Every finding on record at Lawrence Presbyterian Manor

The facility had a census of 37 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to store, distribute, and serve food by professional standards for food service safety in the facility's kitchen, kitchenette, and one of two dining rooms. Findings included:- On 02/16/26 at 01:30 PM, observation in the kitchen revealed a silver one-door refrigerator contained an unlabeled, undated container with two fish filets. On 02/01/26 at 01:40 PM, Dietary Staff (DS) DD verified the above finding and stated staff should label and date food items before placing them in the refrigerator. DS DD discarded the fish filets in a trash can. On 02/16/26 at 05:38 PM, observation during supper meal service revealed Licensed Nurse (LN) G touched R6's hair. LN G did not wash her hands and then passed dinner plates and touched the inside top surface of three residents' plates. On 02/17/26 at 11:25 AM, observation in the kitchenette, during the noon meal service, revealed Certified Nurse Aide (CNA) MM walked into the kitchenette in front of the open steam table with the back of his hair hanging out of a hairnet approximately one inch. Observation revealed DS CC lacked a cover on his beard. Observation on 02/17/26 at 12:00 PM, during the noon meal service revealed DS CC donned gloves, touched the steam table and the hot box door, and with the same soiled gloves, picked up a hamburger bun and placed it in the microwave, touching the microwave door. Further observation revealed DS CC, with the same soiled gloves, picked up the bun from the microwave and transferred it to a plate. DS CC then picked up a hamburger patty with her gloved hands, placed it on the bun, retrieved a container with lettuce and onions, and with the same soiled gloves, picked up lettuce and onions with her gloved hands, and placed them on top of the hamburger, then removed and discarded her gloves. At 12:25 PM, observation revealed DS CC donned gloves, touched the hot box, microwave door, and steam table, then with the same soiled gloves, picked up two chicken strips using her gloved hands, and placed them on a resident's plate, then removed and discarded the gloves. Observation on 02/17/26 at 12:28 PM, in the kitchenette during the noon meal service, revealed CNA MM walked into the kitchenette a second time, in front of the open steam table, with the back of his hair hanging out of a hairnet approximately one inch. CNA MM did not wear a cover on his beard and went to the coffee machine and retrieved a cup of coffee for a resident. On 02/17/26 at 12:11 PM, observation revealed Certified Nurse Aide (CNA) M touched the inside top surface of three residents' plates, took necklaces off of a resident's neck, did not wash her hands, then passed trays again, without washing her hands. On 02/17/26 at 12:30 PM, Certified Dietary Manager (CDM) BB verified CNA MM's hair hanging out in the back and CNA MM did not wear a beard cover. CDM BB instructed CNA MM to cover his hair in the back and use a hair net to cover his beard. CDM BB verified DS CC had picked up the above food items with soiled gloves and stated DS CC should have used tongs. The facility's Storing: Food and Equipment Policy, revised 02/26, documented staff should ensure all food items are labeled. Each label must contain the following information:Product nameUse-by dateDate the product was prepared or openedTime prepared and team member initials where applicableDate frozen, if applicableDate thawed, if applicable.The facility's Personal Hygiene Policy, undated, documented when handling food, refrains from touching face, mouth, nose, hair, exposed skin, and clothing. The policy instructed staff to wear a hairnet or cap to restrain all hair, wear clean, disposable gloves when handling ready- to eat-food without a utensil, and wash hands frequently.

The facility had a census of 37 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to ensure a sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections when staff failed to follow 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)when providing care for Resident (R) 5 and R6. Staff also failed to cover a cart with the resident's linen when transporting it down the hall.Findings included:- R6's Electronic Medical Record (EMR) documented diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), history of transient ischemic attack (TIA- temporary episode of inadequate blood supply to the brain) and cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), peripheral vascular disease(PVD- slow and progressive circulation disorder causing narrowing, blockage, or spasms in a blood vessel), encounter for palliative care(treatment designed to relieve or reduce the intensity of uncomfortable symptoms), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) disorder. R6's Quarterly Minimum Data Set (MDS), dated [DATE], documented R6 had severe cognitive impairment, physical behavioral symptoms directed toward others, which occurred one to three days during the look-back period. R6 had functional range of motion impairment of both sides of the upper and lower extremities, and was dependent on staff for bed mobility, transfers, and activities of daily living. The MDS further documented R6 was always incontinent of urine and bowel, had no infections or skin issues, and R6 received an antibiotic (a class of medications used to treat infections). R6's Urinary Incontinence Care Area Assessment (CAA), dated 02/06/25, documented R6 was dependent on staff for activities of daily living and toileting hygiene. The CAA further documented R6 had a history of urinary tract infection (UTI-an infection in any part of the urinary system), took oral preventative antibiotic, and had 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) due to a diagnosis of multiple drug-resistant organisms (MDRO-common bacteria that have developed resistance to multiple types of antibiotics) in the urine. The Care Plan dated 02/09/26, documented R6 was dependent on staff for toileting needs and care before and after meals, at bedtime, and during night rounds. The Care Plan, further documented, per the Centers for Disease Control and Prevention (CDC) recommendation, the resident was on Enhanced Barrier Precaution for all care due to the MDRO urine, for the protection of R6 and the staff. The Physician Order dated 02/03/25 directed staff to administer cephalexin (antibiotic) 250 milligrams (mgs) capsule by mouth one time a day for UTI prevention. On 02/17/26 at 12:06 PM, R6's room had an EBP sign and a three-drawer tote positioned under the EBP sign, which contained blue gloves and yellow disposable gowns. Certified Nurse Aide (CNA) N and CNA Q entered R6's room and retrieved gloves from the bathroom and donned them. Staff explained to R6 they were going to check her brief and get her up for the midday meal. CNA N and CNA Q both provided peri-hygiene care to R6, by removing the brief, cleansing the area with a disposable wipe, placing a clean brief on the resident, then using the mechanical lift to transfer R6 to the Broda Chair. Neither CNA N nor CNA Q changed gloves during the procedure, nor wore a gown. CNA Q stated she was not sure why R6 had EBP, but thought it had something to do with R6's bottom area. On 02/17/26 at 12:21 PM, Licensed Nurse (LN) H verified R6 had EBP sign and storage tote outside the room. LN H stated she was not sure of the reason for the EBP but knew where to look to find the reason. LN H reported R6 required EBP due to MDRO in the urine. LN H verified staff providing personal care to R6 should wear gloves and gowns. LN H also verified that staff should change gloves and put on clean gloves once they have finished cleaning the resident and placing a clean brief on R6. On 02/17/26 at 02:43 PM, Administrative Nurse E stated the staff had been instructed that during care, if during care the staff's clothing did not come in contact with the resident's clothing, the staff did not have to use a gown. Administrative Nurse E verified changing briefs and providing perineal hygiene, the staff should have donned gowns. Administrative Nurse E also verified the staff should have changed gloves and put clean gloves on following the perineal care and placing clean incontinent products on the resident. The facility's Infection Control policy, dated 10/06/25, documented that EBP refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high-contact resident care activities. EBP are used in conjunction with standard precautions and expand the use of PPE to include donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. EBP are indicated for residents with any of the following: infection or colonization with a CDC-targeted MDRO when Contact Precautions. - On 02/17/26 at 02:30 PM, observation revealed a sign on the wall outside R5's room door EBP, and instructed staff to wear a gown and gloves when providing care for R5. On 02/17/26 at 02:55 PM, Certified Nurse Aide (CNA) O and CNA P entered R5's room, placed gloves on. CNA O assisted R5 to turn on her left side, holding her on it while CNA P provided perineal (private area) care without wearing a gown. On 02/17/26 at 03:09 PM, when CNA P was asked about the EBP signage and the cart with EBP supplies outside the door, CNA P replied that the resident was on EBP and staff were to wear gloves and use hand sanitizer when providing R5 care. On 02/17/26 at 02:43 PM, Administrative Nurse E stated the staff had been instructed that during care, if during care the staff's clothing did not come in contact with the resident's clothing, the staff did not have to use a gown. Administrative Nurse E verified changing briefs and providing perineal hygiene; the staff should have donned gowns. Administrative Nurse E also verified that the staff should have changed gloves and put clean gloves on following the perineal care. - On 02/16/26 at 01:44 PM, a laundry staff member was pushing residents' clothing down C Hall. The cart with residents' clothing did not have a cover. The residents' laundry on C Hall was not delivered in a sanitary manner. On 02/18/26 at 08:35 AM, Housekeeping Supervisor U stated laundry should be covered when delivered to residents. She stated that the laundry personnel were using the smaller cart to deliver laundry as she had hurt her shoulder. Housekeeping Supervisor U stated the smaller cart should always be covered. The facility's Infection Control Policy, revised 10/06/25, documented EBP refers to an infection control intervention designed to reduce transmission of multiple drug-resistant organisms (MDRO-common bacteria that have developed resistance to multiple types of antibiotics) that employ targeted gown and glove use during high-contact resident care activities.

