Every finding on record at Lincoln County Care Center

Based on observation, policy review, and staff interview, it was determined the facility failed to ensure residents were provided with a clean, safe, homelike environment. This was true for all residents who resided in the facility whose environment were observed. This deficient practice created the potential for harm if residents were embarrassed by and/or felt the disrepair in the facility was unacceptable, disrespectful, or undignified or residents were injured due to unsafe areas in the facility. Findings include: The facility's Homelike Environment policy, revision date February 2021, documented residents are provided with a safe, clean, comfortable, and homelike environment and encouraged to use their personal belongings to the extent possible.The following areas were observed: a) On 4/12/26 at 10:30 AM, observed in room [ROOM NUMBER]-B on the wall behind bed, four strips with missing paint, with 4 holes in each strip. Multiple small holes were observed in the wall. The ceiling by the curtain railing observed an approximately 1 x 2 and approximately 1 x 3 area with the paper part of the sheetrock missing. b) On 4/12/26 at 11:09 AM, observed in room [ROOM NUMBER]-B approximately 1.5 x 2.5 part of the bottom right corner of windowsill missing. The lower part of the rebar was exposed. c) On 4/14/26 at 6:42 AM, observed the vent in the dining room covered with a black substance. d) On 4/14/26 at 11:03 AM, observed the large light fixture above nurse's station without a cover and two long, thick cobwebs hanging from the light fixture frame. On 4/14/26 at 11:38 AM, the Maintenance Supervisor stated the walls are concrete and it is hard to replace the walls around the window in the resident's room when the beds keep breaking pieces off and the resident in room [ROOM NUMBER]-B just moved into that room and he has not had time to fix the wall behind her bed. He also stated the cobwebs on the light at the nurse's should have been cleaned up by housekeeping and the vent in the dining room should have been cleaned by housekeeping.

Based on observation, policy review, and staff interview, it was determined the facility failed to ensure medications available for residents were labeled, dated, and stored appropriately. This was true for 1 of 1 medication rooms and 1 of 1 medication carts audited for labeling and storage of medication. This failure created the potential for residents to have missed doses of medication, to receive expired medications with decreased efficacy, and residents to receive the wrong medication due to the medication label being illegible. Findings include:The facility's Storage of Medication policy revision date April 2019, documented:- discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed.- Scheduled II-V controlled medications are stored in separately locked, permanently affixed compartments.The EVENCARE ProView operator's manual documented:- Record the date on the bottle when you open a new bottle of test strips. Discard any unused test strips three months after opening.- Test strips are good three months after opening or until the last day of the month of expiration, whichever comes first.On 4/13/26 at 10:15 AM, a medication storage audit was completed of the medication room with LPN #1 present. The following was observed: - a bottle of liquid lorazepam (an antianxiety medication) 2mg/ml was observed in the medication refrigerator. The label was illegible on the bottle and on the box. On 4/13/26 at 10:17 AM, LPN #1 stated she was able to read part of the label on the bottle of lorazepam, but she did not know if the bottle should be in the refrigerator to be used. - observed a vial of tuberculin purified protein derivative with an open date of 11/24/25. On 4/13/26 at 10:20 AM, LPN #1 stated she was not sure how long the bottle was good after it was open. - observed a Hepatitis B vaccine syringe with an expiration date of 7/7/25. On 4/13/26 at 10:27 AM, LPN #1 stated the Hepatitis B vaccine should not have been in the refrigerator. - observed a metal box with a lock on it. On 4/13/26 at 10:29 AM, LPN #1 stated the metal box had insulin and narcotics from the pharmacy in it. She stated the metal box was not permanently attached to the refrigerator and was too big to lock it in the lock box on the bottom of the refrigerator. LPN #1 also stated the narcotics could not be removed from the metal box and placed in the lock box of the refrigerator because the narcotics had to be assigned to a resident and the nurse would need to get the key to the box from the pharmacy. On 4/13/26 at 2:21 PM, the DON stated the metal box in the refrigerator, in the medication room had narcotics in it and it should have been permanently attached to the refrigerator and had not been. On 4/13/26 at 2:25 PM, the Regional Nurse Consultant stated the bottle of lorazepam should have been replaced since you could not read the resident's whole name and 30 days after the Tuberculin testing solution was opened the bottle should have been thrown out. On 4/13/26 at 10:32 AM, the following was observed in the west hall medication cart: - on the right side, second drawer observed 3 small round, unlabeled, white pills - on the left side, second drawer, observed 1 duloxetine HCl 60 mg tablet, 1 Lasix 20 mg tablet, 1 Atorvastatin Calcium 40 mg tablet, 1 Divalproex sodium 250 mg tablet, 1 Atorvastatin Calcium 20 mg tablet, 1 Atorvastatin Calcium 10 mg tablet, 1 pantoprazole sodium 40 mg tablet, and 1 Quetiapine 50 mg tablet. On 4/13/26 at 10:39 AM, LPN #1 stated the loose pills should not have been in the medication cart. On 4/13/26 at 2:29 PM, the Regional Nurse Consultant stated the nurses should have destroyed the loose pills in the medication cart. On 4/14/26 at 10:58 AM, observed RN #1 remove a glucometer strip from the Evencare Proview glucose strip bottle to be used to check Resident #18's blood sugar. The bottle of glucose test strips did not have an open date. On 4/14/26 at 11:00 AM, RN #1 stated the bottle of glucose test strips should have had an open date but she was not sure how long the strips were good for after they were opened. On 4/12/26 at 9:37 AM, an unattended medication cart was observed across from the nurses station with one round white pill lying on the ground near the corner of the medication cart. On 4/12/26 at 9:45 AM, LPN #1 stated she had dropped the medication that morning but could not find it. On 4/12/26 at 9:47 AM, LPN #1 stated she should have moved the medication cart when looking for the lost medication and destroyed the medication but had not.

Based on record review and staff interview, it was determined the facility failed to ensure informed consent was obtained prior to initiation of psychotropic medications for 2 of 3 residents (#1 and #35) reviewed for unnecessary medications. This deficient practice placed residents at risk of receiving medications without knowledge of the reason why medications were prescribed, the expected benefits, and the risks associated with the medications. Findings include:The facility's Medication Therapy policy, version 1.1, documented 1. Each resident's medication regimen shall include only those medications necessary to treat existing condition and address significant risks. 2. Medication use shall be consistent with an individual's condition, prognosis, values, wishes, and responses to such treatments.Resident #1 was initially admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including heart failure and anxiety.A physician order dated 3/1/26, documented Citalopram Hydrobromide oral tablet 20 mg by mouth one time per day. On 4/13/26 at 4:09 PM, the RNC stated Resident #1 did not have a signed Informed Consent for Use of Antidepressant Medications for the ordered Citalopram Hydrobromide.Resident #35 was initially admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including stable fracture of lumbar vertebra (the back), depression, and repeated falls.A physician order dated 4/1/26, documented Sertraline HCl oral tablet 200 mg by mouth at bedtime.On 4/13/26 at 1:30 PM, Resident #35's medical record included an Informed Consent for Use of Antidepressant medication for the prescribed Sertraline signed and dated 4/10/26.On 4/13/26 at 4:10 PM, the RNC stated the Informed Consent for the Sertraline should have been signed before Resident #35 received the medication but had not been.

Based on policy review, observation, record review, and staff interview, it was determined the facility failed to ensure a resident's call light was within reach for 2 of 12 residents (#12 and #35) reviewed for residents' rights. This deficient practice had the potential to cause harm if the resident could not call for assistance when needed or experienced an adverse medical event that required attention. Findings include: The facility's Answering the Call Light policy, version 1.3, documented. The purpose of this procedure is to ensure timely responses to the resident's requests and needs.Ensure that the call light is accessible to the resident. Resident #12 was admitted to the facility on [DATE], with multiple diagnoses including chronic obstructive pulmonary disease (disease process which causes decreased ability of the lungs to function) and dementia. On 4/12/26 at 9:59 AM, observed Resident #12 lying in bed with his call light plugged into the wall and hanging down the wall and under the foot of his bed and not within his reach. Resident #12 unable to independently reach call light. On 4/12/26 at 10:25 AM, CNA #1 stated Resident #12's call light should be within reach and had not been. Resident #35 was initially admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including stable fracture of lumbar vertebra (the back) and repeated falls. On 4/12/26 at 10:09 AM, observed Resident #35 sitting in her recliner in her room with her call light draped over the overbed table that was pushed against the bed on the other side of the room and not within reach. Resident #35 stated, staff pushed her table against the bed this morning after removing her breakfast tray from her room and she cannot reach her call light. On 4/12/26 at 10:27 AM, CNA #1 stated Resident #35's call light should be within reach and had not been. On 4/13/26 at 10:48 AM, the RNC stated residents' call light should be within reach and had not been.

