Every finding on record at Lincoln Park Manor Inc

The facility identified a census of 34 residents. The facility had one main kitchen and one main dining area. Based on observation, record review, and interview, the facility failed to ensure the director of food and nutrition services had the required qualifications of a certified dietary manager (CDM). This placed residents at risk for unmet dietary and nutritional needs.Findings included:- On 08/19/25 at 08:20 AM, Dietary BB stated she did not have her CDM certification, but the administrator and she were currently enrolled in classes to get certified.On 08/19/25 at 10:15 AM, Administrative Staff A stated that the dietary manager and she were currently in classes to get certified as a dietary manager. Administrative Staff A stated the registered dietician came to the facility twice a month, but she was always available by phone.The facility's Dietician policy dated July 2025 documented if a dietician was not employed full-time, a director of food and nutrition services would be designated. This individual would be a certified dietary manager; or a certified food service manager; or be nationally certified in food service management and safety; or have an associate's degree in food service management or hospitality; or has two or more years of experience in the position of director of food and nutrition services in a nursing facility setting and has completed a course of study in food safety and management.The facility failed to ensure the director of food and nutrition services had the required qualifications of a CDM. This placed residents at risk for unmet dietary and nutritional needs.

The facility identified a census of 34 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to ensure staff followed appropriate Enhanced Barrier Precautions (EBP- infection control interventions designed to reduce transmission of resistant organisms which employ targeted gown and glove use during high contact care) and hand hygiene while providing wound care to Resident (R) 38 and R2. The facility failed to ensure R10's nasal cannula (NC- a hollow tube medical device that provides supplemental oxygen therapy to people who have lower oxygen levels) and nebulizer (a device that changes liquid medication into a mist easily inhaled into the lungs) mask was properly stored when not in use. This placed R38, R2, and R10 at risk of infection development and possible respiratory complications.Findings included:- The Electronic Medical Record (EMR) for R2 had diagnoses of Alzheimer's disease (a progressive mental deterioration characterized by confusion and memory failure), chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), hemiparesis/hemiplegia (weakness and paralysis on one side of the body), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). The “Quarterly Minimum Data Set” (MDS), dated [DATE], documented R2 had severely impaired cognition. R2 was dependent upon staff for all activities of daily living, had a Stage 2 (partial-thickness skin loss into but no deeper than the dermis, including intact or ruptured blisters), and was on received Hospice (specialized care that mainly aims to provide comfort and dignity to the patients, by providing physical comfort and emotional, social, and spiritual support for people nearing the end of life) services. R2’s “Care Plan,” initiated on 07/12/23, documented R2 had actual skin impairment due to dry skin and limited mobility. The care plan directed staff to follow policies/protocols for the prevention and treatment of skin breakdown, monitor, and report any changes in skin status. The care plan lacked documentation. R2 was on Enhanced Barrier Precautions (EBP- infection control interventions designed to reduce transmission of resistant organisms, which employ targeted gown and glove use during high contact care) and lacked direction to staff on what personal protective equipment (PPE- gowns, face shields, and/or eyeglasses/goggles, and gloves) to use. The Physician’s Order,” dated 07/22/25, directed staff to apply Opti foam (a brand of foam wound dressing designed to absorb fluid and protect wounds) to her Stage 2 pressure ulcer, change the dressing every seven days and as needed, and discontinue when healed. On 08/20/25 at 10:15 AM, Licensed Nurse (LN) G and LN H sanitized their hands and donned clean gloves. LN G stated R2 had recently gotten a small open area on her coccyx. LN H got on the side of the bed closest to the wall, and LN G was on the opposite side. R2 had bilateral heel protectors on, and LN G pulled down her pants, checked her incontinence brief, and stated she had a bowel movement (bm). R2’s heel protectors and pants were removed due to LN G had gotten BM on her pants while she was providing personal care. Both LN G and LN H removed their soiled glove and donned clean gloves. LN G and LN H assisted R2 onto her left side so that LN H could perform wound care. LN H removed the old dressing, used gauze to cleanse the wound, placed the wound cleanser on the bed, and measured the wound. LN H put Opti foam on R2’s wound, assisted with a clean brief, and still had on soiled gloves. LN H verified that she should have changed her gloves after she cleansed the wound. LN H stated that she had discussed with Administrative Nurse D that R2 needed to be on EBP, and she had not done it yet. LN H stated, it was on her list and would do it