The facility had a census of 37 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to utilize an antibiotic stewardship program that included tracking, monitoring, and attempts to decrease the use of unnecessary antibiotics (a class of medications used to treat infections). Findings included: - R6's Quarterly Minimum Data Set (MDS), dated [DATE], documented R6 received an antibiotic (a class of medications used to treat infections). R6's Urinary Incontinence Care Area Assessment (CAA), dated 02/06/25, documented R6 was dependent on staff for activities of daily living and toileting hygiene. The CAA further documented R6 had a history of urinary tract infection (UTI-an infection in any part of the urinary system), took oral preventative antibiotic, and required 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) due to a diagnosis of multiple drug-resistant organisms (MDRO-common bacteria that have developed resistance to multiple types of antibiotics) in the urine. The Care Plan dated 02/09/26, documented R6 had functional bladder and bowel incontinence, dementia, impaired mobility, a history of UTI, and was on enhanced barrier precautions to protect herself and others from spreading of a MDRO. The care plan directed staff to keep the resident's incontinent brief dry and clean and encourage adequate fluids. The care plan further documented R6 had long-term antibiotics as a preventative for UTI. The Physician Order dated 02/03/25 directed staff to administer cephalexin (antibiotic) 250 milligrams (mgs) capsule by mouth one time a day for UTI prevention. On 02/17/26 at 12:06 PM, R6's room had an EBP sign and a three-drawer tote positioned under the EBP sign, which contained blue gloves and yellow disposable gowns. Certified Nurse Aide (CNA) N and CNA Q entered R6's room and retrieved gloves from the bathroom and donned them. Staff explained to R6 they were going to check her brief and get her up for the midday meal. CNA N and CNA Q both provided peri-hygiene care to R6, by removing the brief, cleansing the area with a disposable wipe, placing a clean brief on the resident, and then using the mechanical lift to transfer R6 to the Broda Chair. Neither CNA N nor CNA Q changed gloves during the procedure, nor wore a gown. CNA Q stated she was not sure why R6 had EBP, but thought it had something to do with R6's bottom area. On 02/17/26 at 12:21 PM, Licensed Nurse (LN) H verified R6 required EBP due to MDRO in the urine. On 02/17/26 at 02:43 PM, Administrative Nurse E reported prophylactic antibiotics were not tracked, trended, or reviewed by the pharmacist, and therefore had not been part of the reporting to the QAPI plan or meetings. The facility's Infection Control policy, dated 10/06/25, documented that the community is committed to following an antibiotic stewardship program based on Center for Disease Control Antibiotic Stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use through the community with surveillance protocols. The facility's Antibiotic Stewardship policy dated 02/04/25, antibiotic stewardship can be defined as a set of coordinated strategies to improve the use of antimicrobial medications with the goal of enhancing resident health outcomes, reducing antibiotic resistance, and decreasing unnecessary cost.

The facility had a census of 37 residents. The sample included 12 residents. Based on observation, interview, and record review the facility failed to resolve recurring issues reported by the Resident Council. Findings included:- A review of the facility's Resident Council minutes from 01/2025 to 02/2026 indicated the council had recurring concerns related to call light response times, long waits from posted mealtime, and hot menu items that were served cold. The Resident Council Minutes for 01/2025 noted that the previous discussion of dining service was slow. The Resident Council Minutes for 02/2025 noted the bacon had improved, and the upcoming updated call light system and security cameras would be done before carpet replacement in 2025. The Resident Council Minutes for 03/2025 noted the facility would have plate warmers by the beginning of March. The Resident Council Minutes for 04/2025 noted previous discussion of receiving fewer green beans, more cooked carrots, broccoli, or corn. Plate warmers were now in service, and residents had difficulty getting the staff's attention during meals if residents wanted more coffee. The Resident Council Minutes for 05/2025 noted the food was still being served cold, waiting up to 40 minutes to have food served. Per the dining director, the designated mealtimes were 07:00 AM, 12:00 PM, and 05:00 PM and food was transferred from the main kitchen in a hotbox up to the second floor, then transferred into the steam table. The notes also included that staff were reminded that all staff could respond to call lights and the new call light system was coming in the next month or two. The Resident Council Minutes for 06/2025 noted the food was still being served cold, the quality of the food had deteriorated, plates had only starch foods, the meat was very tough, and residents reported they continued waiting up to 40 minutes for their meal to be served. The Resident Council Minutes for 07/2025 noted questions regarding slow response to call lights and getting more help in the dining room. The Resident Council Minutes for 08/2025 noted food did not get to the resident's tables hot, the quality of food worsened, and people could not chew food well. The minutes also noted some of the residents did not like the new call light system. The Resident Council Minutes for 09/2025 noted the food was not hot, the fries were cold, the meat was overcooked, and help was not available in the dining room. The notes also included call light wait periods of 30 to 40 minutes. The Resident Council Minute for 10/2025 noted the food was lukewarm, items on the menu were not available, and out of options to choose from, tough meat, especially pork, waiting 30 to 40 minutes to be served the meal, and up to 49 minutes for call light response in the early morning. The Resident Council Minutes for 11/2025 noted residents continued getting cold food and received something different than what the resident had ordered. The Resident Council Minutes for 12/2025 noted food was getting better, breakfast could be warmer, and it was a hassle to get food heated in the microwave. The Resident Council Minutes for 01/2026 noted that sometimes the food was cold. On 02/17/26 at 03:09 PM, Social Service X explained she assisted the residents with the resident council meeting and note-taking. Social Service X explained that the dietary supervisor was present at most of the monthly meetings due to the dining complaints and concerns and felt most of the dining issues were mostly repeated by a resident who was discharged in 11/2025, but the residents continued to report cold food. On 02/17/26 at 08:00 AM, Administrative Nurse D reported the resident council's concerns were brought to the department director to resolve the concerns. If the concerns continued, the facility would develop a plan through the Quality Assurance Performance Improvement (QAPI) plan to correct the ongoing issues. Administrative Nurse D stated the Executive Director and herself pulled call light response times which she reported were not lengthy, and the response time expectation was for call lights to be answered within three to five minutes. Administrative Nurse D reported the new call light system alerts were adjusted. On 02/18/26 at 12:30 PM, Administrative Staff A reported that a QAPI plan had not been implemented to address the ongoing dining service complaints. The facility's Resident Council policy, dated 01/05/23, documented the purpose of the resident Council will to provide an orderly means of communication between residents and Community administration, assist with activities which will benefit resident of the community, and allow residents to retain part of the responsibility for certain action affecting their day-to-day lives. The Executive Director shall act upon the recommendations of the Council concerning proposed policy and operational decisions affecting resident care and life in the community.

The facility had a census of 37 residents. Based on observation, record review, and interview, the facility staff failed to measure food portions for two of three residents who received ground meat diets, Resident (R) 33 and R28. Findings included:- Observation on 02/17/26 at 12:00 PM, during the noon meal, revealed Certified Dietary Manager (CDM) BB oversaw the meal service. Dietary Staff (DS) CC took a pan of ground country fried chicken out of the hot box, used a plastic teaspoon, and placed three teaspoons of ground meat on plates for R33 and R28. Observation revealed DS CC removed a pan with collard greens from the same hot box and placed three teaspoons onto the plates for R33 and R28, and staff served the plates to the residents. On 02/17/26 at 12:30 PM, Certified Dietary Manager (CDM) BB verified the above finding and stated each resident should receive three ounces (oz) of both food items listed above. CDM BB stated staff should measure the proper portion before serving them to R33 and R28. The facility's Adjusted Portions Policy, revised 02/26, documented that the standard portion of meat for each resident should be three to four oz. The standard portion of vegetables for each resident should be half a cup.