Based on observation, resident and staff interviews, policy review and record review, it was determined the facility failed to ensure residents were initially assessed to determine if they were safe to self-administer medications for 1 of 1 resident (Resident #35). This failure created the potential for adverse effects if residents self-administered medications inappropriately. Findings include:The facility's Self-Administration of Medications policy, revised date February 2021, documented, Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so.if it is deemed safe and appropriate for a resident to self-administer medications, this is documented in the medical record and the care plan. On 4/12/26 at 9:47 AM, observed Resident #35 had Calcitonin nasal spray on her overbed table. Resident #35 stated, she keeps it in her room for use when she needs it and had used it before she came to the facility.Resident #35's medical record had no documentation of an IDT patient assessment for self-administration of medications and no documentation in her care plan to allow self-administration of medications.On 4/13/26 at 2:27 PM, the Regional Nurse Consultant stated, Resident #35 should not have had Calcitonin nasal spray in her room and had not been assessed by IDT for self-administration of medications.

Based on policy review, record review, and staff interview, it was determined the facility failed to refer residents for further evaluation when residents were diagnosed with a major mental illness. This was true for 1 of 3 residents (Resident #4) reviewed for Pre-admission Screening and Resident Review (PASRR) level 2 evaluations. This deficient practice had the potential to cause harm if residents' specialized services for mental health needs were not evaluated by an appropriate state-designated authority. Findings include: The facility's Resident Assessments PASRR Screening Coordination policy, dated 4/25, documents 3. PASRR Level I and Level II screenings, when needed, will be conducted prior to the resident being admitted to the facility. 4. The facility will utilize Level II evaluation reports when conducting assessments of the resident, developing care plans. The State Operation Manual, Appendix PP revised on 7/23/25, documents a positive Level I screen necessitates an in-depth evaluation of the individual by the state-designated authority, known as PASRR Level II, which must be conducted prior to admission to a nursing facility. Resident #4 was admitted to the facility on [DATE], with multiple diagnoses including Chronic Obstructive Pulmonary Disorder (a progressive lung disease that restricts airflow), Bipolar Disorder (a chronic mental health condition characterized by extreme mood swings), and Post-Traumatic Stress Disorder (a mental health condition triggered by experiencing or witnessing terrifying events). Resident #4's care plan dated 8/18/24, documented Resident #4 meets PASRR Level II of determination secondary to serious mental illness diagnoses including: Anxiety, Bipolar Disorder, and Long Term Care Stay. Resident #4's medical record documented a PASRR Level I screening was completed on 4/15/25 (over 8 months after admission). The PASRR Level I screening documented Resident #4 had major mental illnesses of Depressive Disorders, Anxiety Disorders, Bipolar Disorders, and Post-Traumatic Stress Disorder and instructed that the PASRR Level I be forwarded to the states-designated authority for a PASRR Level II evaluation. On 4/14/26 at 8:17 AM, Resident #4's medical record had not documented a PASRR Level II evaluation had been completed. On 4/14/26 at 8:41 AM, the RNC stated the facility did not have a PASRR Level II for Resident #4 and should have had one.

Based on policy review, and staff interview, it was determined the facility failed to provide a resident's baseline care plan to the resident or his/her representative for 3 of 5 residents (#10, #30, and #35) reviewed for baseline care plan. This failure placed residents and their representatives at risk of not being informed and having input in their care plan. Findings include:The facility's Care Plans - Baseline policy, version 1.2, documented 3. The resident and/or representative are provided a written summary of the baseline care plan (in a language that the resident/representative can understand). 5. Provision of the summary to the resident and/or representative is documented in the medical record.Resident #10 was admitted to the facility on [DATE], with multiple diagnoses including muscle wasting (the loss of muscle mass) and respiratory failureResident #10's medical record had not documented that a baseline care plan was provided and discussed with him or his resident representative.Resident #30 was admitted on [DATE], with multiple diagnoses including Parkinson's disease (a chronic nervous disease characterized by fine slowly spreading tremor) and malignant neoplasm of prostate (cancerous tumor).Resident #30's medical record had not documented that a baseline care plan was provided and discussed with him or his resident representative.Resident #35 was initially admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including stable fracture of lumbar vertebra (the back) and repeated falls.Resident #35's medical record had not documented that a baseline care plan was provided and discussed with her or her resident representative.On 4/14/26 at 8:40 AM, the RNC stated there was no documentation that the residents or their representatives had received a copy of their baseline care plans.

Based on record review and staff interviews, the facility failed to ensure care was provided for 1 of 1 resident (Resident #3) per professional standards of practice. Findings include:Resident #3 was admitted to the facility on [DATE], with multiple diagnoses including end stage renal disease and diabetes.Resident #3's care plan dated 5/13/25, documented she needed hemodialysis related to end stage renal disease and the listed following interventions:- administer medications as ordered- encourage Resident #3 to go for the scheduled dialysis appointments. Resident receives dialysis on (TUESDAY, THURSDAY, SATURDAY)Resident #3's physician's order dated 3/19/26, documented Amlodipine Besylate (calcium channel blocker used to treat hypertension), give 10 mg by mouth one time a day every Mon, Fri, Sun related to hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease. Hold for SBP less than 100 or pulse less than 60.Review of Resident #3's medical record did not contain dialysis communication forms for Tuesday 3/17/26, and Saturday 3/21/26.Resident #3's Dialysis communication form dated 3/19/26, documented: decrease Amlodipine to 5mg every day. On 4/13/26 at 9:11 AM, review of Resident #3's medical record did not document the decrease in the dose of her Amlodipine as ordered.On 4/13/26 at 2:30 PM, the DON stated Resident #3's Amlodipine dose was not correct and was not sure why it had not been changed. On 4/14/26 at 8:44 AM, the Regional Nurse Consultant stated Resident #3's dialysis communication sheets for 3/19/26, and 3/21/26, were missing. She also stated Resident #3's Amlodipine dose was clarified with the doctor, and it should have been 5 mgs every day and had not been.

Based on observation, record review, policy review, and staff interview, it was determined the facility failed to ensure nurse staffing information was accurate and posted daily for each shift. This failed practice had the potential to affect all residents residing in the facility and their representatives, visitors, and others who wanted to review the facility's staffing levels. Findings include: The facility's Staffing, Sufficient and Competent Nursing policy, revision date April 2025, documented. Direct care daily staffing numbers (the number of nursing personnel responsible for providing direct care to residents) are posted in the facility for every shift.On 4/13/26, the daily postings of licensed and unlicensed nurse staffing were reviewed between 11/1/25 - 4/11/26. There were no adjustments to the posted staffing when the scheduled hours did not match the actual hours worked.On 4/13/26 at 11:37 AM, the RNC and DON stated the facility does not make adjustments to the daily postings with actual hours worked, they only adjust the time on the daily assignment sheets.

