such programs, including services that would be provided and the coordination of services. The community may limit the hospice providers as related to the coordination and communication of care within the community. The facility would identify in writing the services that the Hospice would be providing and address in the resident's person-centered care plan. The facility would obtain a physician's order for Hospice services to include diagnosis. Including the physician's orders with the prognosis and the basis for the prognosis.

The facility reported a census of 47 residents. The sample included 12 residents with one reviewed for self-determination. Based on record review, interviews, and observations, the facility failed to accommodate Resident (R)28's preferred sleep schedule. This deficient practice placed R28 at risk for decreased psychosocial well-being. Findings Included: - The Medical Diagnosis section within R28's Electronic Medical Records (EMR) included diagnoses of peripheral vascular disease (PVD- slow and progressive circulation disorder causing narrowing, blockage, or spasms in a blood vessel), hypertension (high blood pressure), chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), and diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin). R28's Quarterly Minimum Data Set (MDS) completed 01/10/24 indicated a Brief Interview for Mental Status (BIMS) score of 13 indicating intact cognition. The MDS indicated he was independent with his activities of daily living (ADLs). The MDS indicated he took insulin (a hormone that lowers the level of glucose in the blood) seven days a week. R28's ADLs Care Area Assessment (CAA) completed 05/30/23 noted he could independently complete his ADLs. The CAA noted he was at risk for impaired ADLs, falls, skin breakdown, weight loss, dehydration, and cognitive decline related to his medical diagnoses. R28's Care Plan initiated 05/05/23 indicated he was at risk for complications related to his diabetes mellitus and cardiovascular health concerns. The plan instructed staff to ensure his medication was administered as ordered. The plan indicated he took metoprolol medication related to his hypertension and inulin for his type two diabetes mellitus. The plan instructed staff to monitor, document, and report changes related to his medication use or side effects. The care plan indicated he slept during the day and preferred to stay up at night but failed to provide interventions related to his missed medications. An Activities -Recreation note dated 12/27/23 indicated R28 preferred to sleep during the day. The note indicated he preferred to wake up around 01:00 AM and hang out with staff at night. A review of R28's Medication Administration Report (MAR) between 11/01/23 through 02/08/24 (99 days reviewed) indicated he was to receive 24 units of Insulin Glargine (long-acting insulin medication) subcutaneously (beneath the skin) twice daily related to his type two diabetes mellitus. A review of the MAR for 01/2024 indicated this medication was not administered on 16 occasions due to R28 sleeping. The missed medication occurrences occurred during his scheduled 08:00 AM administration. A review of R28's Medication Administration Report (MAR) between 11/01/23 through 02/08/24 (99 days reviewed) indicated he was to receive 20 units of insulin aspart (fast-acting insulin medication) subcutaneously three times daily for DM. A review of the MAR for 01/2024 indicated this medication was not administered on 42 occasions due to R28 sleeping. The missed medication occurrences occurred during his scheduled 08:00 AM administration. A review of R28's MAR between 11/01/23 through 02/08/24 (99 days reviewed) indicated he was to receive 25 milligrams (mg) of metoprolol (medication used to lower blood pressure) by mouth twice daily for hypertension. A review of the MAR for 01/2024 indicated this medication was not administered on 27 occasions due to R28 sleeping. The missed medication occurrences occurred during his scheduled 08:00 AM administration. On 02/07/23 at 11:45 AM R28 sat in his wheelchair in his room and awaited lunch. R28 stated he often missed his medication due to he often slept in. He stated the facility had not offered to adjust his medication to fit his preferred sleep schedule and he was often wakened by staff right when he attempted to go to bed. On 02/08/24 at 12:39 PM Certified Nurses Aid (CNA) M stated R28 would often sleep through morning medications and eat breakfast later in the morning before his smoke break. She stated he preferred to stay up late at night and took naps throughout the day. On 02/08/24 at 01:00 PM, Licensed Nurse (LN) G stated R28's sleep schedule was hard to predict. She stated R28 preferred to sleep late in the mornings and would often miss morning medications. She stated if medications were refused or missed, the nurse should document the event in the MAR and notify the physician. She was not sure if R28 was offered to change his medication administration times to coincide with his preferred sleep schedule. On 02/08/24 at 01:12 PM Administrative Nurse D stated staff were expected to document missed medications and refusals in the MAR and notify the physician. She stated the residents would be assessed for side effects of the medications. She stated the facility has not attempted to adjust his medication times due to the difficulty of his insulin and cardiac medications. The facility failed to provide a policy related to preferences and choices as requested on 02/08/24. The facility failed to accommodate and personalize services around R28's preferred sleep schedule. This deficient practice placed R28 at risk for decreased psychosocial well-being.

The facility identified a census of 47 residents. The sample included 12 residents with three residents reviewed for Beneficiary Notification. Based on record review and interview the facility failed to ensure a Center for Medicare/Medicaid Services (CMS) form 10055 Advance Beneficiary Notice of Non-coverage (ABN) form was provided to Resident (R) 13. This placed R13 residents at risk of uninformed treatment decisions and unexpected costs. Findings included: - A review of R13's Electronic Medical Record (EMR) documented the Medicare Part A episode began on 09/06/23 and ended on 10/02/23. R13 remained in the facility for custodial care. A review of R13's EMR revealed the ABN form CMS-10055 was not provided as required after her Medicare Part A coverage ended. On 02/08/24 at 01:05 PM Administrative Nurse F stated it was brought to the management's attention that the ABN form was not being issued to the residents as it should be. The facility lacked a policy for ABN Notification. The facility failed to ensure R13 was provided with CMS ABN Form 10055. This placed this resident at risk for uninformed treatment decisions and unexpected costs.

The facility identified a census of 47 residents. The sample included 12 residents with three residents reviewed for hospitalization . Based on observation, record review, and interviews, the facility failed to provide written notification of the reason and location for the facility-initiated transfer for Resident (R)43 and R47. This deficient practice placed the resident at risk of delayed care or uncommunicated care needs. Findings Included: - The Medical Diagnosis section within R43's Electronic Medical Records (EMR) included diagnoses of end-stage renal failure, hypertension (high blood pressure), muscle weakness, cerebral infarction (stroke- sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), and type two diabase mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin). R43's EMR recorded a Discharge Assessment-Return Anticipated Minimum Data Set (MDS) which recorded R43 discharged to the acute hospital on 01/30/24. R43's Entry Tracking Record MDS documented R43 returned to the facility on [DATE]. R43's Admission Minimum Data Set (MDS) completed on 12/08/23 noted a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The MDS indicated he required moderate staff assistance with transfers, bathing, toileting, dressing, and bed mobility. The MDS indicated he used a wheelchair for mobility. R43's Care Plan initiated 12/03/23 indicated he was at risk for falls and impaired nutrition related to his medical diagnoses. The plan instructed staff to assist R43 with bathing, grooming, dressing, transfers, and bed mobility as needed. The plan noted R43 received dialysis (a procedure where impurities or wastes were removed from the blood) services three times weekly. R43's EMR under the Progress Notes tab documented a Nursing Note on 01/30/24 indicating he reported weakness and difficulty breathing. The note indicated R43 was sent out for emergency treatment to an acute care facility. The note indicated he was admitted for pneumonia (inflammation of the lungs). R43's EMR indicated he returned to the facility on [DATE]. R43's clinical record lacked evidence written notification of the facility-initiated transfer which included the location and reason for the transfer was provided to R43 or his representatives. The facility was unable to provide this documentation as requested on 10/03/23. On 02/08/24 at 08:30 AM R43 transferred from his wheelchair to his bed with staff assistance. R43 reported he recently returned from an acute care facility due to pneumonia but he felt better now. R43 was not aware of the facility giving him written documentation about his transfer. On 02/08/24 at 10:21 AM Social Service X reported the facility sent a bed hold form but did not include a written notification of transfer. She stated the facility called the resident representative and told them in person. The facility did not provide a policy for written notification of transfer/discharge. The facility failed to provide written notification of the reason and location for the facility-initiated transfer to the hospital to R43 or his representative. This deficient practice placed R43 at risk of delayed care or uncommunicated care needs. 41713 - The electronic medical record (EMR) for R47 documented diagnosis of congestive heart failure (CHF- a condition with low heart output and the body becomes congested with fluid), end-stage renal disease (ESRD-a terminal disease of the kidneys), atrial fibrillation (A fib- rapid, irregular heartbeat), and diabetes mellitus (DM-when the body cannot use glucose, not enough insulin was made, or the body cannot respond to the insulin). The Admission Minimum Data Set (MDS) dated [DATE] documented R47 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated an intact cognition. R47 required supervision to partial/moderate assistance from staff for functional abilities. R47 was on dialysis (a procedure where impurities or wastes were removed from the blood) services. The Discharge Care Plan initiated on 04/14/23 for R47 directed staff that the resident was staying in long-term care. R47 was on dialysis. R47 had weekly family visits and the only activities R47 was interested in was watching old movies. The Activities of Daily Living (ADL) Care Area Assessment (CAA) dated 08/02/23 for R47 documented he was admitted to this facility for aftercare related to a fall with a fracture. R47 had a diagnosis of heart failure, ESRD with dialysis, and syncope (fainting or passing out). R47 was alert and able to communicate his needs with a BIMS score of 15. R57 required limited assistance with ADLs and was independent with eating. R47 was steady walking but was able to stabilize without staff assistance. R47 utilized the use of a wheelchair for locomotion throughout the facility. R47's EMR documented a Nursing Note dated 01/30/24 at 02:48 PM. The note documented R47 returned from dialysis at 01:15 PM and had audible wheezing along with gurgling. Staff contacted the provider and received an order to send R47 out to the emergency room to be evaluated. R47's EMR documented a Nursing Progress Note dated 02/02/24 at 02:37 PM. R47 was admitted to the hospital due to respiratory failure and hypoxia (inadequate supply of oxygen). R47 returned to the facility at 01:00 PM vital signs were obtained. The resident was transferred to his recliner with the standby assist of one using R47's walker. Upon request, a copy of the Bed Hold was received for R47's unplanned discharge on 01/30/24. The facility lacked any written notification of transfer/discharge provided to R47 or his representative for his unplanned discharge on 01/30/24. On 02/06/24 at 03:10 PM Social Services X stated upon discharge/transfer the resident and/or representative would be provided the Bed Hold. Social Services X stated typically the representative was notified by phone call when R47 was discharged . Social Services X stated she did not believe the facility had a transfer/discharge form that was used and/or provided to the resident and mailed to the representative. The facility lacked a policy for written notification of transfer/discharge. The facility failed to provide written notification of transfer with the required information for R47 in a practicable amount of time. This deficient practice had the risk of miscommunication between the facility and resident/family and possible missed opportunity for healthcare service for R47.