The facility identified a census of 37 residents. The sample included 12 residents with one resident reviewed for activities of daily living (ADL). Based on observation, record review, and interview, the facility failed to ensure staff assisted Resident (R) 25 with grooming and shaving and further failed to ensure R25's clothing was clean, and without dried food stains.Findings Included: - R25's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), major depressive disorder (major mood disorder that causes persistent feelings of sadness), hypertension (elevated blood pressure), lack of coordination, and need assistance with person care.The Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 12, which indicated moderately impaired cognition. The MDS documented R25 needed setup or clean up assistance with eating, supervision or touch assistance with oral hygiene, partial/moderate assistance with toileting, and substantial/maximal assistance from staff for bathing. R25's Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) dated 10/29/25 documented R25 triggered for further development/review of his functional abilities due to a BIMS score greater than five and requiring more assistance with ADLs. The CAA documented R25 required assistance for eating and noted he used a wheelchair.R25's Care Plan documented the following:11/05/25 - R25 required maximum assistance with his four wheeled walker, with the wheelchair to follow due to endurance when ambulating.08/08/25 - R25 was dependent on one staff with bathing two times a week, R25 refused baths, and staff were to offer bathing at different times, or offer a bed bath.02/05/25 - R25 required moderate assistance with personal hygiene and set up assistance for oral care. R25 liked to be shaved daily and had his own teeth.02/05/25 - R25 required moderate assistance by one staff member to dress.02/05/26 - R25 had an activity of daily living (ADLs) self-care performance deficit related to activity intolerance and Alzheimer's.02/05/25 - R25 would decline showers for no reason when he was asked.02/05/25 - R25 would take at least one bath weekly in the next 90 days. R25's EMR under Task under Bathing documented the resident received a bath on 02/02/25, bathing was not applicable on 02/04/26, received a bath on 02/09/26, and refused a bath on 02/12/26. On 02/16/26 at 01:22 PM R25 sat in his grey reclining chair looking out the window, with his TV on. R25's hair appeared greasy, he had a three-to-four-day hair growth on his face, and his blue shirt had two large food stains on the front of his shirt. On 02/16/26 at 01:22 PM R25 stated he liked his face shaved every day. R25 stated the food stains on his shirt were from the supper meal on 02/15/26 and staff had not changed his shirt. R25 stated he could not remember when his last bath was. On 02/18/26 at 11:12 AM Certified Nurses Aide (CNA) NN stated the CNAs asked residents if they would like their bath on their scheduled bath days. She stated if the resident refused a bath, the aide would let the nurse on duty know and ask the resident if they would like a bed bath. She stated bathing was the resident's choice. CNA NN stated if the resident refused the bed bath, the aide was to change residents' clothes, brief, apply deodorant, and lotions. On 02/18/26 at 08:03 AM Licensed Nurse (LN) I stated the CNAs were to ask the resident twice, if the resident would like a bath or shower. She stated if the CNA stated the resident refused, it was the policy for the nurse to ask the resident, if the nurse could not get the resident to take a bath or bed bath, the nurse would chart this information in the resident's progress notes. On 02/18/26 at 08:09 AM Administrative Nurse D stated it was the facility's process to give each resident at least one shower a week. She stated there were times two showers a week were not given. Administrative Nurse D stated she expected CNAs to wash the residents and change the resident's clothes anytime the resident appeared unclean, or the residents' clothing was soiled. Administrative Nurse D stated CNAs were to shave residents anytime the resident wished to be shaved.The facility's Resident Right and Responsibility policy dated 04/22/19 documented the community would ensure the resident right to dignified existence, delf determination and person-centered care with access to persons and services inside and outside the community. The community would protect and promote the rights of each resident.

The facility identified a census of 35 residents. The sample included 12 residents and five Certified Nurse Aides (CNAs) reviewed for performance evaluations and the associated in-service training. Based on record review and interview, the facility failed to ensure two of the five CNA staff reviewed had the required yearly performance evaluations completed. This placed the residents at risk for inadequate care. Findings included: - A review of the facility's staffing list revealed the following CNAs were employed with the facility for more than 12 months: CNA N, hired on 01/10/14 had no yearly performance evaluations upon request. CNA M, hired on 05/26/22 had no yearly performance evaluations upon request. On 05/08/24 at 12:44 PM, Administrative Nurse D stated in August 2023, he started to get all the nursing staff's yearly performance reviews up to date. Administrative Nurse D stated he had not completed CNA M and CNA N at this time. Administrative Nurse D stated he had not received the self-performance paperwork back from CNA M and CNA N. Administrative Nurse D stated he started a performance improvement plan on the topic in December 2023. The facility's Staff Competency policy last reviewed on 10/11/21 documented all staff would receive education and training applicable to their position and job description. Checklists, Relias courses, and competency testing would be used to ensure staff are appropriately trained for the position. All clinical employees must complete the competency test at their annual review. The facility failed to ensure two of the five CNA staff reviewed had the required yearly performance evaluations completed. This placed the residents at risk for inadequate care.

The facility identified a census of 35 residents. The sample included 12 residents with one resident reviewed for treatment and services to prevent pressure ulcers (localized injury to the skin and underlying tissue usually over a bony prominence, because of pressure, or pressure in combination with shear and friction). Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 2's low air loss mattress was set at the appropriate setting for R2's weight, who was prone to pressure-related injury. This placed R2 at increased risk for the development of pressure ulcers and the development of new pressure ulcers. Findings included: - R2's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of dementia (a progressive mental disorder characterized by failing memory, and confusion), Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness)with Lewy body's, neurocognitive disorder (a type of progressive dementia that leads to a decline in thinking, reasoning, and independent function) psychotic disorder (a collection of symptoms that affect the mind, where there has been some loss of contact with reality), and hypertension (HTN-elevated blood pressure). The Significant Change in Status Minimum Data Set (MDS) dated [DATE] for R2 documented a Brief Interview of Mental Status (BIMS) score of zero. The MDS documented R2 was at risk for developing pressure ulcers. The MDS documented R2 was dependent on staff for all activities of daily living (ADLs). The Pressure Ulcer Care Area Assessment (CAA) dated 04 /01/24 documented R2 was at risk for pressure injury. The CAA documented a Braden (a tool developed to foster early identification of patients at risk for forming pressure ulcers) and pressure ulcer risk screening was completed. R2 had no skin issues at that time. R2's Care Plan dated 04/04/24 documented R2 was at risk for pressure ulcers and other skin impairments. The plan of care documented that every nursing shift would check to ensure a low-loss air mattress was plugged in and inflated. The plan of care for R2 dated 04/30/24 documented that every nursing shift would check the redness on R2's left gluteal (pertaining to the buttocks or buttocks muscles) area and apply barrier cream after incontinence care. The plan of care did not indicate the setting for a low-air loss mattress. R2's EMR under the Orders tab dated 04/01/24 revealed the following physician orders: Every nursing shift to check and ensure the air mattress was plugged in and inflated. R2's EMR under the Weights/Vital Sign tab revealed her current weight was 140.50 pounds on 05/05/24. On 05/29/24 at 01:35 PM R2 laid in her bed, turned to her left side. She had a washcloth on her forehead. R2's low air loss mattress was set at 210 pounds. On 05/30/24 at 07:07 AM R2 laid in her bed on her back with her eyes shut. R2's low air loss mattress was set at 210 pounds. On 05/08/24 at 09:41 AM, Licensed Nurse (LN) G stated the adjustments for setting on R2's bed were not in the EMR. She stated the order directed nursing to check to ensure the bed was plugged in and the mattress was inflated. LN G stated she thought checking settings was part of the order. LN G said she thought the setting on the mattress should be closer to R2's weight, but she was unsure. On 05/08/24 at 12:44 PM, Administrative Nurse D stated the facility did not take care of the low air loss mattress settings. He stated the settings were adjusted when the hospice set up the mattress. Administrative Nurse D stated facility staff had an order to check the mattress, not the settings. He stated the facility was working on putting something in place to ensure the settings were correct on mattresses that had weight settings. The facility's Skin Integrity policy revised on 10/22 documented that all residents are considered to some risk for the development of pressure ulcers and injuries. Nursing staff will evaluate skin integrity and tissue tolerance, implement preventative measures as indicated, and treat skin breakdown. The primary care provider admission orders authorize approval to begin using established skin and wound treatment guidelines. Dressing changes are performed by a licensed nurse. Licensed nurses may delegate minor skin tear treatments and preventative treatments in closed areas. The facility failed to ensure the low air loss mattress was set at the appropriate setting for R2's weight, who was prone to pressure-related injury. This placed R2 at increased risk for the development of pressure ulcers and the development of new pressure ulcers.

The facility identified a census of 35 residents. The sample included 12 residents with one resident reviewed for respiratory care. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 27'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 to decrease exposure and contamination. This deficient practice placed R27 at an increased risk of developing respiratory infection. Findings included: - R27's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of asthma (a disorder of narrowed airways that causes wheezing and shortness of breath), pulmonary nodule, and obstructive sleep apnea (a disorder of sleep characterized by periods without respirations). The Significant Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 14 which indicated intact cognition. The Quarterly MDS dated [DATE] documented a BIMS score of 14 which indicated intact cognition. The MDS documented that R27 used a non-invasive mechanical ventilator during the observation period. R27's Activities of Daily Living (ADLs)Functional/Rehabilitation Potential Care Area Assessment (CAA) dated 01/04/24 documented R27 required extensive assistance with her ADLs. R27's Care Plan dated 03/26/24 documented R27 was to wear her CPAP at night with no oxygen. R27's EMR under the Orders tab revealed the following physician orders: CPAP at night for obstructive sleep apnea dated 01/03/24. On 05/06/24 at 10:20 AM R27 lay on her bed. Her CPAP mask laid directly on her bedside table unbagged. On 05/08/24 at 09:07 AM R27 laid on her bed as she watched TV. R27's CPAP mask laid directly on the bedside table unbagged. On 05/08/24 at 10:25 AM, Certified Nurse Aide (CNA) O stated she believed the CPAP mask should be stored in a plastic bag like oxygen was stored when R27 was not wearing it. CNA O stated she had never removed R27's CPAP mask in the morning, R27 was usually awake when she entered R27's room. On 05/08/24 at 10:35 AM, Licensed Nurse (LN) G stated R27's CPAP mask should be bagged when not in use. LN G stated R27's daughter replaced the CPAP mask and cleaned the mask periodically when she visited her mother. On 05/08/24 at 12:44 PM, Administrative Nurse D stated CPAP masks should be stored in a container on the table, along with a cleaning solution. Administrative Nurse D stated the nursing staff should clean the CPAP mask. The facility was unable to provide a policy related care of respiratory equipment. The facility failed to ensure R27's CPAP mask was stored in a sanitary manner to decrease exposure and contamination. This deficient practice placed R27 at an increased risk of developing respiratory infection.