Based on observation, resident and staff interview, and food test tray evaluation, it was determined the facility failed to ensure resident meals were palatable and maintained safe and appetizing temperatures to the residents. This had the potential to affect the 26 residents who resided in the facility who consumed meals prepared in the facility's kitchen. This failed practice had the potential to negatively affect the residents' nutritional status and psychosocial well-being. Findings include: The 2022 FDA Food Code states hot food will be maintained at 135 degrees F or above and cold food will be maintained at 41 degrees F or below. On 4/13/26 at 10:42 AM, during the Resident Council meeting, 6 of 6 residents stated the food served was often cold, tasteless, and not nutritious. The residents stated there are no condiments on the meal tray, especially when trays are delivered to their room, and the dinner meal is usually the worst meal of the day. On 4/14/26 at 11:27 AM, observed the lunch meal service with the following observations: - The menu documented the main entree was roast beef/gravy, scalloped potatoes, seasoned green beans, roll with margarine, coconut cake, and beverage. -The meal served was roasted pork with gravy, scalloped potatoes, green beans, roll with margarine, white cake, and beverage. - There were no garnishes or condiments served with the meal. On 4/14/26 at 12:06 PM, the last tray from the meal cart was presented to the surveyor for testing the serving temperature, taste, and presentation with the following observations: - Scalloped potatoes were served at 135 degrees F and tasted bland. - Gravy was bland and tasteless. - [NAME] beans were served at 128 degrees F and should have been 135 degrees F, tasted bland, and mushy in texture. - No beverage served on the tray. On 4/14/26 at 1:12 PM, the Dietary Manager stated the facility used frozen food and often the food did not have much flavor, and the green beans should have been at 135 degrees F. On 4/14/26 at 1:16 PM, the Dietary Manager stated the Dietary department has only one staff member scheduled for the dinner meal service each day.

Based on the FDA Food Code, observation, and interview, the facility failed to ensure food was appropriately stored, distributed, and labeled, and cleaning logs were properly documented. This deficient practice had the potential to affect all residents who received meals prepared in the facility's kitchen. This placed residents at risk for potential contamination of food and adverse health outcomes including food-borne illnesses. Findings include:The FDA Food Code 2022, 3-501.17 documented, Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking . refrigerated, ready-to-eat, time/temperature control for safety food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1.On 4/12/26 at 9:41 AM, observed the following:- the walk-in refrigerator contained one large, opened package of provolone cheese with no use by date. - the pantry contained three bags of cookies dated 4/8/26, with use by date 4/11/26, and one bag of sliced cake not dated.- the walk-in freezer contained an opened box of enchiladas dated 3/24/26, and no use by date.On 4/12/26 at 11:48 AM, observed dietary trays being delivered to resident rooms. The dietary tray included an uncovered bowl of gelatin dessert. On 4/14/26 at 11:24 AM, observed dietary trays being delivered to resident rooms with an uncovered plate of sliced cake.On 4/14/26 at 11:35 AM, the [NAME] stated she was not aware that all food on the dietary trays delivered to resident rooms must be covered.On 4/14/26 at 1:40 PM, observed the daily cleaning log marked completed (with an X) for Sunday through Saturday.On 4/14/26 at 1:42 PM, the Dietary Aide stated she did not have a new cleaning log so she continued to use the same one.On 4/14/26 at 1:44 PM, the Dietary Manager stated the daily cleaning log should have been replaced with a new daily cleaning log for the current week and had not been.

Based on observation, policy review, and staff interview, it was determined the facility failed to ensure infection control prevention practices were maintained to provide a safe and sanitary environment. These failures had the potential to impact all residents in the facility by placing them at risk for cross contamination and infection. Findings include:The facility's Handwashing/Hand Hygiene Policy Revised date March 2022, documented use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water before and after eating or handling food.The facility's Homelike Environment policy revision date February 2021, documented the facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include a clean, sanitary, and orderly environment.The following was observed for hand hygiene:On 4/12/26 at 12:04 PM, observed 14 residents served their meals in the dining room. The residents were not offered hand hygiene before eating their meals.On 4/12/26 at 12:12 PM, CNA #1 stated the resident's hands should have been sanitized before they started eating.On 4/13/26 at 2:44 PM, the DON stated the residents in the dining room should have been offered hand hygiene using the hand sanitizer from the bottle before eating their meals.The following was observed for infection control:On 4/14/26 at 6:53 AM, the housekeeper was observed carrying clean gowns down the hallway, uncovered.On 4/14/26 at 6:56 AM, the housekeeper stated she should have covered the gowns.On 4/14/26 at 8:36 AM, with the housekeeper present, the following was observed in the laundry room:-Behind the small, personal washing machine on the pipes observed a white, hard substance and a grey fuzzy substance.-By the entrance to the laundry room observed a tube of wires covered with a fuzzy grey substance.-Behind the large washing machine, observed on the water pipes a teal-colored substance and a fuzzy grey substance.-On the cover of the chemical dispenser of the large washing machine observed a layer of white substance.-On the wall and on the wires by the bucket of washing chemical observed a grey fuzzy build up on the chemical buckets and walls.On 4/14/26 at 8:41 AM, the housekeeper stated there was no cleaning schedule, but they do sweep every day.

Based on record review and staff interview, it was determined the facility failed to ensure the MDS assessment accurately reflected resident's status. This was true for 2 of 12 residents (#11, and #15) whose MDS assessments were reviewed. This deficient practice had the potential for negative outcomes if the residents were not monitored properly due to inaccurate assessments. Findings include:Resident #11 was initially admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including epilepsy and dementia.On 4/12/26 at 11:20 AM, observed Resident #11 in his wheelchair. No restraints were observed in his wheelchair or in his bed.Resident #11's Quarterly MDS dated [DATE], documented in section P0100. Physical Restraints, Other used daily, for restraint.Resident # 15 was initially admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including diabetes and acquired absence of the left leg above the knee.On 4/12/26 at 11:14 AM, observed Resident #15 lying in his bed with a trapeze bar over his bed to assist him with repositioning. No restraints were observed in his bed or in his wheelchair.Resident #15's admission MDS dated [DATE], documented in section P0100. Physical Restraints, Other used daily, for restraint.On 4/13/26 at 10:12 AM, the DON & the MDS coordinator stated the MDS was coded incorrectly. Resident #11 does not have a restraint and neither does Resident #15. Restraints should not have been coded on the MDS.

Based on record review and interview, it was determined the facility failed to ensure all components of the baseline (initial) care plan were included upon resident's admission. This was true for 1 of 14 residents (Resident #129) reviewed for baseline care plan. This failure created the potential for harm when the baseline care plan failed to provide directions for care. Findings include: Resident #129 was admitted to the facility on [DATE], with multiple diagnoses including chronic obstructive pulmonary disease (a progressive lung disease that makes it difficult to breathe) and diabetes. Resident #129's baseline care plan had not documented or addressed her mobility assistance needs. Resident #129's nursing progress note dated 4/9/25, documented resident is able to ambulate around facility using her walker. Resident #129's nursing progress note dated 4/10/25, documented resident is a stand by assist with some assistance into bed. Resident using a wheelchair in facility assist X 1 for mobility, she also uses a walker for transfers. On 4/15/25 at 3:51 PM, the Regional Nurse stated the baseline care plan had not contained documentation related to Resident #129's mobility needs of assistance X 1 and should have.

Based on record review and staff interview it was determined the facility failed to ensure resident's discharge summary included a reconciliation of medications (an accurate list of pre-discharge medications to post-discharge medications by creating an accurate list to prevent unintended changes or omissions at transition points in care). This was true for 1 of 1 resident (Resident #27) reviewed for discharge. This failure created the potential for the receiving facility to not provide appropriate and timely care. Findings include: Resident #27 was admitted to the facility on [DATE], for neuroleptic induced parkinsonism (movement disorder with symptoms like Parkinson's disease as a side effect of taking certain medications) and major depression. On 4/15/25 at 4:02 PM, a record review of Resident #27's Nurse Progress Note, dated 1/15/25, documented resident was here for long term care and decided to move to a different facility. On 4/15/25 at 4:04 PM, Resident #27's Discharge Summary/Recap of Stay documented No - Current reconciled medication list not provided to the subsequent provider. On 4/16/25 at 8:39 AM, The Regional Nurse stated the facility's discharge process was to send the resident's medication reconciliation list to the receiving facility. Resident #27's reconciled medication list was not sent and should have been.

Based on observation and interview, the facility failed to employ a certified Activities Director (AD). This failure had the potential to affect residents' quality of life when design of activities appropriate for residents was not implemented. Findings include: During resident council meeting on 4/14/25, residents stated the AD left about a month ago and one of the CNA's stepped in to help with activities. On 4/14/25 at 1:00 PM, the Administrator stated they had not been able to hire a certified AD, so one of the CNA's had been assigned as an interim AD.