right away. On 08/20/25 at 11:00 AM, Certified Nurse Aide (CNA) N stated she did not know that R2 required EBP and that she had never worn a gown while she provided care to R2, only gloves. On 08/20/25 at 12:20 PM, Administrative Nurse D stated R2 should be on EBP due to her open area and that staff should have changed her gloves after she cleaned R2’s wound. Administrative Nurse D further stated she would review the care plan and make sure the EBP information was on the care plan. The facility’s “Enhanced Barrier Precautions” policy, dated 12/24, documented that EBP is utilized to prevent the spread of multidrug-resistant organisms (MDRO) to residents. Enhanced barrier precautions apply when a resident is not known to be infected or colonized with any MDRO, has a wound or indwelling medical devices, and does not have secretions or excretions that are unable to be covered or contained, and contact precautions do not otherwise apply. EBPs employ targeted gown and glove use in addition to standard precautions during high-contact resident care activities when contact precautions do not otherwise apply. High-contact resident care activities requiring the use of a gown and gloves for EBPs included: dressing, bathing, providing hygiene or grooming, changing briefs or assisting with toileting, transferring, bed mobility, changing linens, and wound care. Signs are posted on the door or wall outside the residents’ rooms, which communicate the type of precautions and PPE required. - On 08/18/25 at 11:35 AM, an observation of R38’s Stage 4 (a deep pressure wound that reaches the muscles, ligaments, or even bone) pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as the result of pressure, or pressure in combination with shear and/or friction) wound care revealed the following: Licensed Nurse (LN) G gathered the wound care supplies to complete R38’s wound care. LN G placed a barrier on R38’s bedside table and placed all supplies needed on top of the barrier. LN H was in R38’s room to assist LN G. LN H performed hand hygiene with hand sanitizer prior to applying clean gloves. LN G applied clean gloves without performing hand hygiene. Neither LN G nor LN H donned a protective gown prior to beginning wound care for R38. LN G raised R38’s bed to be at a height appropriate to do wound care. LN G and LN H assisted in rolling R38 to his right side. LN G unfastened R38’s brief and then placed a clean barrier under his bottom. LN G removed her gloves and threw them in the trash. LN G then put on a clean pair of gloves (no hand hygiene performed) and began to remove R38’s old wound dressings and placed the dressings in the trash can. LN G then grabbed the wound cleanser and cleans the wound area, and wiped with clean 4 x 4 gauze. LN G then started to grab the bottle of packing tape, but stopped and stated, “I guess I should probably change my gloves.” LN G removed the dirty gloves and put on a clean pair of gloves (no hand hygiene performed). LN G continued to perform the wound care as ordered. LN G gathered the trash after the task was completed and removed her gloves. LN G failed to perform hand hygiene after disposing of the trash. LN H removed her gloves and performed hand hygiene before leaving R38’s room. On 08/18/25 at 11:50 AM, LN G stated she should have washed her hands and done hand hygiene after removing her gloves. LN G stated that a gown should have also been worn while providing cares to R38. On 08/20/25 at 12:15 PM, Administrative Nurse D, the facility’s Infection Preventionist, stated the staff had just had an education session with staff about the EBP. Administrative Nurse D stated staff should know to always wear gloves and gowns when providing a resident on EBP as well as doing hand hygiene in between glove changes. The facility’s “Enhanced Barrier Precautions” policy dated December 2024 documented EBPs were utilized to prevent the spread of multidrug-resistant organisms (MDRO) to residents. EBP applies when a resident was infected with a Centers for Disease Control and Prevention (CDC)- targeted MDRO. EBPs employ targeted gown and glove use in addition to standard precautions during high-contact resident care activities when contact precautions do not otherwise apply. Gloves and a gown are applied prior to performing the high-contact resident care activity. Examples of high-contact resident activities requiring the used of gown and gloves for EBPs included: dressing bathing/showering; providing hygiene or grooming changing briefs or assisting with toileting; transferring; providing bed mobility; changing linens; prolonged, high-contact with items in the resident’s room, with resident’s equipment, or with resident’s clothing or skin’ device care or use; and wound care. The undated facility’s Handwashing/Hand Hygiene” policy documented all personnel were trained and regularly in-service on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. All personnel were expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and visitors. Hand hygiene products and supplies were readily accessible and convenient for staff use to encourage compliance with hand hygiene policies. Alcohol based hand-rub (ABHR) dispensers were placed in areas of high visibility and consistent with workflow throughout the facility. All personnel were to perform hand hygiene before applying non-sterile gloves. After removing gloves, perform hand hygiene.