The facility had a census of 35 residents. The sample included 12 residents with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure nonpharmacological interventions were attempted and documented prior to administration of an antipsychotic (class of medications used to treat a mental disorder characterized by a gross impairment testing) medication for Resident (R) 2, who had a diagnosis of dementia (a progressive mental disorder characterized by failing memory, confusion). This placed the resident at risk for unnecessary psychotropic (alters perception, mood, consciousness, cognition, or behavior) medications and related complications. Findings included: - R2's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of dementia, Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness)with Lewy body's, neurocognitive disorder (a type of progressive dementia that leads to a decline in thinking, reasoning, and independent function), psychotic disorder (a collection of symptoms that affect the mind, where there has been some loss of contact with reality), and hypertension (HTN-elevated blood pressure). The Significant Change in Status Minimum Data Set (MDS) dated [DATE] for R2 documented a Brief Interview of Mental Status (BIMS) score of zero. The MDS documented R2 received antipsychotic drugs during the observation period. R2's Psychotropic Drug Use Care Area Assessment (CAA) dated 04/01/2024 documented a psychotropic drug medication side effect screening on 03/15/24, and psychotropic drug use side effects will be part of the plan of care. R2's Care Plan dated 04/04/24 documented R2 took Seroquel (antipsychotic medication) for Parkinson's psychosis. Staff would monitor for potential side effects such as urinary retention, skin changes, slurred speech, mental status, and behavioral changes. Staff would report side effects to the charge nurse for further evaluation. The Physician's Order dated 12/18/23 directed to give Seroquel 50 milligram (mg) tablet once daily for psychotic disorder with delusions. R2's EMR lacked documentation or evidence of nonpharmacological symptom management interventions that were implemented and failed before starting Seroquel. On 05/08/24 at 09:41 AM Licensed Nurse (LN) G stated that antipsychotic medications were ok to give to a resident with a dementia diagnosis. She stated residents with a diagnosis of psychosis needed antipsychotic medication. LN G stated she would try nonpharmacological interventions first if that was possible. On 05/08/24 at 12:44 PM Administrative Nurse D stated a nonpharmacological approach would be the best approach. He stated he would do talk therapy, but he had no residents who needed the therapy yet. He stated residents came into the facility on an antipsychotic and the facility tried to get the residents to the lowest dose. Administrative Nurse D stated the facility worked closely with physicians and pharmacists to ensure the resident was on the lowest dose of each medication. The facility's Psychotropic Medication Use policy, revised on 07/22 documented that psychoactive medications will not be used for discipline or convenience and will not be used unless necessary to treat medical symptoms. Residents receiving psychoactive medications will be monitored and observed for improvement or decline in functional status, target behaviors, and side effects. For any of the types of antipsychotics, gradual dose reductions and behavioral interventions will be done per physician orders, unless clinically contraindicated in an effect to discontinue the medication or to reach the lowest effective dose. Psychotropic medications are given to treat a specific condition diagnosed and documented in eh clinical record. The facility failed to ensure nonpharmacological interventions were attempted prior to the administration of an antipsychotic medication for R2, who had a diagnosis of dementia. This placed the resident at risk for unnecessary psychotropic medications and related complications.

The facility identified a census of 35 residents. The sample included 12 residents with one resident reviewed for hospice. Based on observation, record review, and interviews, the facility failed to ensure a communication process was implemented, which included how the communication would be documented between the facility and the hospice provider. This deficient practice created a risk for missed or delayed services and impaired care for Resident (R)32. Findings included: - R32s Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), dementia (progressive mental disorder characterized by failing memory, confusion), hearing loss, anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and dysphagia (swallowing difficulty). The Significant Change Minimum Data Set (MDS) dated [DATE] documented R32 had severely impaired cognition, and never or rarely made decisions. The MDS documented R32 was dependent on two staff assistants for all activities of daily living (ADLs). The MDS documented R32 received hospice services during the observation period. R32's Cognitive Loss/Dementia Care Area Assessment (CAA) dated 04/15/24 documented R32 was unable to participate in a Brief Interview of Mental Status (BIMS) assessment; the causes included general decline, advanced age, dementia, and cognitive communication deficit. R32's risk factors include falls, agitation, behaviors, weight loss, and communication. R32's Care Plan dated 04/25/24 documented the facility would coordinate R32's care and services with the hospice provider. The plan of care directed the facility to communicate with hospice regarding R32's preferences, care concerns, and needs. The plan of care documented a nurse would visit weekly to assess for changes, symptoms management, pain, discomfort, dyspnea (difficulty breathing), air hunger, mobility, and skin and recommend and implement changes. The hospice aide was to have one-on-one visits with reading, music, personal hygiene, preventative skin care, eating, drinking, and toileting. A review of the communication binder provided by the hospice revealed R32 was admitted to hospice services on 04/15/24. The hospice communication binder lacked the plan of care for R32 and the physician-signed terminal diagnosis for admission to hospice. The last documentation of hospice care was dated 05/02/24. On 05/08/24 at 09:35 AM Certified Nursing Aide (CNA) P stated there were binders in the front halls by the nursing station that contained hospice information. CNA P stated the binders contained R32's care needs. CNA P stated he was unsure what to look for in the binder and stated there were tabs with different instructions for nursing staff. On 05/08/24 at 09:41 AM Licensed Nurse (LN) H stated all hospice binders were kept in the cabinet next to the nursing charting station. LN H stated the facility had its care plan for communication of care, and hospice also had a care plan for each resident. R32 ' s care would be found in both care plans. On 05/08/24 at 12:44 Administrated Nurse D stated the facility had care plans for everyone. He stated R32 ' s Care Plan was found in medical records; the document had been scanned into his file instead of being put in the hospice binder. Administrative Nurse D stated the facility collaborated with hospice through the care plans. He stated all hospice providers were welcome to attend the weekly care plan meetings. The facility was unable to provide a policy related to hospice services. The facility failed to ensure a communication process was implemented, which included how the communication would be documented between the facility and the hospice provider. This deficient practice created a risk for missed or delayed services and impaired care for R32.

The facility identified a census of 35 residents. The sample included 12 residents with five residents reviewed for pneumococcal (a disease that refers to a range of illnesses that affect various parts of the body and are caused by infection) vaccinations. Based on record review and interviews, the facility failed to obtain a signed consent or declination for pneumococcal vaccination Prevnar 20 (PCV20) for Resident (R) 2, R25, and R86. This deficient practice placed the residents at risk of acquiring, spreading, and experiencing complications from pneumococcal disease. Findings included: - R2's clinical record documented she received Prevnar 13 (pneumococcal vaccination used for the prevention of pneumococcal disease caused by 13 serotypes of Streptococcus pneumoniae [bacteria that causes pneumonia]) on 04/01/15 and Pneumovax 23 (pneumococcal vaccination used for the prevention of pneumococcal disease caused by 23 serotypes of Streptococcus pneumoniae) on 05/01/17. R2's clinical record lacked evidence she received Prevnar 20 (pneumococcal vaccination used for the prevention of pneumococcal disease caused by 20 serotypes of Streptococcus pneumoniae) or had a signed declination for Prevnar 20 vaccination. R25's clinical record documented she received Pneumovax 23 on 01/01/97 and Prevnar 13 on 01/01/16. R25's clinical record lacked evidence she received Prevnar 20 or had a signed declination for Prevnar 20 vaccination. R86's clinical record documented she received Pneumovax 23 on 01/01/07 and Prevnar 13 on 10/09/18. R86's clinical record lacked evidence she received Prevnar 20 or had a signed declination for Prevnar 20 vaccination. On 05/08/24 at 10:28 AM, Licensed Nurse (LN) H stated when a resident was admitted to the facility, she asked them about their immunizations and the dates they were immunized or reviewed their admission records for their immunization history. She stated that was all she did with immunizations on admission. On 05/08/24 at 10:31 AM, Administrative Nurse E stated when a resident was admitted to the facility, if they had received Pneumovax 23 but not the Prevnar 13 or Prevnar 20, the resident was asked if they wanted to receive the vaccination. She stated if a resident had not received Prevnar 20, staff called the physician for immunization verification or to get an order to give the vaccination. She stated the resident or their representative then signed the consent form. Administrative Nurse E stated if the resident or their representative refused the vaccination, they signed a declination. On 05/08/24 at 10:57 AM, Administrative Nurse E stated the facility received the guidance on Prevnar 20 last week but she had heard the guidance was happening, so she started looking at who needed Prevnar 20 in April. She stated the facility received an order for R25 to receive Prevnar 20 on 05/01/24. Administrative Nurse E stated R2 was receiving end-of-life care and the facility did not receive an order to give Prevnar 20 yet. On 05/08/24 at 01:00 PM, Administrative Nurse D stated Administrative Nurse F was in charge of immunizations. He stated the facility found out about four weeks ago that Prevnar 20 was important and they started working on it two weeks ago. Administrative Nurse D stated the pharmacy informed the facility of new immunization guidance and if corporate received new guidance, they sent it to the facility too. On 05/08/24 at 01:03 PM, Administrative Nurse F stated when a resident was admitted to the facility, she looked through their immunization record or obtained their records for their immunizations. She stated she reviewed for Prevnar 13 and Pneumovax 23 but the guidance just changed to include Prevnar 20. Administrative Nurse F stated if a resident received Prevnar 13 or Pneumovax 23 over five years ago, it was recommended the resident receive Prevnar 20 with a physician order and family approval. She stated she tried to get consent or declinations within a couple of weeks after admission. The facility's Immunization- Pneumococcal policy, last revised 01/31/22, directed residents were provided the opportunity and were encouraged to receive the pneumococcal vaccination(s). The policy directed the facility to provide educational material regarding risks and benefits to residents and obtained the resident's consent for, or refusal of, each pneumococcal vaccination(s). If vaccination status was unknown, the pneumococcal vaccinations were offered upon admission. The facility failed to obtain a signed consent or declination for the PCV 20 for R2, R25, and R86. This deficient practice placed the residents at risk of acquiring, spreading, and experiencing complications from pneumococcal disease.