Based on observation, record review, and interview, it was determined the facility failed to ensure professional standards of care were followed. This was true for 1 of 14 residents (Resident #18) whose records were reviewed. This had the potential for adverse effects and possible harm to resident's medical and physical status. Findings include: Resident #18 was initially admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including left side hemiplegia and hemiparesis following stroke (weakness or the inability to move one side of the body, rather than complete paralysis) and chronic respiratory failure with hypercapnia (caused by an imbalance in the load-capacity-drive relationship of the respiratory muscle pump). A) On 4/13/25 at 12:15 PM, observed Resident #18's left arm had a Lidocaine patch without date or initials of the nurse that applied the patch. On 4/15/25 at 2:20 PM, the DON stated the Lidocaine patch should have be labeled with the date applied and initials of the nurse who applied the patch and had not. B) Resident #18's medical record documented blood sugar of 502 on 4/8/25. Resident #18's medication administration record documented for blood sugars over 400 to contact the provider. Resident #18's nursing note dated 4/8/25, documented the provider was notified and authorized administering 15 units of insulin. On 4/15/25, Resident #18's medical record had not documented a physician's one time order for 15 units of insulin for resident when blood sugar was 502. On 4/15/25 at 3:10 PM, the Regional Nurse and DON stated the order for 15 units of insulin for Resident #18 was missed and not documented in the resident's chart.

Based on observation and staff interview, it was determined the facility failed to ensure nurse staffing information was accurate for each shift. This failed practice had the potential to affect all residents residing in the facility and their representatives, visitors, and others who wanted to review the facility's staffing levels. Findings include: On 4/15/25, during review of nurse staffing hours, observed the scheduled and actual hours worked were documented with the number 1 instead of the hours worked on the following dates: - 10/1/24 - 12/9/24 - 12/10/24 - 12/11/24 - 3/15/25 On 4/15/25 at 3:15 PM, the DON stated the hours listed on the nurse staffing hours were both the scheduled and actual worked hours and the use of number 1 on these sheets was done in error.

Based on record review and staff interview, it was determined the facility failed to ensure controlled medications were tracked and kept secure from potential theft and/or diversion. This was true for 2 of 2 medication carts reviewed. This failure created the potential for undetected misuse and/or diversion of controlled medications and had the potential to affect all residents who received controlled medication in the facility. Findings include: On 4/13/25 at 1:47 PM, during [NAME] hall medication cart audit, observed the narcotic accountability record, dated 4/1/25 to 4/13/25, with nine licensed nurse signatures not documented. On 4/13/25 at 1:54 PM, the DON stated two nurses should have signed the narcotic accountability sheet when they accepted the medication cart or released the medication cart. On 4/13/25 at 2:03 PM, during East hall medication cart audit, observed the narcotic accountability record, dated 4/1/25 to 4/13/25, with two licensed nurse signatures not documented. On 4/13/25 at 2:05 PM, the DON stated two nurses should have signed the narcotic accountability sheet when they accepted the medication cart or released the medication cart.

Based on record review, Drugs.com review, Federal Drug Administration review, and staff interview, it was determined the facility failed to ensure residents were monitored appropriately for medication use. This was true for 1 of 5 residents (Resident #2) reviewed for unnecessary medications. This failure created the potential for residents to experience adverse reactions due to the lack of appropriate monitoring. Findings include: Drugs.com documented Seroquel is an antipsychotic/antimanic agent that has a black box warning related to those with dementia. Seroquel may increase the risk of death in older adults with mental health problems related to dementia. The FDA requires manufacturers to place a black box warning on Seroquel and other antipsychotic drugs, highlighting the increased risk of death in elderly patients with dementia and that these drugs are not approved for the treatment of behavioral symptoms in elderly patients with dementia. Resident #2 was admitted to the facility on [DATE], with multiple diagnoses including dementia with behavioral disturbance and muscle weakness. Resident #2 medical record documented physician order dated 3/18/25, Seroquel Oral Tablet give 25 mg by mouth two times a day and give 50 mg by mouth one time a day related to unspecified dementia, moderate, with other behavioral disturbance. Resident #2's medical record had not documented the resident/resident representative had been notified of the black box warnings prior to medication being started. Resident #2's behavior tracking for March 2025, documented no improvement of behaviors with 10 to 20 or more behavior occurrences during days or nights. On 4/16/25 at 8:27 AM, the DON stated during the QAPI meeting yesterday, the medical staff agreed the Seroquel was not the appropriate medication for Resident #2's diagnosis.