The facility identified a census of 47 residents. The sample included 12 residents with five reviewed for unnecessary medications. Based on record review, interviews, and observations, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported missed medication administrations related to Resident (R)28's prescribed insulin (a hormone that lowers the level of glucose in the blood) and metoprolol (medication used to treat high blood pressure) on the monthly reports. This practice placed R28 at risk for unnecessary medication administration and unwarranted side effects. Findings Included: - The Medical Diagnosis section within R28's Electronic Medical Records (EMR) included diagnoses of peripheral vascular disease (PVD- slow and progressive circulation disorder causing narrowing, blockage, or spasms in a blood vessel), hypertension (high blood pressure), chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), and diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin). R28's Quarterly Minimum Data Set (MDS) completed 01/10/24 indicated a Brief Interview for Mental Status (BIMS) score of 13 indicating intact cognition. The MDS indicated he was independent with his activities of daily living (ADLs). The MDS indicated he took insulin seven days a week. R28's ADLs Care Area Assessment (CAA) completed 05/30/23 noted he could independently complete his ADLs. The CAA noted he was at risk for impaired ADLs, falls, skin breakdown, weight loss, dehydration, and cognitive decline related to his medical diagnoses. R28's Care Plan initiated 05/05/23 indicated he was at risk for complications related to his diabetes mellitus and cardiovascular health concerns. The plan instructed staff to ensure his medication was administered as ordered. The plan indicated he took metoprolol medication related to his hypertension and inulin for his type two diabetes mellitus. The plan instructed staff to monitor, document, and report changes related to his medication use or side effects. The care plan indicated he slept during the day and preferred to stay up at night but failed to provide interventions related to his missed medications. A review of R28's Medication Administration Report (MAR) between 11/01/23 through 02/08/24 (99 days reviewed) indicated he was to receive 24 units of insulin glargine (long-acting insulin medication) subcutaneously (beneath the skin) twice daily related to his type two diabetes mellitus. A review of the MAR for 01/2024 indicated this medication was not administered on 16 occasions due to R28 sleeping. The EMR lacked evidence of physician notification. A review of R28's MAR between 11/01/23 through 02/08/24 (99 days reviewed) indicated he was to receive 20 units of insulin aspart (fast-acting insulin medication) subcutaneously three times daily for type 2 diabetes mellitus. A review of the MAR for 01/2024 indicated this medication was not administered on 42 occasions due to R28 sleeping. The EMR lacked evidence of physician notification. A review of R28's MAR between 11/01/23 through 02/08/24 (99 days reviewed) indicated he was to receive 25 milligrams (mg) of metoprolol by mouth twice daily for hypertension. A review of the MAR for 01/2024 indicated this medication was not administered on 27 occasions due to R28 sleeping. R28's metoprolol order instructed staff to hold the medication if R28's systolic blood pressure (SBP-relating to the phase of the heartbeat when the heart muscle contracts and pumps blood from the chambers into the arteries) was less than (<) 110 millimeters of mercury (mmHg) or pulse (heart rate) (<) 60 beats per minute (bpm). The EMR lacked R28's blood pressure or heart rate for the missing days. The EMR lacked evidence of physician notification. A review of the Facility's pharmacy Consultation Reports from 05/04/23 through 02/01/24 revealed no reporting of the missed medication occurrences or recommendations to review the medication occurrences. On 02/07/23 at 11:45 AM R28 sat in his wheelchair in his room and awaited lunch. R28 stated he often missed his medication due to he often slept in. He stated the facility had not offered to adjust his medication to fit his preferred sleep schedule and he was often wakened by staff right when he attempted to go to bed. On 02/08/24 at 01:00 PM, Licensed Nurse (LN) G stated R28's stated holes in the MAR or missed medications should be reported to the physician and Administrative Nurse D. On 02/08/24 at 01:12 PM Administrative Nurse D stated the pharmacist sent the monthly reports for review but had not identified the medication irregularities to the facility. She stated she received the monthly reviews and reviewed them with her team and recorded the physician orders. She stated she was usually able to do chart checks to see missed medication passes but recent issues with the EMR system prevented her from doing so. On 02/12/24 at 02:03 PM, the CP reported staff should report missed dosages and record them in the EMR. He stated he believed staff was incorrectly coding refusals as him sleeping. He stated the monthly reports should reflect irregularities found on the MAR and should be reported to the facility. The facility's provided Pharmacy Services policy revised 11/2017 indicated the pharmacy will work with the facility to provide monthly monitoring services to identify medication irregularities and report the findings to the facility's interdisciplinary team. The policy noted the CP will help develop processes to improve the receiving, monitoring, writing, and reviewing of medication orders. The facility failed to ensure the CP identified and reported missed medication administrations related to R28's prescribed insulin and metoprolol medications on the monthly reports. This practice placed R28 at risk for unnecessary medication administration and unwarranted side effects.