The facility identified a census of 35 residents. Based on observation, record review, and interviews, the facility failed to retain the daily posted nursing staffing data for the 18 months as required. Findings included: - Review of the daily posted nursing staffing data provided by the facility lacked any posted nursing staffing data for December 2023 (31 days). On 05/08/24 at 12:44 PM, Administrative Nurse D stated the nursing staff scheduler was responsible for ensuring the daily posted nursing hours form was retained for the required 18 months. Administrative Nurse D stated the previous staff member who was responsible for maintaining the posted nursing staff hours had not retained the forms as required. The facility ' s Daily Nurse Staffing Report policy last reviewed on 10/11/21 documented that the nursing service was to provide each resident admitted to the health care center with the appropriate level of care to attain his/her optimum level of functioning. Nursing service was staffed, organized, and equipped to provide nursing care on a 24-hour-a-day basis. Daily resident census and staffing information was available to the public. The facility would maintain the Daily Nurse Staffing Form for a minimum of 18 months and file it in the business office. The facility failed to retain the daily posted nursing staffing data for the 18 months as required.

The facility had a census of 36 residents. The sample included 12 residents with one reviewed for abuse. Based on observation, interview, and record review the facility failed to implement protective measures for the resident immediately after an allegation of abuse. This deficient practice placed Resident (R) 11 at risk for impaired safety and psychosocial wellbeing. Findings included: - R11's Electronic Medical Record (EMR), dated 09/22/22 documented diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS), dated [DATE], documented R11 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 14. The MDS documented R11 was verbally abusive one to three times weekly, required limited staff assistance for eating, and extensive staff assistance for bed mobility, transfers, toileting, and hygiene. R11 had range of motion impairment in all extremities, and received antipsychotic (medications used to treat major mental disorders), and antianxiety (medication used to calm fears and stress) medications. The Activities of Daily Living (ADL) Care Plan, dated 08/26/22, directed staff to provide total assistance of one to two nursing staff with ADL such as grooming, repositioning, toileting, bathing, eating, transferring and locomotion. The care plan directed staff to explain each procedure to R11 so she can participate in ADL care to the maximum of her ability. The Progress Note, dated 11/02/22 at 06:55 AM, documented about 04:00 AM staff alerted the nurse that R11 had a very large bowel movement. R11 was crying, and stated she had been raped. The nurse checked on her and R11 was sleeping soundly. The note stated at 05:30 AM the nurse offered R11 [MEDICATION(S)] (a narcotic drug used for moderate to moderately severe pain); R11 was awake and refused the medication. The nurse asked R11 how she was doing, and R11 said, you can see for yourself. The Progress Note, dated 11/02/22 at 07:03 AM, documented at 04:43 AM the nurse called the on-call nurse to report R11's crying and allegation. The Progress Note, dated 11/02/22 at 08:56 AM documented the nurse called R11's representative and reported the resident's statement that she had been raped. The nurse documented R11 had an extra-large bowel movement and staff were performing cares when R11 reported being raped. The nurse documented no male staff worked on the night shift when R11 reported being raped. The note documented the nurse offered the representative the choice of sending R11 to the emergency room (ER) for a rape exam. R11's representative reported that he did not think R11 was raped and reported R11 had made allegations of a man taking and doing things to her in the past. R11's representative did not feel it necessary for R11 to be sent to the ER for a rape exam at that time. The Social Worker Progress Note, dated 11/02/22 at 09:11 AM, documented the social worker interviewed R11 regarding her allegation of rape that she made to a nurse that morning. The note documented R11 denied telling anyone that she had been raped, stating I've never told anyone that. R11 denied being touched inappropriately by anyone. The Progress Note, dated 11/02/22 at 09:20 AM, documented staff called R11's hospice services and left a message for hospice to call back regarding pain/burning with urination and R11's report of rape. The Progress Note, dated 11/02/22 at 10:26 AM, documented hospice returned the call and spoke with the nurse regarding resident's report of rape and R11's behavior the last couple of days. On 11/02/22 at 08:34 AM, observation revealed R11 in bed, call light in reach, eyes closed, and lying on her left side. The facility's social worker went into the room to visit the resident. On 11/02/22 at 08:59 AM, observation revealed Certified Nurse Aide (CNA) M and Licensed Nurse G placed non-skid socks on R11, and after three minutes of attempting to get R11 to accept the gait belt, they laid her back down. R11 tried to swing her lags out of bed and self-transfer, she kicked at the blankets, and continued to complain while the aide was getting the lift. The nurse stayed with her. R11 was upset, would not allow them to use the total lift, and told them to leave her alone. R11 stated she knew her rights and wanted to stay where she was, with the lift sling under her. The aide was able to get her to cooperate and they used a gait belt and extensive assistance to transfer R11 to her recliner. On 11/02/22 at 09:35 AM, Administrative Staff A stated the resident denied the allegation of rape when the social worker interviewed her and R11 stated no one had ever raped her. Administrative Staff A stated R11 had a very large bowel movement around that time and said that hurt. Administrative Staff A stated no male aids worked that night and none of the male residents came out of their rooms during the night per nursing staff on duty. Administrative Staff A stated R11 had made false accusations before and when she lived at another facility, she had alleged rape. Administrative Staff A verified the following timeline of notification, intervention, and interviews for 11/02/22: At 03:40 AM, R11's call light activated, and two aides found R11 asleep and she mumbled when asked if anything was needed. The aides left room without providing cares. At 04:00 AM, two aides assisted R11 with incontinence cares and during cares R11 complained that she had been raped. The aides notified the nurse who checked on the resident and found her asleep. Administrative Staff A stated the nurse had come to the room while care was being provided but verified the nurse had not documented an assessment. At 04:43 AM, LN H called the Assistant Director of Nursing (ADON) to report the allegation and that R11 was crying. They discussed if any men were working or if any male residents had been up walking around. Administrative Staff A reported no cameras were reviewed. At 05:30 AM, LN H attempted to administer medications and R11 refused. At 06:15 AM, staff reported the allegation to Administrative Staff A. At 09:00 AM, the social worker interviewed the resident who denied the allegation happened. On 11/02/22 at 01:15 PM Administrative Staff A verified the nurse did not document an assessment of the resident at the time of the allegation. She stated, based on the fact that no men were working or wandering, the facility felt the triggers that caused her to allege rape were events of the past 24 hours of overstimulation and her past behaviors were taken into account. The resident had stated a man came into her room and raped her. The night nurse checked on the resident at 05:30 AM, The day shift supervisor LN G, and Administrative Nurse E both had been to see the resident, but had not assessed her due to the social worker had just interviewed R11 and they felt she might become upset with too much stimulation. Administrative Staff A stated without a potential perpetrator, staff established R11 was in a safe place and verified no immediate safety interventions were implemented from the time of the allegation to R11 denying the allegation. The facility's Abuse Prevention, Intervention, Reporting and Investigation policy, dated 09/07/22, documented upon receiving reports of suspected sexual abuse the executive director and the health services director are immediately notified to arrange for the examination of the resident. Residents will be monitored for possible signs of abuse. Residents are to be protected during investigations. The facility failed to implement protective measures for R11 immediately after an allegation of rape, placing the resident at risk for impaired safety and psychosocial wellbeing.