Based on observation, staff interview and record review, it was determined the facility failed to ensure staff recognized and reported the need for suctioning to licensed nurses for 1 of 1 sample residents (#8) with orders and care plan interventions for oral suctioning as needed. The failure placed the health and safety of Resident #8 in immediate jeopardy of serious harm, impairment, or death from choking and/or aspiration. In addition, the facility failed to ensure pain medications were administered per physician orders [REDACTED].#2 and #6) with orders for [MEDICATION NAME]es. The failure created the potential for harm if residents' pain was not controlled. Findings include: 1. Resident #8 was admitted to the facility in 2013 with multiple diagnoses, including intracranial injury, convulsions, salivary secretion disturbances, [MEDICAL CONDITION] reflux disease (GERD), nausea, and history of recurrent pneumonia. Resident #8's most recent quarterly Minimum Data Set (MDS) assessment, dated 5/30/17, documented persistent vegetative state/no discernable consciousness; total assistance of 2 or more staff required for bed mobility and transfers; total assistance of 1 staff required for eating; 51% or more caloric intake and daily fluids received via enteral route; functional limitation in range of motion in both upper and both lower extremities; and wheelchair (W/C) use. Resident #8's care plan documented: * GI (gastrointestinal) upset related [MEDICAL CONDITION]- Place on side if emesis, initiated 12/17/13. * History of recurrent pneumonia, wheezing and cough - Orders for oral suctioning by licensed nurses if needed, initiated 3/18/14. * Persistent vegetative state, dependent for all cares - special W/C when up, initiated 12/8/15. * Nutrition/feeding tube - History of recurrent upper respiratory infections (aspiration pneumonia). If symptoms of aspiration (fever, moist cough, choking, watery eyes, nasal discharge, increased respirations, or audible breathing) notify nurse, initiated 11/30/16. Resident #8's Total Plan of Patient Care directions for Certified Nursing Assistants (CNAs) contained an undated Additional Comments section which documented, Notify nurse if resident has excessive oral salivation - suctioning PRN (as needed). Resident #8's Order Summary Report for 12/28/16 - 6/30/17 documented: * Change suction canister, tubing and Yankeur (brand of suction tip) every week as needed upon usage, dated 1/11/17; * [MEDICATION NAME] 1.0 at 100 ml/hour (miliLiters per hour) from 5:00 pm to 8:00 am, dated 3/3/16: * [MEDICATION NAME] 1 milligram (mg) via feeding tube 3 times a day for excessive salivation, dated 2/13/16. On 6/28/17 at 5:40 pm, Resident #8 was observed laying on his back in a geriatric chair next to his bed. The resident's head was elevated 30 degrees and [MEDICATION NAME] 1.0 was infusing at 100 ml/hour via feeding tube. Occasional gurgling sounds were heard coming from the resident's mouth. There was a suction machine on the resident's bedside table, but no suction tubing or suction tip device. On 6/28/17 at 5:45 pm, CNA #2 entered the room and began assisting Resident #8's roommate. When asked about suction tubing and a suction tip for Resident #8, CNA #2 said she had seen them earlier, but not now. CNA #2 looked in Resident #8's bedside table drawers but did not find suction tubing or a suction tip. The CNA resumed assisting the roommate, but stopped a few moments later and looked briefly at Resident #8 when he made a loud gurgling sound. CNA #2 said she would get a nurse then left the room. On 6/28/17 at 5:46 pm, CNA #2 returned to Resident #8's room and said a nurse was coming. CNA #2 resumed assisting the roommate and during this time, Resident #8 made more loud gurgling sounds and saliva/phlegm was observed bubbling up in his mouth. CNA #2 continued assisting the roommate then took the roommate out of the room and toward the restrooms. On 6/28/17 at 5:48 pm, while enroute to take Resident #8's roommate to the restroom, CNA #2 motioned toward Licensed Practical Nurse (LPN) #3 who was preparing medications at a medication cart several rooms away. At 5:49 am, LPN #3 walked to and stopped briefly in the doorway to room [ROOM NUMBER] with a medication cup in hand, then walked toward the dining room. On 6/28/17 at 5:50 pm, when LPN #3 did not come to Resident #8's room, the surveyor left the room to find a nurse. The Director of Nursing Services (DNS) was in the hallway to the dining room and she accompanied the surveyor to Resident #8's room. When asked about suction tubing and a suction tip, the DNS looked, but did not find suction tubing or a suction tip. The DNS said that suction tubing and a Yankeur tip should be in the resident's room. She said the resident rarely needed to be suctioned and that staff hook up the suction equipment when they need to suction the resident. At that point, loud gurgling sounds were heard and bubbling phlegm was observed in Resident #8's mouth; the DNS said, He needs suctioning now. The DNS left the room to get suction tubing and a suction tip. On 6/28/17 at 5:56 pm, the DNS and the MDS nurse entered Resident #8's room with suction tubing and a suction tip. They connected the tubing and suction tip to the suction machine and began suctioning the resident, who was gurgling and observed with phlegm bubbling in his mouth. On 6/28/17 at 6:15 pm, the DNS and MDS nurse were observed in Resident #8's room. The suction canister at the bedside contained 50 miliLiters (ml) of clear, frothy liquid. The MDS nurse stated, He needed to be suctioned and that the mucus was thick. The MDS nurse said she used 30 ml of water to flush the suction tip and tubing and the rest of the canister's contents was mucus/phlegm. The DNS and MDS nurse both said the resident could have aspirated or choked on 20 mls of mucus/phlegm. On 6/28/17 at 7:10 pm, CNA #2 said she had heard a little gurgling from Resident #8 while in the room assisting his roommate. The CNA said, But usually he'll have a little cough. He does that. Like a little cough. CNA #2 said she told LPN #3 that the surveyor was asking about suction tubing. The CNA said No when asked if she told the LPN that the resident was gurgling. On 6/28/17 at 7:12 pm, LPN #3 said CNA #2 told her a surveyor wanted to know about suction tubing but the CNA did not say anything else. The LPN said she told the CNA she would go to Resident #8's room as soon as she finished her current task. On 6/28/17 at 8:00 pm, the facility's Administrator was informed verbally and in writing of the Immediate Jeopardy situation regarding Resident #8 and of the need to develop and implement a plan to remove the immediacy. On 6/29/17 at 11:30 am, the facility provided evidence that an acceptable plan to remove the immediacy had been developed and implemented. The plan documened: * All licensed staff were to be inserviced before working with residents related to aspiration prevention and having functional suctioning equipment present. * Head-of-bed elevation levels were to be monitored every hour during the enteral feeding process, and at least one hour after feeding is completed, order written. * Licensed staff were to assess for signs of aspiration/need for suction every hour and PRN, order written. * DNS or designee was to audit MARs for compliance with above orders weekly for 3 months then monthly, starting 6/29/17. * Resident #8's care plan was updated to reflect changes in care, 6/28/17 revised 6/29/17. * CNAs were to be inserviced on elevating head-of-bed and reporting to licensed staff if the resident exhibited signs and/or symptoms of saliva around the mouth or choking. * The Maintenance Supervisor was to place a mark on the wall to assist in properly elevating the resident's head-of-bed. * No other resident at risk at this time, due to no other feeding tube/PRN suction machine orders. * Systemic changes: Enteral Feedings - Safety Precautions policy updated 6/28/17 to include suctioning: 1. Obtain order for suctioning, as appropriate 2. If order present, ensure suction machine is readily available and functioning 3. Recognize the need to suction 4. Suction as appropriate, document in eMAR (electronic MAR). * All employees were to receive inservice to monitor for coughing, choking noises, excessive saliva, and when performing room rounds to assess for placement of tubing to suction machine, starting 6/28/17. * All licensed staff were to complete inservice training by 7/5/17. 2. Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. physician's orders [REDACTED].#6 was to receive a 12 mcg [MEDICATION NAME] every 72 hours for pain. The April 2017 MAR indicated [REDACTED]. On 6/29/17 at 2:52 pm, the DNS stated the [MEDICATION NAME] was not applied as ordered by the physician. Resident #6's April 2017 MAR indicated [REDACTED]. The Controlled or Antibiotic Drug Record documented the [MEDICATION NAME] was not applied until 4/23/17 at 11:30 pm, 3 days after the patch was removed on 4/20/17. On 6/29/17 at 1:35 pm, the DNS and the Regional Clinical Director stated the [MEDICATION NAME]es had not been reordered because when the physician came into the facility staff did not realize there were no more [MEDICATION NAME]es on hand and did not ask the physician to order more. On 6/29/17 at 3:00 pm, the DNS stated a [MEDICATION NAME] was not applied until 4/23/17, but should have been provided to Resident #6 on 4/21/17. Resident #6 was at increased risk for increased pain when the [MEDICATION NAME] for treatment of [REDACTED]. 3. Resident #2 was admitted to the facility with [DIAGNOSES REDACTED]. A 5/20/17 physician order [REDACTED].#2 with a 50 mcg [MEDICATION NAME] every 72 hours for pain. The June 2017 MAR indicated [REDACTED]. The Controlled or Antibiotic Drug Record documented Resident #2's [MEDICATION NAME] was applied on 6/12/17 at 10:00 pm, and on 6/15/17 at 1:14 am.