The facility identified a census of 47 residents. The sample included 12 residents with five reviewed for unnecessary medications. Based on record review, interviews, and observations, the facility failed to consistently administer Resident (R)28's prescribed insulin (a hormone that lowers the level of glucose in the blood) and metoprolol (a class of medication used to treat high blood pressure) medications This practice placed R28 at risk for unnecessary medication administration and unwarranted side effects. Findings Included: - The Medical Diagnosis section within R28's Electronic Medical Records (EMR) included diagnoses of peripheral vascular disease (PVD- slow and progressive circulation disorder causing narrowing, blockage, or spasms in a blood vessel), hypertension (high blood pressure), chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), and diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin). R28's Quarterly Minimum Data Set (MDS) completed 01/10/24 indicated a Brief Interview for Mental Status (BIMS) score of 13 indicating intact cognition. The MDS indicated he was independent with his activities of daily living (ADLs). The MDS indicated he took insulin seven days a week. R28's ADLs Care Area Assessment (CAA) completed 05/30/23 noted he could independently complete his ADLs. The CAA noted he was at risk for impaired ADLs, falls, skin breakdown, weight loss, dehydration, and cognitive decline related to his medical diagnoses. R28's Care Plan initiated 05/05/23 indicated he was at risk for complications related to his diabetes mellitus and cardiovascular health concerns. The plan instructed staff to ensure his medication was administered as ordered. The plan indicated he took metoprolol medication related to his hypertension and inulin for his type two diabetes mellitus. The plan instructed staff to monitor, document, and report changes related to his medication use or side effects. The care plan indicated he slept during the day and preferred to stay up at night but failed to provide interventions related to his missed medications. A review of R28's Medication Administration Report (MAR) between 11/01/23 through 02/08/24 (99 days reviewed) indicated he was to receive 24 units of insulin glargine (long-acting insulin medication) subcutaneously (beneath the skin) twice daily related to his type two diabetes mellitus. A review of the MAR for 01/2024 indicated this medication was not administered on 16 occasions due to R28 sleeping. The EMR lacked evidence of physician notification. A review of R28's MAR between 11/01/23 through 02/08/24 (99 days reviewed) indicated he was to receive 20 units of insulin aspart (fast-acting insulin medication) subcutaneously three times daily for type 2 diabetes mellitus. A review of the MAR for 01/2024 indicated this medication was not administered on 42 occasions due to R28 sleeping. The EMR lacked evidence of physician notification. A review of R28's MAR between 11/01/23 through 02/08/24 (99 days reviewed) indicated he was to receive 25 milligrams (mg) of metoprolol by mouth twice daily for hypertension. A review of the MAR for 01/2024 indicated this medication was not administered on 27 occasions due to R28 sleeping. R28's metoprolol order instructed staff to hold the medication if R28's systolic blood pressure (SBP-relating to the phase of the heartbeat when the heart muscle contracts and pumps blood from the chambers into the arteries) was less than (<) 110 millimeters of mercury (mmHg) or pulse (heart rate) (<) 60 beats per minute (bpm). The EMR lacked R28's blood pressure or heart rate for the missing days. The EMR lacked evidence of physician notification. A review of the Facility's pharmacy Consultation Reports from 05/04/23 through 02/01/24 revealed no reporting of the missed medication occurrences or recommendations to review the medication occurrences. On 02/07/23 at 11:45 AM R28 sat in his wheelchair in his room and awaited lunch. R28 stated he often missed his medication due to he often slept in. He stated the facility had not offered to adjust his medication to fit his preferred sleep schedule and he was often wakened by staff right when he attempted to go to bed. On 02/08/24 at 12:39 PM Certified Nurses Aid (CNA) M stated R28 often slept through morning medications and ate breakfast later in the morning before his smoke break. She stated he preferred to stay up late at night and he took naps throughout the day. On 02/08/24 at 01:00 PM, Licensed Nurse (LN) G stated R28's sleep schedule was hard to predict. She stated he preferred to sleep late in the mornings and would often miss morning medications. She stated if medications were refused or missed, the nurse should document the event in the MAR and notify the physician. On 02/08/24 at 01:12 PM Administrative Nurse D stated she expected staff to document missed medications and refusals in the MAR and notify the physician. She stated the residents would be assessed for side effects of the medications. She stated the facility had not attempted to adjust R28's medication times due to the difficulty of his insulin and cardiac medications. A review of the facility's Physician's Orders policy revised 06/2023 indicated the facility will provide adequate monitoring for medications. The policy indicated that licensed staff were expected to verify and administer medications only upon a written order. The policy indicates the facility must notify the medical provider of changes in the resident's treatment, conditions, administration, or behaviors. The facility failed to consistently administer R28's prescribed insulin and metoprolol medications This practice placed R28 at risk for unnecessary medication administration and unwarranted side effects.

The facility identified a census of 47 residents. The sample included 12 residents with one resident sampled for food. Based on observation, record review, and interview the facility failed to ensure facility staff accommodated Resident (R) 8's food allergies and food choices. This deficient practice had the potential for adverse food reactions and negative outcomes. Findings included: - The electronic medical record (EMR) for R8 documented diagnosis of hypertension (HTN- elevated blood pressure), chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). The Annual Minimum Data Set (MDS) dated [DATE] for R8 documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. R8 required substantial/maximal to dependent assistance with functional abilities. The Quarterly MDS dated [DATE] for R8 documented a BIMS score of 15 which indicated intact cognition. R8 required set-up for eating and substantial/maximal to dependent assist with functional abilities. The Activities of Daily Living (ADL) Care Area Assessment (CAA) dated 08/23/23 documented R8 was a long-term resident of the facility. R8 was alert and able to communicate her needs with a BIMS of 15. R8 required extensive assistance with bed mobility and dressing. R8 required total assistance with toileting and transfers with a mechanical lift, limited assistance with hygiene and grooming, and supervision with eating. R8 did not want to come out of her room and preferred watching TV in her room in peace. R8 had voiced concern about her weight and was referred to the dietician. R8's Nutritional Care Plan last revised 04/27/23 directed staff to honor R8's food preferences and update them as needed. Staff was directed to provide R8 with a regular diet, and regular texture. The registered dietician was to evaluate and make recommendations as needed. R8's EMR dashboard and main screen documented allergies to milk and milk products. R8's printed meal tickets listed allergies to milk and milk products. R8's meal tickets also documented her dislike of gravy, eggs, ham, white bread, tomatoes or tomato soup, and apple juice. R8's printed meal ticket listed her beverage preference of water, coffee, and soy milk. The printed meal tickets also documented assist instructions for soy milk for breakfast, a cup with a lid, and smaller portions. On 02/05/24 at 09:18 AM R8 stated she had an allergy to milk and milk products but was served eggs with cheese and other foods that had cheese in them which caused her to have diarrhea. R8 stated she often got served gravy on foods and other foods she disliked. R8 stated the kitchen staff usually did okay at the breakfast meal as she ate cereal, and was provided soy milk. On 02/07/24 at 01:02 PM, R8 stated for lunch that day, the potatoes had so much cheese in them that she had to stop eating them and then shortly after, had to call for assistance because she felt diarrhea/loose stools coming on. On 02/08/24 at 10:12 AM Dietary CC stated she was aware of R8's milk and milk product allergy. Dietary CC stated she tried as much as possible to provide R8 meals that accommodated her allergy as well as her other likes and dislikes, but she was not always able to. Dietary CC stated R8's meal tickets did list the allergies and her dislikes, but at times R8 still ate foods she did not like or knew she could have a reaction from and would eat them anyway. On 02/08/24 at 12:39 PM Certified Nurse Aide (CNA) M stated that R8 did have a milk allergy and her meal tickets indicated that. CNA M stated R8 did at times eat foods that she disliked. CNA M stated R8 had never voiced that the foods she ate caused her stomach to be upset or diarrhea. On 02/08/24 at 01:20 PM Administrative Nurse D stated she visited with R8 frequently to go over her preferred foods. Administrative Nurse D stated that the kitchen staff and the nurses were aware of R8's allergy and preferences and tried to accommodate meals to follow them. Administrative Nurse D stated R8 would at times order food that she should not eat but ordered it anyway. The facility policy Resident Food Preferences last revised October 2023 documented that nutritional assessments would include an evaluation of individual food preferences. Residents receive food prepared in a form designed to meet individual needs, including preference, attending to allergies and intolerances. The Food Service Manager and/or Dietician would discuss the resident food preferences with the resident when such preferences conflict with a prescribed diet. The resident had the right to not comply with the prescribed diet or dietary restrictions. The Dietician, and nursing staff, assisted by the physician, would identify any nutritional issues or dietary restrictions that might affect the facility's effort to accommodate resident preferences. The resident's clinical record would document the resident's likes and dislikes and special dietary instructions or limitations such as altered food consistency and therapeutic restrictions. The Food Services Manager, Dietician, or nursing staff would visit residents periodically to determine if a revision was needed regarding food preferences. The nursing staff would inform the kitchen about resident requests. The facility failed to ensure R8's allergy and food preferences were accommodated at mealtimes. This placed R8 at risk for adverse food reactions and possible negative outcomes.