The facility had a census of 36 residents. The sample included 12 residents. Based on observation, interview, and record review the facility failed to ensure staff possessed the skills and knowledge necessary to perform and record an immediate physical assessment of Resident (R) 11 after an allegation of rape. This deficient practice placed R11 at risk for unidentified injury and delayed treatment decisions. Findings included: - R11's Electronic Medical Record (EMR), dated 09/22/22 documented diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS), dated [DATE], documented R11 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 14. The MDS documented R11 was verbally abusive one to three times weekly, required limited staff assistance for eating, and extensive staff assistance for bed mobility, transfers, toileting, and hygiene. R11 had range of motion impairment in all extremities, and received antipsychotic, and antianxiety medications. The Activities of Daily Living(ADL) Care Plan, dated 08/26/22, directed staff to provide total assistance of one to two nursing staff with ADLs such as grooming, repositioning, toileting, bathing, eating, transferring and locomotion. The care plan directed staff to explain each procedure to R11 so she can participate in ADL care to the maximum of her ability. The Progress Note, dated 11/02/22 at 06:55 AM, documented about 04:00 AM staff alerted the nurse that R11 had a very large bowel movement. R11 was crying and stated she had been raped. The nurse checked on her and R11 was sleeping soundly. The note stated at 05:30 AM the nurse offered R11 [MEDICATION(S)] (a narcotic drug used for moderate to moderately severe pain),R11 was awake and refused the medication. The nurse asked R11 how she was doing, and R11 said, you can see for yourself. R11's medical record lacked a physical or mental assessment of the resident after the allegation of rape. On 11/02/22 at 08:34 AM, observation revealed R11 in bed, call light in reach, eyes closed, and lying on her left side. The facility's social worker went into the room to visit the resident. On 11/02/22 at 09:35 AM, Administrative Staff A verified the following timeline of notification, intervention, interviews for 11/02/22: At 03:40 AM, R11's call light activated, and two aides found R11 asleep and she mumbled when asked if anything was needed. The aides left room without providing cares. At 04:00 AM, two aides assisted R11 with incontinence cares and during cares R11 complained that she had been raped. The aides notified the nurse who checked on the resident and found her asleep. Administrative Staff A stated the nurse had come to the room while care was being provided but verified the nurse had not documented an assessment. On 11/02/22 at 01:15 PM Administrative Staff A verified the nurse did not document an assessment of the resident at the time of the allegation. Administrative Staff A verified the day shift supervisor LN G, and Administrative Nurse E both had been to see the resident but had not assessed her due to the social worker had just interviewed R11 and they felt she might become upset with too much stimulation. Administrative Staff A verified no immediate safety interventions were implemented and no physical assessment had been completed from the time of the allegation to when R11 denied the allegation. The facility's Abuse Prevention, Intervention, Reporting and Investigation policy, dated 09/07/22, documented upon receiving reports of suspected sexual abuse the executive director and the health services director are immediately notified to arrange for the examination of the resident. Residents will be monitored for possible signs of abuse. Residents are to be protected during investigations. The facility failed to ensure licensed nurse staff possessed the skills and knowledge necessary to perform a full assessment to assess for injuries and attempt to preserve the scene in the presence of a rape allegation. placing R11 at risk for unidentified injuries.

The facility identified a census of 38 residents. The sample included 14 residents. Based on interviews and record reviews the facility failed to document the discharge plans, current needs, and a summary of the discharge for Resident (R)37, sampled for discharge. Findings included: - The physician's orders [REDACTED]. The Admission Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status score of 13, which indicated intact cognition. She required supervision to extensive staff assistance with her Activities of Daily Living (ADLs). She received speech, occupational, and physical therapies for five of the seven days in the look back period. The Discharge MDS dated [DATE] documented a BIMS score of 12, which indicated moderately impaired cognition. She required supervision with her ADLs. The discharge Care Plan dated 06/12/19 documented R37 used a walker for ambulation and was receiving therapy to decrease her assistance needs. She planned to discharge to an assisted living facility after completion of therapy. The nurse's progress note dated 07/26/19 documented a request to R37's physician for discharge from the facility to an assisted living facility. The electronic medical record (EMR) lacked documentation for R37's current care needs or a summary of her discharge to the assisted living facility. On 10/29/19 at 04:10 PM Administrative Nurse [NAME] stated the nursing staff review the discharge summary with the residents and families prior to their discharge. A discharge summary is documented in the residents' EMR. On 10/29/19 at 04:34 PM Administrative Nurse D stated she expected nurses to document a discharge summary in the residents' EMR. The facility's Admission, Transfer, And Discharge policy dated 10/02/19 documented Interdisciplinary Notes contain the time and date of the discharge, mode of transportation, who accompanied the resident, reason for the transfer, the resident's vital signs, mental and physical condition to include skin integrity, and disposition of medication and personal belongings. The facility failed to document the discharge plans, her current needs and a summary of the discharge to an assisted living facility for R37.

The facility identified a census of 38 residents. The sample included 14 residents, with five sampled for unnecessary medication use. Based on observations, record reviews, and interviews the facility failed to withhold medications and notify the physician when pulses and/or blood pressures were outside of physician ordered parameters for Resident (R)28, R7, and R34. Findings included: - The Electronic Medical Record (EMR) for R28 documented [DIAGNOSES REDACTED]. The annual Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 12, which indicated moderately impaired cognition. She required supervision with her Activities of Daily Living (ADLs). The ADL Care Area assessment dated [DATE] documented R28's ADL potential was affected by her dementia and current increase in weakness. The Medication care plan dated 10/07/19 documented her current medication regimen ensure her current quality of life. The EMR documented an order for [REDACTED]. Review of the Medication Administration Record [REDACTED]. The EMR lacked documentation for the Losartan being held or physician notification of the pulses outside of physician ordered parameters. On 10/29/19 at 04:10 PM Administrative Nurse [NAME] stated medications are not given and the physician is called when pulses are outside of physician ordered parameters. The information is documented in the EMR. On 10/29/19 at 04:34 PM Administrative Nurse D stated she expected nurses to hold medications if the pulses were outside of physician ordered parameters, and to notify the physician, as ordered. The information should be documented in the resident's EMR. The facility's Medication Review And Education policy dated 06/10/19 lacked documentation on the withholding of medications and the notification of physicians if pulses are outside of ordered parameters. The facility failed to withhold the Losartan and notify the physician for pulses outside of physician ordered parameters for R28, which had the potential of causing irregular heartbeats, slowing heartbeats, or [MEDICAL CONDITION]. - The Electronic Medical Record (EMR) for R7 included [DIAGNOSES REDACTED]. The annual Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of nine which indicated moderately impaired cognition. She required one person staff assistance with most Activities of Daily Living (ADLs). R7's quarterly MDS dated [DATE] documented no change from the annual assessment. The Care Area Assessment (CAA) for cognition dated 5/6/19 documented that R7 had severe cognitive impairment. The care plan for Medications dated 5/9/18 documented that R7 received multiple medications, and was at risk of side effects and/or complications due to polypharmacy (multiple medications). R7 takes [MEDICATION NAME] (a medication to reduce blood pressure) for hypertension. The EMR revealed an order dated 12/05/18 for [MEDICATION NAME] 25 milligram (mg) one tablet by mouth daily for hypertension. Hold the medication and call the physician if the systolic blood pressure is less than 90 or the pulse is equal to or below 60. Review of the Medication Administration Record [REDACTED]. On 10/24/19 at 9:56 AM R7 walked in the hallway with her walker. She exhibited no behaviors. On 10/29/19 at 12:33 pm R7 sat in the dining room and fed herself without difficulty. On 10/29/19 at 4:00 PM Certified Nurse Aide (CNA) M stated that vital signs (measurement of blood pressure, pulse, respirations and pain) on the residents are obtained by the nurses, and CNAs can help. On 10/29/19 at 4:11 PM Administrative Nurse [NAME] stated that vital signs on residents are taken by the nurse. Problems are reported to the Director of Nursing (DON), or the supervisor and the primary physician. When asked what should be done if the pulse or blood pressure are out of the ordered parameters, Administrative Nurse [NAME] stated that it depends on the physician, but the medication should be held, and the physician notified. This should be documented in the nurse's notes. On 10/29/19 at 4:34 PM Administrative Nurse D stated that the nurses obtain vital signs on the residents. If the pulse or blood pressure are out of parameters, the nurse is to hold the medication until the physician is notified for orders, and a note is documented in ID notes that the physician was notified. The facility policy Medication Review and Education dated 6/10/19 failed to provide direction for monitoring high blood pressure medications. The facility failed to hold the hypertensive medication when R7's blood pressure and/or pulses were outside of the physician ordered parameters. The facility also failed to notify the physician as ordered for R7. This had the potential for unnecessary medication administration, thus leading to possible harmful side effects. - The Electronic Medical Record (EMR) for R34 included [DIAGNOSES REDACTED]. The annual Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status score of five which indicated severely impaired cognition. She required one person staff assistance with most Activities of Daily Living (ADLs). R34's quarterly MDS dated [DATE] documented no change from the annual assessment. The Care Area Assessment (CAA) for Cognition dated 7/11/19 documented that R34 had severe cognitive impairment. The Care Plan for medications dated 7/12/19 documented that R34 takes multiple medications and was at risk of side effects and/or complications due to polypharmacy (multiple medications). R34 takes [MEDICATION NAME], Losartan, [MEDICATION NAME], and [MEDICATION NAME] (medicines to reduce blood pressure) for hypertension. R 34 also has an alteration in cardiopulmonary function related to hypertension. The EMR revealed an order dated 9/17/19 for [MEDICATION NAME] 10mg (milligram) tablet daily for hypertension, call primary care physician (PCP) if systolic blood pressure (BP) greater than 180. The EMR revealed an order dated 6/28/19 for Losartan 100 mg-hydrochlolorothiazide 25 mg tablet daily for hypertensive [MEDICAL CONDITION], call PCP for systolic BP less than 90 or greater than 180, diastolic BP greater than 90 or less than 50. The EMR revealed an order dated 6/28/19 for [MEDICATION NAME] 50 mg tablet two times a day for hypertensive [MEDICAL CONDITION], call PCP for systolic BP less than 90 or greater than 180, diastolic BP greater than 90 or less than 50. The EMR revealed an order dated 9/17/19 for [MEDICATION NAME] 5 mg daily for hypertensive [MEDICAL CONDITION], hold if pulse less than 60 or systolic BP less than 90. Review of the Medication Administration Record [REDACTED]. Review of the MAR indicated [REDACTED]. Review of the MAR indicated [REDACTED]. The MAR indicated [REDACTED]. Review of the MAR indicated [REDACTED]. On 10/24/19 at 8:39 AM R34 was sitting in her wheelchair in her room. On 10/29/19 at 8:43 AM resident was walking in the hallways with her walker, singing at times. She was walking with a steady gate. On 10/29/19 at 4:00 PM Certified Nurse Aide (CNA) M stated that vital signs (measurement of blood pressure, pulse, respirations and pain) on the residents are obtained by the nurses, and CNAs can help. On 10/29/19 at 4:11 PM Administrative Nurse [NAME] stated that vital signs on residents are taken by the nurse. Problems are reported to the Director of Nursing (DON), or the supervisor and the primary physician. When asked what should be done if the pulse or blood pressure are out of the ordered parameters, Administrative Nurse [NAME] stated that it depends on the physician, but the medication should be held, and the physician notified. This should be documented in the nurse's notes. On 10/29/19 at 4:34 PM Administrative Nurse D stated that the nurses obtain vital signs on the residents. If the pulse or blood pressure are out of parameters, the nurse is to hold the medication until the physician is notified for orders, and a note is documented in ID notes that the physician was notified. The facility policy Medication Review and Education dated 6/10/19 failed to provide direction for monitoring high blood pressure medications. The facility failed to hold the hypertensive medication as ordered when R7's blood pressure and/or pulses were outside of the physician ordered parameters. The facility also failed to notify the physician. This had the potential for unnecessary medication administration, thus leading to possible harmful side effects.