Based on observation, staff interview and record review, it was determined the facility failed to ensure bedside suctioning equipment was operational for 1 of 1 sampled residents (#8) with orders and care plan interventions for suctioning as needed. The failure placed Resident #8 in immediate jeopardy for choking, aspiration, and death when excessive oral secretions were in his mouth and the suctioning equipment was incomplete, and therefore not operational. The facility also failed to ensure: * Cigarette lighters for 1 of 2 residents (#2) who smoked tobacco products were secured; * One of 2 staff restrooms without a call system or safety bars was secured; * Lawn sprinklers did not leak; and *A stove drawer in the Therapy Room closed completely. The failures created the potential for harm if independently mobile and cognitively impaired residents (#s 15-18) were to start a fire using an unsecured lighter and/or were unable to summon help in the unsecured Staff Restroom. Residents were also at risk for injury from the broken and protruding stove drawer in the Therapy Room, and for falls if they slipped on wet, slick spots on the sidewalk. Findings include: 1. Resident #8 was admitted to the facility in 2013 with multiple diagnoses, including intracranial injury related to a motor-vehicle accident, convulsions, disturbances of salivary secretion, gastroesophageal reflux disease (GERD), nausea, and history of recurrent pneumonia. Resident #8's most recent quarterly Minimum Data Set (MDS) assessment, dated 5/30/17, documented persistent vegetative state/no discernable consciousness, total assistance of 2 or more staff for bed mobility and transfers, 51% or more calories and daily fluids received via the enteral route, functional limitation in range of motion in both upper and both lower extremities, and wheelchair (W/C) use. Resident #8's care plan documented: * GI (gastrointestinal) upset related to GERD - Place on side for emesis, initiated 12/17/13. * History of recurrent pneumonia, wheezing and cough - Orders for oral suctioning by licensed nurses if needed, initiated 3/18/14. * Persistent vegetative state, dependent for all cares - Special W/C when up, initiated 12/8/15. * Nutrition/feeding tube - History of recurring upper respiratory infections (aspiration pneumonia). If symptoms of aspiration (fever, moist cough, choking, watery eyes, nasal discharge, increased respirations, or audible breathing) notify a nurse, initiated 11/30/16. Resident #8's Total Plan of Patient Care directions for Certified Nursing Assistants (CNAs) contained an undated Additional Comments section which documented, Notify nurse if resident has excessive oral salivation-suctioning PRN (as needed). Resident #8's physician orders [REDACTED].>* Change suction canister, tubing and Yankeur every week as needed upon usage, dated 1/11/17; * Jevity 1.0 at 100 ml/hour (miliLiters per hour) from 5:00 pm to 8:00 am, dated 3/3/16; * Glycopyrrolate 3 times daily for excessive salivation, dated 2/13/16. On 6/28/17 at 5:40 pm, Resident #8 was observed laying on his back in a geriatric chair in his room. The resident's head was elevated 30 degrees and the Jevity enteral feeding was infusing at 100 ml/hour via feeding pump. The resident made occasional gurgling sounds. A suction machine was on the resident's bedside table, however the suction tubing and suction tip device was not visible. On 6/28/17 at 5:45 pm, CNA #2 entered the room and began assisting Resident #8's roommate. When asked about suction tubing and suction tip for Resident #8's suction machine, the CNA said she had seen them earlier, but not now. CNA #2 looked in Resident #8's bedside table drawers, but did not find suction tubing or a suction tip. She resumed assisting the roommate a few more moments, but stopped when Resident #8 made a loud gurgling sound. CNA #2 said she would summon a nurse then left the room. CNA #2 returned to the room at 5:46 pm and said a nurse was coming. Resident #8 made more loud gurgling sounds and phlegm was visible bubbling in his mouth while CNA #2 continued assisting the roommate before taking her out of the room. On 6/28/17 by 5:50 pm, a nurse did not come to Resident #8's room. The surveyor left the room and found the Director of Nursing Services (DNS) in the hallway to the dining room. The DNS accompanied the surveyor to Resident #8's room. The DNS looked for, but did not find, suction tubing or a suction tip in the resident's room. The DNS said that suction tubing and a Yankeur tip should be in the resident's room. The DNS stated the resident rarely needed to be suctioned and that staff hook up the suction equipment when they need to suction the resident. At that point, loud gurgling sounds were heard and bubbling phlegm was observed in Resident #8's mouth. The DNS said, He needs suctioning now. The DNS left the room to get suction tubing and a suction tip. On 6/28/17 at 5:56 pm, the DNS and the MDS nurse entered Resident #8's room with suction tubing and a suction tip. The nurses connected the tubing to the suction machine and began suctioning the resident, who was gurgling with phlegm bubbling in his mouth. On 6/28/17 at 6:15 pm, the DNS and MDS nurse said that 20 miliLiters (ml) of 50 ml of clear, frothy liquid in the suction canister was mucus/phlegm. The MDS nurse said, He needed to be suctioned and that the mucus was thick. The DNS and MDS nurse both said the resident could have aspirated or choked on 20 mls of mucus/phlegm. On 6/28/17 at 8:00 pm, the facility's Administrator was informed verbally and in writing of the Immediate Jeopardy situation regarding Resident #8's incomplete, and therefore inoperable, suctioning equipment and of the need to develop and implement a plan to remove the immediacy. On 6/29/17 at 11:30 am, the facility provided evidence that an acceptable plan to remove the immediacy had been developed and implemented. The plan included: * All licensed staff were to be inserviced that a complete and functioning suction system must be present for immediate use before working with the resident. * Staff were to monitor and assess for placement of suction tubing to suction machine every shift and PRN, order written. * Licensed staff were to assess for any signs of aspiration/need for suctioning every hour and PRN, order written. * DNS or designee were to audit Medication Administration Records (MAR) for compliance with orders weekly for 3 months then monthly, starting 6/29/17. * Resident #8's care plan was updated to reflect change in care on 6/28/17 and 6/29/17. * Systemic changes: Enteral Feedings - Safety Precautions policy updated 6/28/17 to include suctioning: 1. Obtain order for suctioning, as appropriate 2. If order present, ensure suction machine is readily available and functioning 3. Recognize the need to suction 4. Suction as appropriate, document in eMAR (electronic MAR). * Facility to review and audit MARs for signatures, weekly room rounds, monitoring of Yankeur (suction tip device), and tubing to suction machine. * All employee's - Housekeeping/Dietary/Activities/Nursing/Social Services/Business Office/Human Resources/Medical Records - inserviced to monitor for cough, choking noise, saliva, and when performing room rounds to assess for placement of tubing to suction machine, starting 6/28/17. * All licensed staff were to complete inservice by 7/5/17. 2. One of two Staff Restrooms in the hallway to the dining room, which did not have a call system or safety bars, was observed unsecured. The door was either unlocked or not fully closed as follows: * 6/26/17 at 10:25 am - The door was closed, but not locked. * 6/27/17 at 10:38 am - The door was closed, but not locked. * 6/27/17 at 11:23 am - The door knob was locked, but the door was not closed completely. The Human Resource staff member was in the hallway at the time and said the door should be closed. She closed the door. * 6/27/17 at 1:30 pm - The door was closed, but not locked. * 6/27/17 at 2:10 pm - The door was closed, but not locked, when LPN #1 and LPN #2 went to the restroom to destroy a medication. One of the LPNs locked and closed the door. On 6/27/17 at 2:15 pm, the Administrator said the maintenance supervisor would fix the door. 3. Facility lawn sprinklers by the sidewalk in front of the facility were observed leaking continuously in 4 places from 6/26/17 through 6/29/17. Water with a layer of silt underneath was pooled on the sidewalk by the 4 leaking sprinklers. The pools of water and slick pavement were 2 to 4 feet wide and crossed the sidewalk. Residents were observed ambulating and moving about on the sidewalk in front of the facility during each day of the survey. A tour of the facility environment was conducted with the Maintenance Supervisor on 6/29/17. The Maintenance Supervisor said the lawn sprinklers were fed by water from a hose placed in a water canal receptacle on facility property. He said the lawn sprinklers were set to run every Monday, Wednesday and Friday and that the first staff member to arrive for work the next morning was supposed to remove the hose. He said the task was not assigned to any staff member in particular and it was not getting done. The Maintenance Supervisor removed the hose from the water canal receptacle. 4. The drawer at the bottom of the stove in the Therapy Room was observed sticking out 2 inches on the left side as follows: * 6/26/17 at 12:25 am - one resident was in the room eating lunch and 1 staff was present; * 6/27/17 at 9:00 am - during a Group Interview with 7 residents present; * 6/28/17 at 10:00 am and 6/29/17 11:30 am - the drawer would not close. On 6/29/17 at 2:30 pm, during a tour of the facility environment, the Maintenance Supervisor said the stove drawer was broken and needed to be repaired. 5. The facility's smoking policy, dated April 2012, documented, This facility shall establish and maintain safe resident smoking practices . Resident (with independent smoking privileges) may keep disposable lighters. All other forms of lighters . shall be prohibited . Resident #2 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #2's roommate, Resident #17, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A significant change Minimum Data Set (MDS) assessment, dated 4/17/17, documented Resident #2 was cognitively intact. Resident #2's care plan, dated 4/2/17, documented she was safe to smoke independently, was not on a smoking schedule, but required staff assistance getting outside to smoke; occasionally required staff assistance lighting a cigarette; and was allowed to keep her cigarettes and lighter in her personal possession. A smoking assessment, dated 6/11/17, documented Resident #2 experienced intermittent confusion; had no visual deficits; experienced contractures to her fingers/hands; and that the physician, staff, and family were concerned about the resident's safety related to times that Resident #2 was sleepy but would stay outside for hours at a time. The smoking assessment documented there had not been any smoking related accidents; Resident #2 could flick ashes safely and extinguish cigarettes appropriately; an adaptive cigarette holder was required; and the resident required assistance getting into- and out from the designated smoking area. On 6/26/17 at 2:20 pm, Resident #2 was observed sitting outside in a wheelchair with a cigarette holder containing an extinguished cigarette butt in her hand. The resident stated she did not require supervision to smoke and could keep her cigarettes and lighter. The resident's cigarettes and lighter were observed on her lap. On 6/26/17 at 3:48 pm, the door to Resident #2's room was observed open and 2 disposable lighters and a Zippo lighter could be seen on the resident's overbed table. Resident #2 was not in the room at the time of the observation, Resident #17 was observed lying in her bed. On 6/26/17 at 3:55 pm, CNA #1 stated Resident #2 leaves her lighters on the overbed table, which staff does not remove to a secure location because the resident would become upset if the lighters were moved. CNA #1 then lit each lighter to show they worked as intended. On 6/26/17 at 4:02 pm, the DNS stated Resident #2 could keep the cigarettes and lighters in her personal possession, although she was told they had to be in a secure location. The DNS stated Resident #2 was very particular about her personal possessions, but that she would speak to the resident about keeping her lighters in a secured location. On 6/26/17 at 4:52 pm, the DNS stated Resident #2 agreed to relocate her disposable lighters to a secured medication cart, where they would remain when not in use, and the Zippo lighter was taken out of the facility by a family member.