The facility identified a census of 50 residents. Three residents were reviewed for catheter (flexible tubing inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) care. Based on record review, interview, and observation, the facility failed to provide appropriate catheter cares for Resident (R) 1's indwelling urinary catheter when staff failed to provide flushes as ordered by the physician to prevent urinary tract infections (UTI), failed to ensure catheter cares were provided using acceptable standards of infection control practices, and failed to ensure interventions were consistently and correctly implemented to anchor the catheter to prevent worsening of catheter associated trauma. This deficient practice resulted in catheter related complications including UTI and traumatic injury caused by the indwelling urinary catheter. Findings included: - R1's Electronic Medical Record (EMR) under the Diagnosis tab documented diagnoses of neuromuscular dysfunction of bladder (a problem in which a person lacks bladder control due to a brain, spinal cord, or nerve condition), arthritis (inflammation of a joint characterized by pain, swelling, redness and limitation of movement), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin) morbid obesity (excessive body fat) due to excess calories, muscle weakness, abnormal posture, reduced mobility, lack of coordination, and anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). The Annual Minimum Data Set (MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) was not conducted due to R1 rarely/never being understood. Staff assessment revealed R1 had short-term and long-term memory problems and noted he recalled the current season, location of his room, staff names and faces, and that he was in a nursing home. R1 had a urinary catheter. R1 required substantial to maximal assistance from staff with sit-to-stand positioning, toileting, and chair/bed-to-chair transfers. The Urinary Incontinence Care Area Assessment (CAA) dated 06/21/23, documented R1 had a chronic indwelling catheter ordered by the physician. Staff encouraged R1 to lay down when changing the catheter. Staff were to avoid a leg bag as R1 had his legs elevated most of the day. The Psychosocial Well-Being CAA dated 06/21/23, documented R1 needed assistance with activities of daily living (ADLs) related to functional deficits. R1 experienced chronic pain related to arthritis in his hands. The ADL Functional/Rehabilitation Potential CAA dated 06/21/23 documented R1 required extensive assistance with bed mobility and toileting. R1's Care Plan revised on 08/05/21 documented R1 had an ADL self-care deficit related to osteoarthritis and dementia (progressive mental disorder characterized by failing memory and confusion). Interventions dated 08/05/21 directed staff to provide the resident with choices of assistance whether it be physical assistance, supervision, cueing, or encouragement and provide the resident with his need for assistance regarding toilet use. The resident was able to wash his hands, hold grab bars, wipe himself and adjust his clothing. An update was added on 05/12/23, which directed staff to provide R1 one-person limited assistance with a walker and a gait belt; if R1 was unable to complete the transfer safely due to weakness, nursing staff should assess and use the Hoyer (full body mechanical lift) as needed. R1's most recent ADL intervention was added on 08/15/23, which directed R1 refused to allow staff to place foot pedals on his wheelchair at times. R1's Care Plan, initiated 12/25/21 documented R1 was at risk for falls related to his balance problems. An intervention dated 12/25/21 directed staff to ensure R1's call light was within reach and remind him to use it when he needed assistance. An intervention dated 06/11/22 documented R1 had a BIMS of 14 (no cognitive impairment) and received education from the staff on proper transferring, and instruction to reach back to feel the chair before sitting down. Staff encouraged R1 to use his call light and allow staff to stand by assist with transfers for safety. An intervention dated 08/15/22 directed to send R1 to the emergency room for evaluation and treatment and an additional intervention revised on 08/29/22 documented the resident had a BIMS of 14 and received education on the importance of using his call light to alert staff to assist him with transfers when he felt short of breath or unsteady. An intervention dated 07/28/23 directed staff to offer R1 assistance to the toilet after dinner. R1's Care Plan, initiated 08/05/21, documented R1 had an indwelling catheter related to urinary retention. The care plan directed staff to monitor R1 for pain/discomfort due to the catheter and document. The care plan directed staff monitored, recorded, and reported to the physician any signs and symptoms of a urinary tract infection, which included burning, pain, blood-tinged urine, cloudiness, deepening of urine color, and foul-smelling urine. An intervention, dated 04/18/22, documented R1's family was educated on the need of a suprapubic catheter (urinary bladder catheter inserted through the abdomen into bladder) but refused related to the risks involved with the procedure. An intervention, last revised 06/28/22, directed R1 had an 18 French catheter and staff positioned the catheter bag and tubing below the level of the bladder. The care plan documented an intervention, initiated on 11/10/22, which directed staff to encourage R1 to lay down when having his catheter changed. An intervention, initiated on 01/05/23, directed R1 moved his catheter bag independently throughout the day, staff encouraged R1 to keep the bag below the bladder lever and staff educated R1 on the importance of catheter bag placement. R1's Care Plan did not address the need to ensure a securement device was in place to decrease tension and stabilize tubing during routine cares or when resident moved his catheter bag independently until during the onsite survey on 12/18/23 when an intervention was initiated which directed staff to ensure a securement device was in place to decrease tension of the tubing. The care plan did not address catheter care, including flushing to prevent sediment build-up; frequency of catheter changes, and monitoring of penile changes and treatments related to long-term catheter usage. Review of the Nursing: Weekly Skin Evaluations done weekly from 03/01/23 to 12/15/23 lacked mention of R1's penile wound, and any associated interventions and treatments during that review period. R1's clinical record lacked any wound assessment or documentation related to R1's penile wound, which included measurements, treatments, periwound (area around the wound) assessment or signs of infection. The Orders tab of R1's EMR revealed the following Physician's Orders: An order with a start date of 07/10/22 to place 18 French Foley catheter related to retention of urine with directions to change the catheter and bag as needed for signs and symptoms of infection, obstruction, or when the closed system was compromised. An order with a start date of 03/23/23 for sodium chloride (NS-normal saline solution) use 100 cubic centimeters (cc-unit of measurement) to irrigate the catheter three times daily. An order with a start date of 03/27/23 for a urology (the branch of medicine that deals with the diagnosis and treatment of diseases of the urinary tract and urogenital system) consult for the possibility of a suprapubic catheter placement. An order with a start date of 04/18/23 to cleanse R1's penis foreskin, pat the area dry, then apply triple antibiotic ointment until healed one time a day for wound care. An order with a start date of 07/11/23 for urine analysis (urinalysis) for white blood cell (WBC- type of blood cell that helps the body fight infection) count of 15.6 (elevated WBCs- normal range for men was between 5,000 and 10,000), blood noted at the catheter tip, and elevated temperature. An order with a start date of 12/12/23 for a STAT (immediate) follow up with urology related to a slit in R1's penis due to his catheter. An order with a start date of 12/18/23 for the wound care specialists to evaluate and treat. The Notes tab of R1's EMR revealed the following: A Nursing Note on 03/19/23 at 11:47 AM documented R1 had his foley catheter changed and staff observed blood and pus (thick liquid produced by infected tissue) at the end of the catheter. R1 received a new catheter utilizing aseptic technique (medical practice to prevent contamination from harmful bacteria) and staff obtained a urinalysis. The record lacked evidence of physician and family notification. An Infection Note on 03/24/23 at 10:09 AM documented R1's urine in the catheter tubing was cloudy yellow. R1's catheter was flushed per order. An Infection Note on 03/25/23 at 01:44 AM documented R1 continued an antibiotic for a urinary tract infection. R1's catheter was patent with yellow urine in the tubing. R1's catheter flushed with some resistance, and cloudy urine and sediment was observed with return. An Infection Note on 04/02/23 at 09:45 AM documented R1 completed the antibiotic for his UTI. R1's catheter was flushed per order without difficulty, with clear yellow urine in the catheter tubing and drainage bag. R1 denied any bladder discomfort. A Nursing Note on 04/18/23 at 11:00 AM documented R1 had blood on his catheter, and he complained of pain from his catheter site. The note documented R1 had a small laceration on his foreskin from possible erosion related to catheter tubing. Staff cleaned the area and applied triple antibiotic ointment. R1 received a new catheter without complication. R1's record lacked evidence of a physician and family notification. A Nursing Note on 04/27/23 at 04:21 PM documented R1 had a catheter tubing holder in place on his upper thigh area of his left leg. An Event Note on 07/11/23 at 02:49 PM documented R1's physician ordered a STAT blood urea nitrogen (BUN- test that measures the amount of urea nitrogen in the blood) and a urine analysis (UA) with culture and sensitivity. A Nursing Note on 07/12/23 at 01:12 AM documented R1 complained of increased pain in his lower abdomen and his foley catheter was not draining correctly. There was approximately 200 cc of yellow urine with moderate sediment in his catheter bag. R1 received a new catheter, with approximately 300 cc of urine return. R1 had a catheter leg strap in place. A Nursing Note on 07/14/23 at 03:45 PM documented R1 continued with an antibiotic for a UTI. R1's catheter was patent with yellow urine in the tubing and flushed without difficulties. A Nurses: Infection Note on 07/19/23 at 12:20 PM documented R1's catheter was patent and flushed easily. A Nursing Note on 09/21/23 at 03:04 PM documented staff placed a new 18 French catheter using aseptic technique without complications. A Social Services Note on 09/26/23 at 10:37 AM documented R1 had a scheduled urology appointment. Staff transported R1 and arrived at a closed office. Staff