The facility identified a census of 38 residents. The sample included 14 residents, with five sampled for unnecessary medication use. Based on observations, record reviews, and interviews the facility failed to ensure the consultant pharmacist (CP) identified and reported as well as follow up on recommendations for pulses and/or blood pressures outside of physician ordered parameters for Resident (R)28, R7 and R34. Findings included: - The Electronic Medical Record (EMR) for R28 documented [DIAGNOSES REDACTED]. The Annual Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 12, which indicated moderately impaired cognition. She required supervision with her Activities of Daily Living (ADLs). The ADL Care Area assessment dated [DATE] documented R28's ADL potential was affected by her dementia and current increase in weakness. The Medication care plan dated 10/07/19 documented R28's current medication regimen would ensure her current quality of life. The EMR documented an order dated 12/5/18 for Losartan (medication used to treat hypertension) 100 milligrams (mgs.) daily for hypertension (elevated blood pressure) and hold the medication and call the physician if the resident's pulse is under 60 beats per minute. The EMR documented an order for [REDACTED]. The (MONTH) 2019 CP's Monthly Medication Review (MRR) documented a request for physician ordered pulse parameters for the administration of the [MEDICATION NAME] to coincide with the current Losartan order for [REDACTED]. Review of the Medication Administration Record [REDACTED]. The EMR lacked documentation for the Losartan and [MEDICATION NAME] being held or physician notification of the pulses outside of physician ordered parameters. On 10/29/19 at 04:10 PM Administrative Nurse [NAME] stated medications are not given and the physician is called when pulses are outside of physician ordered parameters. The information is documented in the EMR. On 10/29/19 at 04:34 PM Administrative Nurse D stated she expected nurses to hold medications if the pulses were outside of physician ordered parameters, and to notify the physician, as ordered. The information should be documented in the resident's EMR. On 10/30/19 at 11:52 AM Consultant HH stated she reviews residents' MARs for medications given outside of physician ordered parameters and reports consistent irregularities to the Director of Nursing. The facility's Drug Regimen Review policy dated 06/10/19 documented the licensed pharmacist reviews residents' medication regimen to identify and possibly prevent potential clinically significant medication adverse consequences. Irregularities are directed to the Director of Nursing. The facility failed to ensure the CP identified or acted upon recommendations for pulses outside of physician ordered parameters for R28 's Losartan and [MEDICATION NAME], which have the potential of causing irregular heartbeats, slowing heartbeats, or [MEDICAL CONDITION]. - The Electronic Medical Record (EMR) for R7 included [DIAGNOSES REDACTED]. The Annual Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of nine which indicated moderately impaired cognition. She required one person staff assistance with most Activities of Daily Living (ADLs). R7's quarterly MDS dated [DATE] documented no change from the annual assessment. The Care Area Assessment (CAA) for cognition dated 5/6/19 documented that R7 had severe cognitive impairment. The care plan for Medications dated 5/9/18 documented that R7 received multiple medications, and was at risk of side effects and/or complications due to polypharmacy (multiple medications). R7 took [MEDICATION NAME] (a medication to reduce blood pressure) for hypertension. The EMR revealed an order dated 12/05/18 for [MEDICATION NAME] 25 milligram (mg) one tablet by mouth daily for hypertension. Hold the medication and call the physician if the systolic blood pressure is less than 90 or the pulse is equal to or below 60. Review of the Medication Administration Record [REDACTED]. The Medication Regimen Review (MRR) from 9/11/18 to 10/2/19 revealed that the consulting pharmacist (CP) failed to notify the facility of medication given out of parameters. On 10/24/19 at 9:56 AM R7 walked in the hallway with her walker. She exhibited no behaviors. On 10/29/19 at 12:33 pm R7 sat in the dining room and fed herself without difficulty. On 10/29/19 at 4:00 PM Certified Nurse Aide (CNA) M stated that vital signs (measurement of blood pressure, pulse, respirations and pain) on the residents are obtained by the nurses, and CNAs can help. On 10/29/19 at 4:11 PM Administrative Nurse [NAME] stated that vital signs on residents are taken by the nurse. Problems are reported to the Director of Nursing (DON), or the supervisor and the primary physician. When asked what should be done if the pulse or blood pressure are out of the ordered parameters, Administrative Nurse [NAME] stated that it depends on the physician, but the medication should be held, and the physician notified. This should be documented in the nurse's notes. On 10/29/19 at 4:34 PM Administrative Nurse D stated that the nurses obtain vital signs on the residents. If the pulse or blood pressure are out of parameters, the nurse is to hold the medication until the physician is notified for orders, and a note is documented in ID notes that the physician was notified. On 10/30/19 at 11:52AM Consultant HH stated that she reviews the MARs for medications given outside parameters and will report to the DON if she finds consistent irregularities. The facility's policy Drug Regimen Review dated 6/10/19 documented the CP reviews residents' medication regimen monthly and as needed. In performing the monthly medication review the CP incorporates federally mandated standards of care. The facility failed to ensure the CP identified and reported R7's blood pressure medication given outside parameters, and the lack of physicain notification related to the abnormal blood pressures. This had the potential for unnecessary medication to be administered, thus leading to possible harmful side effects to R7. - The Electronic Medical Record (EMR) for R34 included [DIAGNOSES REDACTED]. The Annual Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status score of five which indicated severely impaired cognition. She required one person staff assistance with most Activities of Daily Living (ADLs). R34's quarterly MDS dated [DATE] documented no change from the annual assessment. The Care Area Assessment (CAA) for Cognition dated 7/11/19 documented that R34 had severe cognitive impairment. The care plan for Medications dated 7/12/19 documented that R34 takes multiple medications and was at risk of side effects and/or complications due to polypharmacy (multiple medications). R34 received [MEDICATION NAME], Losartan, [MEDICATION NAME], and [MEDICATION NAME] (medicines to reduce blood pressure) for hypertension. R34 also had an alteration in cardiopulmonary function related to hypertension. The EMR revealed an order dated 9/17/19 for [MEDICATION NAME] 10mg (milligram) tablet daily for hypertension, call primary care physician (PCP) if systolic blood pressure (BP) greater than 180. The EMR revealed an order dated 6/28/19 for Losartan 100 mg-hydrochlolorothiazide 25 mg tablet daily for hypertensive [MEDICAL CONDITION], call PCP for systolic BP less than 90 or greater than 180, diastolic BP greater than 90 or less than 50. The EMR revealed an order dated 6/28/19 for [MEDICATION NAME] 50 mg tablet two times a day for hypertensive [MEDICAL CONDITION], call PCP for systolic BP less than 90 or greater than 180, diastolic BP greater than 90 or less than 50. The EMR revealed an order dated 9/17/19 for [MEDICATION NAME] 5 mg daily for hypertensive [MEDICAL CONDITION], hold if pulse less than 60 or systolic BP less than 90. Review of the Medication Administration Record [REDACTED]. Review of the MAR indicated [REDACTED]. Review of the MAR indicated [REDACTED]. The MAR indicated [REDACTED]. Review of the MAR indicated [REDACTED]. The Medication Record Review (MRR) from 9/11/18 to 10/2/19 revealed that the CP failed to notify the facility of medication given out of parameters and the lack of docuemntation of physician notification. On 10/29/19 at 8:43 AM the resident walked in the hallways with her walker, singing at times. She was walking with a steady gate. On 10/29/19 at 4:00 PM Certified Nurse Aide (CNA) M stated that vital signs (measurement of blood pressure, pulse, respirations and pain) on the residents are obtained by the nurses, and CNAs can help. On 10/29/19 at 4:11 PM Administrative Nurse [NAME] stated that vital signs on residents are taken by the nurse. Problems are reported to the Director of Nursing (DON), or the supervisor and the primary physician. When asked what should be done if the pulse or blood pressure are out of the ordered parameters, Administrative Nurse [NAME] stated that it depends on the physician, but the medication should be held, and the physician notified. This should be documented in the nurse's notes. On 10/29/19 at 4:34 PM Administrative Nurse D stated that the nurses obtain vital signs on the residents. If the pulse or blood pressure are out of parameters, the nurse is to hold the medication until the physician is notified for orders, and a note is documented in ID notes that the physician was notified. On 10/30/19 at 11:52AM Consultant HH stated that she reviews the MARs for medications given outside parameters and will report to the DON if she finds consistent irregularities. The facility's policy Drug Regimen Review dated 6/10/19 documented the CP reviews residents' medication regimen monthly and as needed. In performing the monthly medication review the CP incorporates federally mandated standards of care. The facility failed to ensure the CP identified the medications were given outside parameters, and the physician was not notified. This had the potential for unnecessary medication to be administered, thus leading to possible harmful side effects to R34.