Based on observation, record review, and staff and resident interview, it was determined the facility failed ensure a resident received prompt medical treatment after he sustained second-[MEDICAL CONDITION] his bilateral inner thighs and experienced increased pain. This was true for 1 of 8 (#1) sampled residents. Resident #1 was harmed when accurate information was not provided to the physician, resulting in a two-day delay of assessment and treatment by the physician, and when the facility did not recognize that the wound care resulted in pain. Resident #1 was admitted to the facility with multiple diagnoses, including [MEDICAL CONDITIONS], and chronic pain. A Quarterly MDS, dated [DATE], documented: Severely impaired cognition; limited assistance of one staff for eating and drinking; functional limitation in range-of-motion to bilateral upper extremities; received scheduled pain medication; and did not display non-verbal sounds, vocal complaints, facial expressions, protective body movements or postures. The current Pain care plan included the following: - If you ask me if I am in pain I may or may not answer you but you should ask me. I need you to watch for s/sx (of) pain such as increased negative vocals, irritability, furrowed brows, aggression, resisting cares, let my nurse know so she can assess me. I do have prn pain medication ordered, give it to me as ordered. - My pain medication was increased by my provider on 1/6/16. A Skin Incident/Accident report, dated 2/27/16, documented: * 7:00 pm: CNA #19 witness statement - Resident was in dining room. I saw that there was spilled coffee on the place mat. * 7:10 pm: CNA #23 witness statement - Put resident to bed, pulled resident's pants down and noticed blisters on inner thighs. Reported to nurse, I believe resident got blisters from (adult brief) rubbing, also I believe resident spilled coffee while it was hot which could have caused blisters, blanket does smell like coffee. * 7:10 pm: LPN #6 - Resident #1 acquired skin tears with blisters on his bilateral inner thighs, denies pain and discomfort. The left thigh skin tear with blister measured 12 cm x 4 cm. The right thigh skin tear with blister measured 10 cm x 3 cm. * 7:15 pm: CNA #14 witness statement - I noticed (Resident #1) was wet in the middle of dinner so once dinner was over I let his aides know . I do believe he had coffee before dinner and at dinner. He may have spilt (sic) it on his legs and that's where the blisters may have come from. * 10:28 pm: Physician Notified. Physician order [REDACTED]. * Nursing interventions added after the incident included: Pillow between the resident's legs with no hot coffee without staff assistance; in-service staff; resident education. * A staff in-service, dated 2/27/16, attached to the I&A documented, Please do not give hot coffee without staff supervision. We do not want him to spill hot coffee on himself. There were no staff signatures on the in-service to show staff had received this direction. On 2/27/16, the coffee served with dinner was measured at a documented temperature of 174-degrees. The resident's clinical record documented skin tears with blisters. The inaccurate description of Resident #1's injuries led to a physician's orders [REDACTED]. A Nurses Note, dated 2/28/16 at 12:13 pm, documented, (Resident #1) continued with reddened areas to inner thighs. Blister has popped on left thigh but was intact to the right thigh. Inservice was written to inform staff not to give him hot liquids w/o supervision and make sure coffee has been cooled down a little and has lid on cup. A Nurses Note, dated 2/29/16 at 5:15 pm, documented, Provider in to assess burns, (which had initially been described as skin tears) to (Resident #1's) bilateral inner thighs. Order written to apply [MEDICATION NAME] and non-adherent dressing and change every day. Wounds are red and open since blisters have popped . currently on scheduled pain medication which has been effective in controlling pain. Wound Sheets, dated 3/7/16 to 3/28/16, documented: * 3/7/16 - burn wounds are tender, * 3/14/16 - burn wounds are tender, * 3/21/16 - burn wounds are tender, and * 3/29/15 - burn wounds are sometimes painful. * The wound sheet pain assessment did not include an explanation of verbal and/or non-verbal cues expressed by the resident which led to the determination that the wounds were tender and/or painful sometimes. Additionally, the wound sheet did not document what steps were taken when the affected areas were identified as tender and sometimes painful to the resident. On 3/28/15 at 1:45 pm, RN #5 sprayed the resident's bilateral inner thigh dressings with wound cleaner to assist with removal of the dressings. Resident #1 frowned, furrowed his brow, and struck the nurse on her arm several times as she removed the dressings. RN #5 apologized to the resident and said she would be finished in a few minutes. The RN cleaned the wounds, applied [MEDICATION NAME], and non- adhesive dressing approximately 23 cm x 6 cm with adhesive border over the resident's burns. The adhesive border was applied to the recently healed burned areas of the resident's thighs. The nurse then dated and initialed the dressings as the resident retracted his right leg, frowned, and stated,Stop! Don't! That leg is on fire! On 3/31/16 at 9:00 am, the DNS and MDS Coordinator were asked to provide an I&A report, dated 1/5/16, identified on the care plan as related to the resident spilling coffee on his legs. At 9:30 am, the DNS stated the facility had not completed an I&A for 1/5/16 because the resident was not burned. On 3/31/16 at 2:20 pm, when asked why the nurse reported the bilateral [MEDICAL CONDITION] skin tears with blisters to the physician on 2/27/16 and not second degree burns, the DNS stated, We are not allowed to diagnose. On 4/1/16 at 11:05 am, when asked why nursing staff would report [MEDICAL CONDITION] skin tears with blisters to the resident's physician, the corporate medical director stated, That is confusing to me. I don't get it; if it's a burn, it's a burn. When asked what treatment should be initiated upon identification of burned skin with blisters, the corporate medical director stated, [MEDICATION NAME] should be immediately applied to the affected areas. When asked what happened when the physician was not provided with accurate information and/or assessment by the facility, the corporate medical director stated, Not [MEDICAL CONDITION] what they were resulted in a delay of appropriate treatment. On 4/1/16 at 12:55 pm, LPN #4 was observed quickly pulling the dressings off the resident's left and right thigh burns. The resident furrowed his brow, grimaced, retracted his legs, balled up his fist, and shook it at the nurse. The nurse stated he always does that when the dressings are removed. When asked if his legs hurt, the resident stated,Hurts like hell! The nurse sprayed the resident'[MEDICAL CONDITION] wound cleanser without addressing the resident's expressions of pain and stated, I will be done in just a minute. As the nurse wiped the wounds with gauze, the resident raised his fist, retracted his legs, shook his head back and forth, attempted to hit the nurse's arm and stated,G-- damn it, that's enough! The nurse did not stop the procedure or address the resident's pain and the DNS who was present during the dressing change did not instruct LPN #4 to stop the procedure. When the DNS picked up a measuring device and placed it on the resident's right leg burn and left leg burn, the resident grimaced and attempted to strike the LPN on her arm. The LPN grabbed the resident's hands and held onto them until the DNS finished measuring the burns.