called R1's representative since she made the appointment and the facility waited for her to make another appointment. (R1's clinical record lacked any further action, follow up, or evidence of a rescheduled appointment.) A Nursing Note on 10/02/23 at 02:14 AM documented R1 complained of feeling the urge to urinate and of pain. Staff attempted to flush R1's catheter without success. Staff changed R1's catheter with a return of approximately 200 cc of clear, yellow urine. R1 reported he felt relief. A Nursing Note on 10/11/23 at 08:30 PM documented R1 had some bleeding around his penis and catheter insertion area. R1 had a small, dried smear of blood on his brief when his catheter was flushed around 10:00 PM. R1's record lacked evidence of physician or family notification. A Nursing Note on 12/11/23 at 01:20 PM, late entry, documented R1 had severe pain to his peri-area related to a previous wound to the tip of his penis from prior trauma. The area appeared to have worsened. R1's wound was beefy red in color and well-approximated with a small amount of blood in R1's brief. R1's family was at his bedside and was informed that R1 would benefit from a suprapubic catheter. R1's family stated the urologist informed her R1 was not a candidate for a suprapubic catheter. R1's record lacked evidence of physician notification at that time. A Nursing Note on 12/12/23 at 02:00 PM documented R1's family wanted to speak with a nurse related to R1's penile wound. Staff offered to call the physician to obtain an order to send R1 to the emergency room for evaluation and treatment related to her concern. Staff educated R1's family that a suprapubic catheter would probably be needed related to the location of his wound. R1's family declined to have R1 sent to the emergency room at that time, and she did not want a suprapubic catheter placed. Staff informed R1's family that the physician saw R1, and the facility moved forward with the urology consult. R1 rested in bed with no acute pain or discomfort and his catheter had free-flowing amber urine. A Nursing Note on 12/12/23 at 03:51 PM documented R1's family agreed that a suprapubic catheter was a good option. Review of the Tasks section in R1's EMR revealed the following: In October 2023 two days (10/11 and 10/14) lacked evidence catheter cares were provided and lacked record of refusal or out of community. Of the remaining days, catheter care was only provided once daily for 12 of the days. The catheter urine output lacked shift documentation for 26 of 31 day shifts and on four dates (10/05, 10/11, 10/17 and 10/30) no output was recorded at all. In November 2023 seven of the 30 days lacked evidence catheter care was provided more than once daily. The catheter urine output lacked shift documentation for 13 day shifts and on 11/02/23 no output was recorded at all. In December, from 12/01/23 through 12/18/23, two days (12/04 and 12/08) lacked evidence catheter was provided and lacked record of refusal or out of community. Of the remaining 16 days reviewed, seven of the days lacked evidence catheter care was provided more than once daily. The facility provided a physician/provider Progress Note from Consultant GG with a date of service of 12/26/23, which documented the resident was seen that day for a penile laceration secondary to long term use of an indwelling catheter. The note referenced a scholarly medical journal article, which indicated that long term catheterization (range from 6-12 months) along with other risk factors, one of which was poor catheter care, could lead to erosion. The note documented R1's age, weight, DM, wheelchair -bound status, as well as the long-term use of the catheter placed him at high risk for urethral (part of the body which drains urine) injury and penile erosion. The note further documented Consultant GG educated the facility staff to ensure R1's catheter was secure with a catheter securement device and encouraged catheter care. The note documented a plan to consult urology on the possibility of a suprapubic catheter; encourage catheter care, and staff were to make sure the catheter was secure to prevent the catheter from pulling during transfers. On 12/18/23 at 11:25 AM, R1 sat in his wheelchair with his feet on the foot pedals. He appeared clean, well-groomed, and in good spirits. R1's catheter collection bag hung in a privacy bag towards the front of the left side of his wheelchair. On 12/19/23 at 10:38 AM, R1 sat in his wheelchair with fresh clothing on and he appeared well-groomed and smiled when approached. His catheter collection bag hung in the privacy bag under the seat of his wheelchair. R1 stated that the facility emptied his catheter bag and drained the urine. He stated that staff completed catheter care for him, but it did not occur twice a day or even every day. R1 was able to recall that he was waiting for lunch and hoped it would be a good one. R1 stated his spouse would not be in to see him today, but she would be back tomorrow. On 12/19/23 at 12:16 PM, R1 sat on the toilet. Certified Nurse Aide (CNA) N responded to the bathroom call light on in R1's room. Certified Medication Aide (CMA) S also came and asked CNA N if she needed help with R1 and CNA N indicated she needed assistance. Observation revealed R1 had a leg band on his left leg mid-leg with the catheter tubing pulled taut from his penis to the leg band. CNA N donned (put on) gloves without washing her hands. CNA N asked R1 if he was ready to stand. CNA N wiped R1's buttocks, fastened a new brief, and pulled up his pants. CNA N and CMA S assisted R1 to his wheelchair and placed his catheter bag into the privacy bag. CNA N propelled R1 out of the bathroom, doffed (removed) her gloves, then propelled R1 to the dining room. CNA N did not perform hand hygiene. Once in the dining room, CNA N propelled R1 to his table and asked if he would like a drink and his lunch. R1 replied he would, and CNA N went to the kitchen window, grabbed R1's lunch plate, and delivered it to him. CNA N then retrieved R1's drink and placed a straw into the cup. At that point, CNA N had still not washed her hands or used hand sanitizer. On 12/19/23 at 02:18 PM, R1 laid in bed with the covers pulled up to his chest. His catheter bag hung from the side of his bed in a privacy bag. There was cloudy, yellow urine in the catheter tubing. Licensed Nurse (LN) I explained to R1 the procedure of flushing his catheter. LN I cleared off the over-the-bed table, wiped it down, and placed a clear barrier for the supplies needed to flush the catheter. LN I washed her hands, opened her sterile supplies, and donned her sterile gloves. LN I placed the sterile cloth between R1 and the bed. She took out a sterile syringe and drew up 30 cc of normal saline into the syringe. LN I unsecured R1's catheter tubing from the leg band, disconnected the drainage tube from the catheter tubing, disinfected the end of the catheter tubing with an alcohol pad, inserted the syringe, and began flushing the catheter with the 30 cc of normal saline. When LN I finished flushing the 30 cc, the drainage pan was placed, and the catheter tube was allowed to drain normal saline and urine. After drainage was completed, LN I disinfected the end of the catheter tubing and reconnected the drainage tube. LN I noted R1 had a red spot on his catheter tubing, requested a wipe, wiped off the tubing, then proceeded to change his brief. Once the brief was unfastened, R1 had drainage on the side of his leg and between his scrotum and leg. LN I requested a wipe and proceeded to wipe between the scrotum and the leg. There was yellow and reddish-brown drainage on the wipe. Wearing the same gloves, LN I used a second wipe to wipe around R1's catheter insertion site. R1 had a tear down the left lateral side of the penis. The edge of the tear was noted to be pink in color with no active discharge at the edge of the tear. LN I continued with the same wipe and cleansed the base of the penis. There was no odor noted while the cares were being provided and R1 did not appear to be uncomfortable. LN I attempted to wipe R1's leg under the catheter tubing and realized the tubing was too taut. LN I asked Administrative Nurse E if there was a different leg band that could be used as the current leg band appeared to be tight. Administrative Nurse E reported that she would retrieve a Statlock (adhesive device placed on a leg, used to secure an indwelling catheter). Administrative Nurse E doffed her gloves, performed hand hygiene, then left the room. She returned to the room with a Statlock, performed hand hygiene, and donned new gloves. LN I removed the elastic leg band and placed the adhesive Statlock on R1's left leg then secured the catheter tubing in place. On 12/18/23 at 11:26 AM, R1's representative stated that she had not been notified to the severity of R1's penile erosion. She stated when she saw R1's wound, she was upset. R1's representative stated the facility did not notify her about the wound though she visited three to four times a week. R1's representative stated she knew the urologist recommended a suprapubic catheter and shared her concern with whether the facility could care for a suprapubic catheter or not after seeing R1's current condition with a regular catheter. On 12/18/23 at 12:10 PM, CMA R stated R1 did not complain of pain, but she heard staff mention that R1 had a tear or cut on the tip of his penis prior to 12/11/23. CMA R did not recall when exactly she heard that. On 12/18/23 at 01:30 PM, CNA M stated a few months ago, R1 had a pungent odor during peri-care. CNA M said he changed R1's brief and put anti-fungal on his peri-area. CNA M stated on the morning of 12/11/23, R1 took himself to the toilet and when CNA M assisted R1 off the toilet, there were no issues. After breakfast, R1 complained of pain and LN H checked on him. CNA M stated R1's penis had split and was larger than the previous tear. CNA M demonstrated the size of the previous tear to R1's penis using his index finger and thumb, which was about one-fourth to one-half of an inch in size. On 12/18/23 at 01:45 PM, LN G stated on 12/11/23, LN H informed her R1 had pain with his catheter. LN G stated that upon assessment, R1's penis had a tear from the catheter tubing that extended from the tip of R1's penis to the base of his penis. LN G stated LN H told R1's representative he was in pain and that it would be best to have a suprapubic catheter placed. She stated R1's penile wound was there prior but had not worsened until 12/11/23. LN G stated R1 had a tear to the tip of his penis maybe six months prior but was unable to recall the exact timeframe. She stated staff completed peri-care on residents with catheters at least once every shift and the CNA emptied the catheter bag then documented the output every shift. On 12/18/23 at 02:43 PM, LN H stated she had not worked at the facility very long but was told by various staff members that the tear or split on R1's penis had been there for a while, over a year