The facility identified census of 38 residents. The sample included 14 residents with four residents reviewed for falls. Based on observation, record review, and interviews the facility failed to implement an appropriate intervention, monitor for effectiveness of interventions, and review or attempt additional interventions aimed at preventing falls and injuries or pain related to falls for Resident (R) 29. Findings included: -The Electronic Medical Record (EMR) from the [DIAGNOSES REDACTED]. The Significant Change Minimum Data Set ((MDS) dated [DATE] for R29 documented a Brief Interview for Mental Status (BIMS) score of six which indicated severe impaired cognition. The MDS documented that R29 required extensive assistance of two staff members for transfer, bed mobility, dressing, and toilet use. The MDS also documented no falls since admission or prior assessment, had a fall with fracture prior to admission for R29. The Quarterly MDS dated [DATE] documented a BIMS score of six which indicated severe impaired cognition. The MDS documented R29 required extensive assistance of one staff member for personal hygiene, bed mobility, transfer, dressing, toilet use, bathing, and locomotion on the unit. The MDS also documented two non-injury falls and one fall with injury during the look back period for R29. The falls Care Area Assessment (CAA) for R29 dated 04/03/19 documented that she had a fractured right femur and has a history of falls related to her dementia process that include hallucinations, delusions, and poor safety awareness. The Fall assessment dated [DATE] recorded a score of 23 which indicated high risk for falls. The Care Plan for falls with a start date of 02/20/19 indicated resident was a high fall risk with a previous fracture. The care plan recorded a goal of reducing risk of major injury that could impact the quality of life for R29. It also directed staff to offer R29 non-slip socks when getting into bed. A nurse note dated 03/23/19 at 08:45 PM documented R29 fell in her room when attempting to put her shirt on, lost her balance and landed on her right side. She complained of severe pain in right side. R29 was sent to the hospital for evaluation and diagnosed with [REDACTED]. It also directed to ensure an open pathway for mobilization without items/clutter on the floor. A nurse's note dated 04/26/19 at 04:27 PM documented R29 was found lying in a fetal position on her right side, in the middle of the room, on the floor in front of her closet without any pants and shoes on. She reported to staff that she was trying to get something off the top shelf of her closet and lost her balance. R29 complained of right leg pain after fall. The care plan was updated with the intervention for staff to assist the resident when she was observed digging through her dressers, bedside table and closet. A nurse's note dated 05/20/19 at 07:05 PM documented R29 was found laying on the floor on her back, her wheelchair was tipped over. She reported that she was reaching for her phone. An abrasion was noted on right side of her forehead along a 3.0 centimeter (cm) x3.0 cm raised area. R29 complained of her head hurting. R29 was transferred to the hospital for evaluation and returned to the facility. The care plan was updated with the intervention to place the phone within the resident's reach. A nurse's note dated 05/22/19 12:20 AM documented R29 was found sitting on the floor. She reported that she had rolled out of the bed. She was wearing regular socks. R29 complained of left wrist pain. Review of the medical record revealed no intervention was put in place for this fall. The nurses notes recorded the resident had four more falls after the fall on 5/22/19. A nurse's note dated 06/02/19 at 01:27 PM documented R29 was found kneeling on the floor next to her bed. A nurse's note dated 08/06/19 at 03:14 AM documented R29 was found on the floor beside her bed. R29 was complaining of pain in her left leg and back pain. A nurse's note dated 09/04/19 R29 at 12:42 PM recorded R29 was found on the floor at the bedside. R29 complained of back pain upon assessment. A nurse's note dated 10/12/19 at 11:03 AM documented R29 was found on the floor in her room between her bed and wheelchair. R29 complained of back pain upon assessment and was sent to hospital for evaluation for possible compression fractures. She returned to facility no acute issues related to fall noted. On 10/24/19 at 11:40 AM R29 was sitting in her wheelchair in the dining room feeding herself lunch On 10/28/19 at 01:36 PM R29 propelled herself in the wheelchair. On 10/29/19 at 04:00 PM during an interview with Certified Nurses Aide (CNA) M stated that R29 was a high fall risk and that she likes to wander in the hallways and look for her family . On 10/29/19 at 04:11 PM during an interview with Administrative Nurse [NAME] stated that a new intervention should be added to the care plan after each fall. On 10/29/19 at 04:34 PM during an interview with Administrative Nurse D stated that she is notified of the falls by email and that she is the person that updates the care plan with new interventions following a fall. The facility policy Falls dated 03/26/19 documented that residents will be identified for risk of falls and an intervention implemented to reduce falls. Residents with falls will be discussed weekly in risk management meeting to determine further possible interventions to prevent future fall. The facility failed to ensure that interventions were were implemented after each fall with the goal to prevent future falls and injuries, including pain, for R29 who had multiple falls, including a fall with injury.

The facility identified a census of 38 residents. The sample included 14 residents. Based on record review, observation, and interviews, the facility failed to ensure Resident (R) 18's assistive appliance was placed to prevent worsening of contractures of the left hand. Findings included: -The Electronic Medical Record (EMR) from the [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS), dated [DATE], documented a Brief Interview Status (BIMS) score of eight which indicated moderate cognitive impairment. She required extensive assistance of two staff members for Activities of Daily Living (ADL). The MDS documented no nursing restorative splint assistance. The Quarterly MDS, dated [DATE], documented no changes in status. The MDS also documented no nursing restorative splint assistance. The Care Area Assessment (CAA) dated 12/14/18 for ADL's documented R18 required total assistance with all ADL's and physical and occupational therapy to evaluate and treat to determine if any improvement in ADL participation. The Care Plan dated 12/20/19 for ADL's directed staff that R18 had a contracture to left hand on admission and potential for her right hand which was starting to draw up as well. The Occupational Therapy (OT) progress notes signed 02/25/19 documented that nursing was instructed on applying and removing left hand splint techniques and left-hand splint wear schedule with good return demonstration carryover. The clinical record lacked documentation for instructions related to wearing her splint. The instructions for applying the left-hand splint were on a piece of paper hanging on the wall above R18's bed. Observation on 10/24/19 at 11:40 AM revealed R18 sat in her wheelchair at a bedside table in the dining room, and fed herself lunch without assistance. The resident did not have a splint on her left hand. Observation on 10/28/19 at 01:49 PM revealed R18 lying in bed with eyes her closed, resting quietly with no distress and no left-hand splint noted on at this time. On 10/28/19 at 02:03 PM during an interview with Consultant GG stated that nursing staff apply the splints for the residents once discharged from therapy after instructions and educattion are provided. On 10/29/19 at 04:00 PM during an interview with Certified Nurse Aide (CNA) M, she stated that R18 did not wear a splint. She also said that the staff know who is on a nursing restorative program by the resident information documented in the electronic medical record. On 10/29/19 at 04:11 PM during an interview with Licensed Nurse (LN ) E, she stated she was not sure if R18 was to wear a splint on her upper extremity. LN [NAME] said splint documentation would be recorded in the point of care daily charting. On 10/29/19 at 04:34 PM during an interview with Administrative Nurse D, she stated that R18 does wear a splint. Administrative Nurse D confirmed the EMR lacked any documentation to application and removal of the left-hand splint. She identified that it further lacked instructions as to the time frame R18 was to wear the splint. The Nursing Restorative Care Program policy revised 10/22/19 documented the nursing interventions would promote resident's ability to adapt and adjust to independent and safe living, focus on achieving and maintaining optimal physical, mental and psychosocial functioning, improve or maintain function in physical abilities and ADL's and prevent further impairment. The facility failed to ensure R18 was wearing her left-hand splint to in order to prevent R18 from complications related to the presence and/or progression of a left hand contracture.