Based on interview and medical record review, it was determined the facility failed to ensure residents who were identified at risk for accidents and/or falls received the necessary assistance to prevent burns and falls. This was true for 3 of 8 (#s 1, 4, & 8) residents sampled for safety and supervision. Resident #1 was harmed when he sustained second degree burns to his inner thighs and increased pain; Resident #8 was harmed when she experienced two falls in two days, one of which resulted in a left sided hip fracture; and Resident #4 had the potential for injury when she was not adequately assessed and interventions were not monitored for efficacy to prevent repeated falls. Findings included: 1. Resident #1 was admitted to the facility with multiple [DIAGNOSES REDACTED]. A Quarterly MDS assessment, dated 1/6/16, documented: Severely impaired cognition; limited assistance of one-staff for eating and drinking; and functional limitation in range-of-motion to bilateral upper extremities. The ADL flow sheet for January 2016, documented the resident required limited assistance of 1 staff for meals. A Nutrition care plan, dated 1/5/16, documented Resident#1 was dependent on 1 staff for eating/drinking, and identified the following concern and intervention: There are times that I will try to take the lid off of my coffee. I have had an occasion where I have spilled the coffee on my legs but they did not get burned. When you give me my coffee in the morning, make sure that the lid is on it and if I take it off or try to take it off, offer to cool it down for me just in case I were (sic) to spill it. The State Operations Manual, Time and Temperature Relationship to Serious Burns documented it takes one second for a 3rd-degree burn to occur when water temperature is 155-degrees Fahrenheit, and that burns can occur at temperatures below 155-degrees depending on an individual's condition and length of exposure. Food temperature logs from 2/1/16 to 3/31/16 documented coffee temperatures for breakfast and dinner were 160 to 180 degrees Fahrenheit. The documented temperature of the coffee served on 2/27/16 was 174-degrees. A Skin Incident/Accident report, dated 2/27/16, documented Resident #1 acquired skin tears with blisters on his bilateral inner thighs, denies pain and discomfort. The left thigh skin tear with blister measured 12 cm x 4 cm. The right thigh skin tear with blister measured 10 cm x 3 cm. * 7:15 pm: CNA #14 witness statement - I noticed (Resident #1) was wet in the middle of dinner so once dinner was over I let his aides know . I do believe he had coffee before dinner and at dinner. He may have spilt (sic) it on his legs and that's where the blisters may have come from. * Interventions included: Ensure the coffee cup had a lid and if the resident attempted- or took the lid off staff was to offer to cool it down for him just in case he spilled it. * Post skin incident interventions included: Pillow between the resident's legs and staff supervision with hot coffee. * A staff in-service, dated 2/27/16 and attached to the I&A, documented the resident was not to have hot coffee without staff supervision. The in-service did not include staff signatures indicating the information was received. An IDT note documented, On 2/27/16 the resident was possibly trying to place cup on the table and missed the table and spilled (the hot coffee) in (his) lap. A facility document provided by the Administrator and dated 2/29/16 identified coffee dispensers wre moved to prevent care staff from serving coffee to residents, and that dietary staff would serve coffee from that point forward. An IDT note, dated 3/2/16, documented Resident #1 had an open blistered area to his left inner thigh measuring 12 cm x 4 cm and a open blistered area to his right inner thigh measuring 10 cm x 3 cm. As a precaution, the coffee maker temperatures were reviewed and kitchen staff were to attempt brewing coffee at a lower temperature; Resident #1's coffee was to be served cooled in a mug with a lid and only by dietary staff; the resident's dementia prevented him from processing environmental stimuli as others would; and staff were to observe the resident when when provided with warm beverages. On 3/30/16 at 10:30 am, the Regional Consultant and Dietary Manager stated the coffee had to be brewed at 180-degrees and the coffee vendor had been into the facility to turn the temperature down on the coffee maker prior to survey. The Dietary Manager stated coffee was brewed in the coffee machine, poured into an insulated coffee dispenser, and served to residents. She stated if a resident needs his/her coffee cooled down the dietary staff would do so. It was not clear how the facility would ensure cooled coffee would be considered palatable. On 3/31/15 at 1:15 pm, Resident #1 was served a cup of coffee with a lid after completing his RNA exercises. The resident accepted the coffee, and held it in his right hand on his lap between sips. He did not attempt to remove the lid. On 3/31/16 at 2:20 pm, the DNS stated the resident had spilled coffee on his lap on 1/5/16, which his why his care plan was updated. The DNS stated since the resident did not burn himself at that time, further monitoring was not done, and since the plan was to offer to cool his coffee, additional supervision with coffee was not needed following that event. 2. Resident #8 was admitted to the facility on [DATE] with multiple diagnoses, including dementia, fatigue, COPD, and loss of muscle control. An Interim Admission care plan, dated 10/7/15, documented the resident was at risk for falls related to weakness and confusion. Interventions included placing the call light within reach, assisting with toileting and transfers as needed, and PT/OT therapies. The ADL flow sheet, dated from 10/7/15 to 10/9/15, documented the resident required extensive assistance of two staff for transfers, bed mobility, and toileting. An I&A, dated 10/7/15 at 7:45 pm, documented the resident had been very confused, was found on the floor next to the edge of the bed, and stated people were trying to kill her. * Fall prevention interventions included: Call light within reach, bed in low position, and 15-minute checks. * Post fall interventions included: Alarm placed on the bed to alert staff of attempted self transfers, continue 15-minute checks, spouse spoke with resident on the phone, and staff reassured the resident no one was trying to kill her and that she was safe at the facility. A Speech Therapy evaluation and plan of treatment, dated 10/8/15, documented the resident demonstrated moderate-to-severe cognitive and communication impairment relating to attention, recall, auditory comprehension, and problem solving/insight to deficits. Increased dependency on caregivers and falls were identified as risk factors related to obtaining goals. An Occupational Therapy evaluation and plan of treatment, dated 10/8/15, documented the resident was confused and unable to express her thoughts in a coherent manner. OT services were necessary to increase independence with ADLs and increase safety awareness. A Physical Therapy evaluation and plan of treatment, dated 10/8/15, documented the resident was confused during evaluation and treatment and required PT to minimize falls and promote safety awareness. The resident was assessed at risk for further decline in function and falls. An I&A, dated 10/9/15 at 8:00 pm, documented the resident was found on the floor in her room after attempting to self-transfer out of bed. When the nurse asked the resident what she was trying to do, the resident stated she was attempting to go to the bathroom. * Fall prevention interventions included: Call light within reach, bed in low position, wander guard, 15-minute checks, and bed alarm. * Resident #8 was transported to the ER following the fall due to left hip and left shoulder pain. A Nurses Note, dated 10/9/15 at 8:00 pm, documented, The nurse and CNA were on the west hall heard a bed alarm, ran down the hall and were right outside the resident's room when they heard a crash, and found the resident under the bedside table. The resident was assessed with [REDACTED]. The resident received two skin tears on the left forearm, one measured 5 cm and the other measured 7 cm. The resident was sent to the ER and admitted to the hospital. An I&A IDT review, dated 10/13/15, documented the resident was admitted to the hospital with [REDACTED]. On 3/31/16 at 4:00 pm, the DNS stated Resident #8 was placed on 15-minute checks when she was admitted on [DATE]. The DNS stated that on 10/8/15 the facility determined 15-minute checks were ineffective and the resident required 1:1 staffing due to the her verbalized thoughts of people trying to kill her, attempted elopement, confusion, poor safety awareness, and a fall on 10/7/15. The DNS stated that the facility did not typically provide 1:1 supervision, and on 10/8/15 the RSD began the search for another facility that would accept the resident. The DNS stated the facility had not increased supervision to meet the need for 1:1 while alternative placement was found. 3. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS assessment, dated 1/29/16, documented Resident #4 rarely understood others and required extensive 1-staff assistance with ADLs. A February 2015 Falls - Clinical Protocol documented, The licensed nurse and physician will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling and if the individual continues to fall, the licensed nurse and physician will re-evaluate the situation and consider other possible reasons for the resident's falling (besides those that have already been identified) and will re-evaluate the continued relevance of current interventions. A Falls Risk care plan, dated 3/28/16, documented staff were to encourage her to stay up and active until 9:30 pm, place the bed in a low position with fall mat on the floor, provide PT/OT for strengthening and to increase independence with ADLs, place a halo bar and pressure-sensitive alarm on the bed, offer to position the resident in a recliner, and provide a sweet snack if restless. Review of Incident and Accident Reports, dated 3/3/16, 3/11/16, 3/17/16, 3/18/16, 3/21/16, and 3/23/16, documented the resident had experienced 6 falls in her room within a one month period and 3 falls within a week of being discharged from physical therapy. On 3/30/16 at 3:00 pm, the MDS Coordinator, who was also the Restorative Coordinator, said she would need to meet with the Therapy department to discuss starting the resident on a restorative program. She said since Resident #4's falls occurred in her room then strength training would be appropriate as an intervention to help prevent future falls. She said Resident #4 had not been re-evaluated after her 3 falls within 5 days. On 3/31/16 at 11:20 am, the Physical Therapist said he was unaware of Resident #4's recent falls and the resident should be re-evaluated or started on a restorative program. On 3/31/16 at 1:45 pm, the DON said she did not consider increasing Resident #4's 15-minute checks as an intervention to prevent future falls and that the resident was not receiving restorative nursing as an intervention to increase strength and prevent falls. On 4/1/16 at 11:45 am, the Medical Director said she was unaware Resident #4 experienced 6 falls in one month and she would expect the facility to communicate that to her. She also stated she had not identified falls as a problem area in the facility.