or so. She stated CNA M reported to her that R1 had the tear. LN H stated she recalled speaking with Consultant GG about the tearing and Consultant GG was not alarmed. LN H stated she was informed R1 had a previous treatment order of triple antibiotic ointment from a few months ago for an injury to his penis, so the tear was not new. LN H verified she failed to document the conversation with Consultant GG or what happened with R1 on 12/11/23 or 12/12/23. On 12/18/23 at 03:35 PM, Administrative Nurse D stated R1's injury to his penis was related to a self-transfer. R1 took himself to the bathroom and after breakfast and R1 had a lot of pain. LN H assessed R1, and he had a split in his penis. Administrative Nurse D stated the tear had been going on for a very long time and felt that it was related to R1 self-transferring. She stated that she did not notify the staff that R1 could get a tear from his catheter and staff had not mentioned that R1 lacked a leg band or needed a different type of anchoring device at any time. Administrative Nurse D stated she never asked the staff if R1 had a leg band to secure the tubing. On 12/19/23 at 10:50 AM, LN I stated she was aware of the split/tear in R1's penis. LN I stated it resulted when R1 transferred himself and the penile wound tore a little at a time. LN I stated if R1's catheter tubing was not placed correctly, it tugged and pulled. R1 wore a leg band to help secure the catheter, but it did not hold well. LN I stated R1 would benefit from a Statlock, but the facility did not order those. LN I stated she was asked to measure the tear on R1's penis and document the findings in a skin assessment. She stated when she assessed R1's splint/tear, the wound did not look new. LN I stated if a leg band or Statlock was not applied to catheter tube properly, the tube would get tugged on and pulled. She stated if there were concerns with a resident's catheter, she assessed the resident, notified the physician, and documented in the resident's chart. On 12/19/23 at 03:25 PM, LN I stated that usually she used prefilled syringes to flush R1's catheter. LN I stated she always flushed R1's catheter with 30 cc of normal saline. LN I stated she was surprised to have located the Statlock while getting the supplies ready to do R1's catheter flush as the devices were not previously ordered to her knowledge. LN I reviewed R1's catheter flushing order and confirmed the order directed staff to use 100 cc. On 12/19/23 at 05:11 PM, Administrative Nurse D stated she could not recall what the order was for flushing R1's catheter, but she expected staff to follow the physician's order. Administrative Nurse D stated she was concerned about R1's self-transfers due to the tension his catheter might cause. Administrative Nurse D stated there was not any previous event that would have caused trauma to R1's penis from a self-transfer, but she was concerned for his safety. She stated the first time she became aware of the tear or split in R1's penis from the catheter was on 12/11/23. Administrative Nurse D stated she had never heard of anything before that event. She stated she was unaware of any documented concerns for blood, pain, pus, or trauma for R1 from 03/01/23 to 12/11/23. Administrative Nurse D stated she had no concerns with the catheter cares provided by staff and felt staff completed the cares as required, but only charted by exception. She stated R1's family did not want him to have a suprapubic catheter and were firm on that decision. Administrative Nurse D stated the family had the right to refuse cares. Administrative Nurse D stated continued education and conversations with R1's family on the topic of the suprapubic catheter could be viewed as harassment. On 12/19/23 at 06:07 PM LN I stated that staff should definitely wash their hands after providing peri-care and prior to serving residents food. On 12/19/23 at 06:15 PM Administrative Nurse D stated she expected her staff to wash their hands after providing peri-care, when serving lunch or lunch trays, and when entering and exiting resident rooms. On 12/19/23 at 06:25 PM Administrative Staff A stated the nursing administration team should have reviewed and identified any concerns related to R1's catheter. The facility's Indwelling Urinary Catheters F690 policy, revised June 2022, directed staff to review the resident's care plan to assess for any special needs of the resident. The policy directed staff to maintain an accurate record of the resident's daily output, per facility policy and procedure. The policy directed staff to check the resident frequently to be sure he or she is not lying on the catheter and to keep the catheter and tubing free of kinks. The policy directed that routine hygiene was appropriate for catheter care; to empty the drainage bag regularly using a separate, clean collection container for each resident; and to empty the collection bag as least every shift. The policy also directed to change the indwelling catheters or drainage bag based on clinical indications such as infection, obstruction, or when the closed system was compromised. Staff were directed to ensure that the catheter remains secured with a leg strap to reduce friction and movement at the insertion site. The policy noted that catheter tubing should be strapped to the resident's inner thigh. The policy directed staff to notify the physician or supervisor in the event of bleeding; if the catheter was accidently removed; or if the resident reported any complaints of burning, tenderness, or pain in the urethral area. Staff were directed to document the date and time the catheter care was given; any assessment data obtained when giving catheter care such as color, clarity, or presence of odor in the urine; any problems noted with the catheter care at the catheter-urethral junction; any complaints from the resident; and if necessary, how the resident tolerated the procedure. The facility failed to provide adequate catheter cares for R1's indwelling urinary catheter when staff failed to provide flushes as ordered by the physician to prevent UTI, failed to ensure catheter cares were provided using acceptable standards of infection control practices, and failed to ensure interventions were consistently and correctly implemented to anchor the catheter to prevent worsening of catheter associated trauma. This deficient practice resulted in catheter related complications including UTI and traumatic injury caused by the indwelling urinary catheter.

The facility identified a census of 52 residents. The sample included three residents with two reviewed for [CONDITION(S)] (a procedure for the clinical purification of blood as a substitute for the normal function of the kidney). Based on record review, observation, and interview, the facility failed to provide appropriate [CONDITION(S)] care and services consistent with professional standards of practice for Resident (R)1. This placed the resident at increased risk for adverse complications related to [CONDITION(S)]. Findings included: - The electronic medical record (EMR) documented R1 admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) dated [DATE] documented R1 had a Brief Interview for Mental Status (BIMS) score of fourteen which indicated R1's cognition was intact. The MDS recorded R1 required limited assistance from staff with most activities of daily living (ADL). The MDS recorded R1 received [CONDITION(S)] services while a resident at the facility. The ADL Care Area Assessment (CAA) dated 10/17/22 documented R1 received [CONDITION(S)] three times a week at an outside facility. R1 was at risk for physical safety, isolation, depression, decline in ADL, impaired skin integrity, falls, and/or fall related injuries. The CAA documented R1 received therapy services and a care plan would be developed to minimize risks and return R1 to R1's prior level of independent living. R1's Care Plan dated 10/17/22 documented R1 had nutritional risk due to [CONDITION(S)]. The care plan directed staff to provide a regular mechanical soft texture diet, provide double protein, and follow the registered dietician recommendations. R1's Care Plan further lacked documentation to identify [CONDITION(S)] cares needed as indicated in the CAA. The Physicians Order Sheet (POS) dated 10/12/22 documented R1 received Nepro (a therapeutic nutrition shake made specifically to help patients on [CONDITION(S)]) twice a day as a supplement. The POS lacked an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . and lacked any other documentation to identify R1 received [CONDITION(S)] as well as location, times, and or information about the [CONDITION(S)] center. R1's clinical record further direction related to [CONDITION(S)] including location, times, and or information about the [CONDITION(S)] center. The clinical record lacked direction or orders for [CONDITION(S)] assessments, observation and/or precautions and care of the [CONDITION(S)] shunt site (a graft catheter that aids the connection from a hemodialysis access point to a major artery). A Nurses Progress Note dated 10/19/22 at 3:30 PM recorded R1 returned from [CONDITION(S)] and had elevated blood pressure and pulse rate. Staff sent R1 was sent to the hospital. On 11/08/22 at 10:34 AM R1 rested in her room while a nursing student assessed her vital signs. R1 had a [CONDITION(S)] shunt visible to her left arm Interviewed on 11/8/22 at 12:30 PM, Social Services Director (SSD) X stated R1 had a lot of complication since April of this year but her goal was to go home. SSD X said R1 had multiple health issues. She further stated she assisted with creating resident care plans and she was unaware R1's care plan did not reflect R1 received [CONDITION(S)]. On 11/08/22 at 1:30 PM Administrative Nurse D stated the facility did maintain a communication book at the nurses' station for R1's [CONDITION(S)]. Administrative Nurse D acknowledged the lack of orders and care plan directions regarding R1's [CONDITION(S)] and stated the issue would be corrected. The facility's [CONDITION(S)], Care for a Resident With policy revised 05/2021 documented, Residents with [CONDITION(S)] will be cared for according to currently recognized standards of care. The policy documented orders would be recorded for [CONDITION(S)] to be provided at a certified [CONDITION(S)] center. Staff would be educated on the type of assessment data that would be gathered about the resident's condition on a daily or per shift basis; the timing and administration of medication particularly those before and after [CONDITION(S)], and the care for grafts and fistulas. This same policy required agreements between the facility and contracted [CONDITION(S)] facility to include all aspects how the resident care would be managed, including, how the care plan would be developed and implemented. The facility failed to provide appropriate [CONDITION(S)] care for R1. This placed the resident at increased risk for adverse complications related to [CONDITION(S)].

The facility identified a census of 56 residents. Based on observations, record review, and interviews, the facility failed to ensure proper hand hygiene, failed to disinfect mechanical lifts after resident usage, and failed to provide sanitary respiratory care and services for Resident (R) 3. This deficient practice increased the risk to spread illness and infection to all affected residents. Findings included: - On 10/05/22 at 11:28 AM, Administrative Nurse D donned (put on) gloves to perform a glucometer (instrument used to calculate blood glucose) check on R1 then doffed (removed) gloves. She exited R1's room and donned gloves to sanitize glucometer. Administrative Nurse D doffed gloves and touched papers handed to her by another staff member. She donned gloves and continued to sanitize glucometer and the resident specific storage container. Administrative Nurse D doffed gloves and touched the computer then donned gloves and proceeded to pop medication into a medication cup from the narcotic lock box then doffed gloves. No hand hygiene was performed after doffing and before donning gloves during observation. She signed off the medication in the narcotic count book and proceeded to a resident's room to administer medication. Administrative Nurse D exited resident's room and returned to medication cart then performed hand hygiene. On 10/05/22 at 01:41 PM, R3's oxygen tubing was not dated or stored in a bag when not in use. On 10/05/22 at 01:53 PM, Certified Nurse Aide (CNA) M exited a resident's room with the sit-to-stand (mechanical lift that helps patient rise from a seated to a standing position) lift and placed it in the hallway. No disinfecting of the mechanical lift observed. Certified Medication Aide (CMA) R exited resident's room and proceeded down the hallway, no hand hygiene observed. On 10/05/22 at 02:09 PM, CMA R and CNA N exited a resident's room with a Hoyer lift (total body mechanical lift used to transfer residents) and placed it in the hallway. No disinfecting of the mechanical lift observed. On 10/05/22 at 02:05 PM, CNA M stated she did not replace oxygen tubing. She stated hand hygiene was performed after resident cares, when leaving a resident's room, after doffing gloves, and before donning gloves. CNA M stated mechanical lifts should be wiped down after using but she had never done that. On 10/05/22 at 02:17 PM, Administrative Nurse D stated oxygen tubing was replaced on night shift and were dated then stored in a plastic bag. She stated hand hygiene was performed all the time, when visibly soiled, after changing anyone, and after doffing gloves. Administrative Nurse D stated sanitizing wipes were used to cleanse the mechanical lifts between uses. The facility's Handwashing/Hand Hygiene policy, last revised March 2020, directed hand hygiene was performed after removing gloves, when hands were visibly soiled, before and after direct resident contact, and before and after performing any invasive procedures. The facility's Cleaning of Shared Medical Equipment policy, last revised August 2021, directed common shared resident care equipment may have included stethoscopes, glucometers, and mechanical lifts and was routinely cleaned and when appropriate, disinfected before and after reuse. The facility's Oxygen Administration policy, last revised June 2021, directed oxygen pieces of equipment were dated as appropriate. The facility failed to ensure proper hand hygiene, failed to disinfect mechanical lifts after resident usage, and failed to provide sanitary respiratory care and services for R3. This deficient practice increased the risk to spread illness and infection to all affected residents.

The facility had a census of 44 residents. The sample included 7 residents. Based upon observation, record review and staff interview the facility failed to reposition and provide interventions to prevent the development of pressure ulcers for 2 (#2, #3) of 2 residents sampled for pressure ulcers. Findings included: - Review of resident #2's quarterly Minimum Data Set 3.0 ((MDS) dated [DATE] identified the resident scored 9 (moderately impaired cognition) on the Brief Interview for Mental Status, required extensive assistance with bed mobility, extensive staff assistance with eating and dressing, totally dependent upon staff for transfers, locomotion on/off the unit, and personal hygiene and did not walk in the room/corridor. The MDS recorded the resident was always incontinent of bowel and bladder, weighed 178 pounds, had not experienced a weight loss, had (1) Stage 3 pressure ulcer, moisture associated skin damage and was not on a turning/repositioning program. The resident's care plan dated 1/17/13 addressed the resident had a Stage 3 pressure ulcer on his/her right heel, received 120 cubic centimeters of 2 Cal (a nutritional supplement) for wound healing, staff floated the resident's heels, repositioned the resident every 2 hours, and the resident utilized a pressure relieving device in the wheelchair and in bed. On 10/23/12 the facility received a physician's orders [REDACTED]. The resident's wound assessment sheet documented on 11/21/12 (the pressure ulcer developed between 9/14/12 to 9/20/12) the resident had a facility acquired unstagable pressure ulcer on his/her right heel that measured 4.1 centimeters (cm) by 3 cm with a depth of 0.8 cm. On 12/28/12 the pressure ulcer was a Stage 3 that measured 3.8 cm by 2.5 cm by 0.7 cm. On 1/18/13 the Stage 3 pressure ulcer measured 2.7 cm by 1.8 cm by 0.3 cm. The resident's assessment sheet dated 1/25/13 documented the resident had a Stage 1 pressure ulcer on the inner aspect of his/her lower right buttock. The resident's laboratory report dated 1/22/13 recorded the resident's [MEDICATION NAME] level was low at 3.2 grams/deciliter (g/dl) (normal reference range 3.5-5.7 g/dl). Review of the resident's weight log revealed the resident had experienced a weight loss of 15 pounds or 8.3 percent (%) of his/her body weight from 1/14/13 to 1/21/13. On 1/24/13 at 11:30 A.M., 11:40 A.M., 11:50 A.M., 12:00 P.M., 12:10 P.M., 12:15 P.M., 12:20 P.M., 12:30 P.M., 12:40 P.M., and 12:45 P.M. the resident sat in his/her wheelchair at the dining room table. Observation revealed a heel protector boot on the resident's right foot, and a sock on the resident's left foot and the resident's feet rested directly on the wedge. On 1/24/13 at 1:00 P.M. direct care staff J pushed the resident from the dining room to his/her room. The resident continued to sit in the wheelchair in his/her room at 1:05 P.M., 1:10 P.M., 1:15 P.M., 1:25 P.M., 1:35 P.M., 1:45 P.M., 1:55 P.M. and 2:00 P.M. At 1:55 P.M. licensed nurse E changed the dressing on the Stage 3 pressure ulcer of the resident's right heel (the resident sat in the wheelchair). At 2:05 P.M. direct care staff I propelled the resident in the wheelchair to the dining room to an activity. Observation revealed a heel protector boot on the resident's right foot, and a sock on the resident's left foot and the resident's feet rested on the wedge. On 1/24/13 the resident continued to sit in the wheelchair in the dining room at 2:10 P.M., 2:20 P.M., 2:30 P.M., 2:40 P.M., 2:45 P.M., 2:50 P.M., 2:55 P.M., 3:05 P.M., 3:15 P.M., 3:20 P.M., 3:25 P.M., 3:30 P.M., and 3:45 P.M. ( the resident sat in the wheelchair a duration of 4 hours and 15 minutes without a change in position). Observation revealed a heel protector boot on the resident's right foot, and a sock on the resident's left foot and the resident's feet rested on the wedge. At 3:45 P.M. direct care staff I and direct care staff K transferred the resident from the wheelchair to the bed via a mechanical lift. During interview with the resident at that time the resident stated his/her bottom felt raw and burned. Observation revealed the resident had a chaffed area on his/her right buttock that measured 0.5 cm by 0.5 cm and the resident was incontinent of urine. Direct care staff I stated staff should reposition the resident every 2 hours. On 1/25/13 the resident sat in the dining room in his/her wheelchair at 7:20 A.M. The resident sat in the wheelchair at the dining room table at 7:30 A.M., 7:45 A.M., 7:50 A.M., 7:55 A.M., 8:00 A.M., 8:10 A.M., 8:20 A.M., 8:30 A.M., and 8:35 A.M. At 8:45 A.M. the resident sat in the wheelchair in his/her room. The resident continued to sit in the wheelchair in his/her room at 8:55 A.M., 9:00 A.M., 9:10 A.M., 9:20 A.M., 9:30 A.M., 9:40 A.M. and 9:45 A.M. (duration of 2 hours and 25 minutes without a change in position). Observation revealed a heel protector boot on the resident's right foot, and a sock on the resident's left foot and the resident's feet rested on the wedge. On 1/25/13 at 10:25 A.M. direct care staff L entered the resident's room and the resident laid in bed and a bedpan under the resident. During interview with the staff at that time, direct care staff L stated he/she placed the resident in bed around 10:00 A.M. Direct care staff L stated he/she got the resident out of bed that A.M. around 6:45 A.M. The resident complained his/her bottom was sore but not as sore as yesterday. Observation revealed the resident had a red area on the lower aspect of his/her right buttock that measured approximately 0.5 cm by 0.5 cm. Further observation revealed a wedge under the resident's feet, the resident's heels not floated, a heel protector on the resident's right foot, a sock on the resident's left foot and the resident's left foot in direct contact with the wedge. Direct care staff L stated staff repositioned the resident every 2 hours. On 1/25/13 at approximately 1:30 P.M. nursing administrative staff C performed a wound assessment on the resident. During interview with the staff at that time he/she stated the pressure ulcer on the resident's heel was facility acquired. Nursing administrative staff C stated the area on the lower aspect of the resident's right buttock was a Stage 1 pressure ulcer. Nursing administrative staff B on 1/25/13 at approximately 5:15 P.M. stated resident repositioning schedules should be individualized but staff should reposition residents at least every 2 hours. The facility failed to reposition this resident that developed a Stage 3 pressure ulcer in the facility, at least every 2 hours as planned. - Review of resident #3's quarterly Minimum Data Set (MDS) 3.0 dated 1/8/13 identified the resident scored 0 (severely impaired cognition) on the Brief Interview for Mental Status, was totally dependent upon staff with bed mobility, transfers, locomotion on/off the unit, dressing, eating, toilet use and required extensive staff assistance with personal hygiene. The MDS included the resident was always incontinent of urine, weighed 178 pounds, and had not experience a weight loss. The MDS included the resident had (2) Stage 2 pressure ulcers present upon admission, utilized a pressure relieving device in his/her wheelchair and bed and not on a turning/repositioning program. The resident's pressure ulcer Care Area assessment dated [DATE] documented the resident had a Stage 2 on his/her buttock upon admission, the resident was incontinent of bowel and bladder, and totally dependent upon staff for bed mobility and transfers. A nutrition assessment completed by a Registered Dietician on 1/14/13 documented nursing staff reported the resident's wounds opened and closed, the resident consumed 100 percent (%) of meals and there were no recommendations made. On 10/15/12 the resident scored 12 (high risk for the development of pressure ulcers) on the Braden Scale (scale used to predict the development of pressure ulcers). The resident's care plan dated 10/31/12 addressed the resident had a Stage 2 pressure ulcer on his/her left buttock present upon admission, the resident required assistance of 2 staff members for mobility, the resident was incontinent of bowel and urine, and utilized a pressure relieving device in the wheelchair and bed. An entry dated 12/14/12 documented the area on the resident's coccyx reopened. The resident's care plan did not include the frequency of the resident's positioning and did not included interventions to prevent the development of new pressure ulcers. Review of the resident's wound assessment revealed on 1/18/13 the resident had a Stage 2 pressure ulcer on his/her right lower buttock that measured 0.8 centimeters (cm) by 1 cm. The resident's wound assessment dated [DATE] documented the resident had 2 pinpoint area pressure ulcers on his/her right buttock; the upper one measured 0.2 cm by 0.2 cm and the one on the lower portion of the resident's right buttock measured 0.2 cm by 0.2 cm. On 1/24/13 at 11:42 A.M. staff assisted the resident with the lunch meal. Observation at 12:15 A.M. revealed the resident consumed 100 percent of the meal. On 1/25/13 at 7:20 A.M. the resident sat in a tilt/recliner chair (upright position) at the dining room table. The resident continued to sit in the chair at the dining room table at 7:30 A.M., 7:40 A.M., 7:45 A.M., 7:50 A.M., 7:55 A.M., 8:00 A.M., and 8:10 A.M. At 8:20 A.M. the resident sat in the tilt/recliner chair (slightly reclined) at 8:25 A.M., 8:30 A.M., 8:35 A.M., 8:45 A.M., 9:00 A.M., 9:15 A.M., 9:30 A.M., 9:45 A.M., and 9:50 A.M. At 10:05 A.M. (the resident sat in the chair 2 hours and 40 minutes) direct staff L and direct care staff O transferred the resident from the tilt/recliner chair to the bed (direct care staff exited the resident's room after the resident was placed in bed). Observation at that time revealed the resident had a dressing on his/her right buttock, the resident's scrotum reddened and the resident was incontinent of urine. During interview with direct care staff L at that time he/she stated he/she placed the resident in the chair in the upright position at approximately 7:00 A.M. Direct care staff L stated staff repositioned the resident at least every 2 hours which included manually removing the resident from the chair. On 1/25/13 at approximately 10:40 A.M. therapy consultant N stated he/she could not say whether slightly tilting the resident's chair provided sufficient repositioning for this resident with a pressure ulcer. Therapy consultant N stated positioning was based on each individual needs, and he/she did not know if reclining the chair was sufficient for this resident. On 1/25/13 at approximately 1:15 P.M. administrative nursing staff C performed a skin assessment on the resident. Observation revealed the resident in bed on his/her back, a wedge under the resident's feet, the resident had on socks, the resident's heels were not floated and in direct contact with the wedge. Further observation revealed the inner aspect of the resident's legs in direct contact with each other (no device in place to prevent the direct contact). During an interview with administrative nursing staff C, at that time, he/she confirmed the resident's heels were not floated and the resident's legs were in direct contact with each other. Administrative nursing staff C stated the resident's pressure ulcer opened and closed. Administrative staff C stated the pressure ulcer he/she documented on 1/18/13 healed and the Stage 2 pressure ulcers on the resident's upper and lower right buttock were new. Observation revealed both of the areas measured approximately 0.5 cm by 0.5 cm. On 1/25/13 at approximately 5:15 P.M. administrative nursing staff B confirmed the resident's care plan did not address the resident's positioning. Administrative nursing staff B stated positioning was individualized based on the needs of the resident. Administrative nursing staff B stated in order for the pressure to be effectively relieved, staff should remove the resident from the chair. The facility failed to assess the resident to determine if tilting the chair provided effective pressure relief, and failed to implement interventions to minimize the development of pressure ulcers for this cognitively impaired resident with a history of pressure ulcers.

The facility documented a census of 46 residents. The sample included 3 residents. Based on record review and staff interviews, the facility failed to provide effective interventions for the prevention of falls for 1 (#1) resident of the sample that resulted in a fracture. Findings included: - The closed record of resident #1's Physician order [REDACTED]. The quarterly Minimum Data Set 3.0 ((MDS) dated [DATE] documented the resident's Brief Interview for Mental Status score of 4 which revealed the resident had severe cognitive impairment. The MDS further documented the resident required extensive assist of 1 person with bed mobility, transfers, and locomotion. The resident required a walker and/or wheelchair for mobility. The resident had 2 or more falls and 1 fall with major injury. The Care Area Assessment (CAA) dated 12/23/11 for falls documented the resident had several falls and required assistance with toileting. The care plan initiated on 1/24/11 documented the resident was at risk for falls related to history of falls and decreased safety awareness. The interventions included: bed to remain in a low position unless staff performed personal cares, call light and personal items available and in easy reach, resident should wear non-skid footwear to prevent slipping, staff should use a gait belt with transfers, staff should keep the environment well lit and free of clutter, staff should assist the resident as needed to get to his/her personal items, staff moved the resident closer to the nurses ' station for closer observation, staff should observe the resident for side effects of medications, and staff should remind the resident of the consequences of ambulating unassisted. Sometimes the resident would get up unassisted and attempt to ambulate with a walker. Please remind the resident of the risks of walking by self and staff should walk behind the resident with a wheelchair when the resident was adamant about walking. The nurses' notes and care plan revealed the following: Nurses notes documented on 7/6/12 at 7:00 P.M. the staff found the resident on the floor with a skin tear on his/her right elbow with the new intervention to use a mechanical lift for transfers. The nurses notes documented on 7/14/12 at 4:00 P.M. the staff found the resident on the floor. The resident rolled out of his/her bed. The interventions included to add a mat at the bedside and a lipped mattress to define the parameters of the bed. The nurses notes documented on 8/13/12 at 8:15 P.M. the staff found the resident on the floor in front of his/her wheelchair. The resident obtained an abrasion on his/her right leg. No new interventions documented. The nurses notes untimed and dated 8/14/12 documented the resident was moaning. The resident provided no answer when asked by the nurses if he/she was hurting. The nurses notes documented on 8/15/12 at 4:11 P.M. the resident complained of right shoulder pain. The physician ordered an x-ray of the right shoulder. Further documentation on 8/15/12 at 10:19 P.M. revealed the resident's x-ray showed a fracture of the right distal clavicle with mild displacement. The facility transferred the resident to the hospital for further evaluation. The clinical record lacked evidence the facility assessed the causal factors of the fall. Further more the facility failed to impairment interventions after the 8/13/12 fall. The nurses documented on 9/28/12 at 8:12 P.M. the staff heard a yell coming from the resident's room. The staff found the resident lying on his/her left side on the floor with his/her feet tangled in the wheelchair. The resident was bleeding from 2 lacerations, one on the forehead and one on the bridge of his/her nose. The resident's glasses were across the room with one side broken off. The resident complained of pain in his/her chest, head and left shoulder. The facility transferred the resident to the hospital per ambulance. The Hospital Discharge Summary Note dated 9/30/12 documented the resident presented with a fall and a forehead laceration. The patient had very poor prognosis with chronic conditions. The physician recommended hospice consideration upon return to nursing home. Per facility report the patient was at his/her baseline mental status, that being awake and oriented to self only. The computed tomography (CT) of the head revealed no acute intracranial findings and no new problems through the night. The patient appeared to be uncomfortable and refused oral medications. The hospital used Dermabond to glue the lacerations of the forehead and nose into close approximation. On 10/30/12 at 9:18 A.M. licensed nursing staff B revealed the nurses would assess the resident for injuries if a resident was found on the floor. The nursing staff would assist the resident off the floor with a mechanical lift if no injuries found and placed the resident either in his/her bed or in the resident's chair. The nursing staff would then continue to assess for any injuries for the next 72 hours. If the resident obtained a head injury or the fall was not witness, the nursing staff would do neurological checks per the facility policy. The staff would revise the care plan after talking with the director of nursing services. The revised January 2011 facility policy "Falls Management Clinical Guidelines" instructed the facility nurses to continue an ongoing assessment and documentation of the resident's condition. The facility failed to timely assess and provide effective interventions for this cognitively impaired, dependent resident. The resident experienced two falls with injury without evidence the facility assessed and identified the causative factors and failed to provide interventions between the two falls to prevent further falls with injury.