The facility had a census of 34 residents. The sample included 13 residents, with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility pharmacist consultant failed to provide the facility with a monthly Drug Regimen Review for February 2025, which placed all residents who received prescribed medications from the facility at risk for less supervision regarding their medication regimen. The facility pharmacist consultant failed to continue to request a gradual dose reduction (GDR) or a physician's rationale and the risks versus benefits for Resident (R) 6's sertraline (antidepressant- a class of medications used to treat mood disorders), for R17's Seroquel (antipsychotic- a class of medications used to treat major mental conditions that cause a break from reality) use, and obtain a stop date for R10's as needed (PRN) Ativan (antianxiety- a class of medication that calm and relax people).Findings included:- The Electronic Medical Record for R17 documented diagnoses of Alzheimer's disease (a progressive mental deterioration characterized by confusion and memory failure), hypertension (high blood pressure), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). The “Annual Minimum Data Set” (MDS), dated [DATE], documented R17 had severely impaired cognition. R17 required substantial staff assistance for toileting hygiene and personal hygiene. R17 was independent with eating, dressing, mobility, transfers, and ambulation. The MDS further documented R17 received antidepressant (a class of medications used to treat mood disorders) and antianxiety (a class of medications used to calm and relax people) medication daily. The “Quarterly MDS,” dated 06/20/25, documented R17 had severely impaired cognition. R17 required supervision from staff for personal hygiene, eating, oral care, dressing, and set up assistance with mobility and transfers. The MDS further documented R17 received antipsychotic (a class of medications used to treat major mental conditions), antidepressant, and antianxiety medication daily. R17’s “Care Plan” dated 07/02/25, initiated on 02/12/24, directed staff to converse with R17 while providing care, encourage activities, encourage family involvement, and facilitate resident interaction. The care plan update, dated 01/15/24, documented R17 was at risk for adverse reactions from medications with Black Box Warning (BBW- the highest safety-related Warning that medications can have assigned by the Food and Drug Administration) and directed staff to monitor for signs and symptoms of side effects from the medications. The care plan update, dated 01/16/24, directed staff to cue, reorient, and supervise as needed and use task segmentation to support short-term memory deficits. The care plan update, dated 04/07/25, directed staff to consult with the pharmacy and physician to consider dosage reduction when clinically appropriate, at least quarterly. The “Physician’s Order,” dated 01/27/25, directed staff to administer Seroquel (an antipsychotic medication), 12.5 milligrams (mg), by mouth, at bedtime, for anxiety and agitation. The medication was increased to twice per day on 03/07/25. The “Medication Regimen Review,” dated 02/05/25, documented that R17 received the antipsychotic agent Seroquel but lacked an allowable diagnosis to support the use. If continued use of this medication for the indication currently listed in the chart was warranted, please provide a risk versus benefit or discontinue the medication. The Consultant Pharmacist failed to send the recommendations to the facility or the physician; therefore, there was no response from the physician. On 08/19/25 at 03:55 PM, Administrative Nurse D stated the Pharmacist Consultant had forgotten to send the February 2025 Medication Regimen Reviews to the facility. Administrative Nurse D stated that, after she received the monthly recommendations, she would send the recommendations to the physician. The facility’s “Pharmacy Services-Role of the Consultant Pharmacist” policy, dated 04/19, documented that the Consultant Pharmacist would review the medication regimen of each resident at least monthly, or more frequently under certain conditions, based on applicable federal and state guidelines. Appropriate communication of information to prescribers and facility leadership about potential or actual problems related to any aspect of medications and pharmacy services, including medication irregularities, and pertinent resident-specific documentation in the medical record, as indicated. - R6‘s “Electronic Medical Record” included diagnoses of diabetes mellitus (DM- when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin) and major depressive disorder (major mood disorder which causes persistent feelings of sadness). R6‘s “Quarterly Minimum Data Set” (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate cognitive impairment, and no mood issues or behaviors. The MDS documented R6 required substantial staff assistance with most activities of daily living. The MDS documented R6 received insulin (a hormone that lowers the level of glucose in the blood), antidepressant (a class of medications used to treat mood disorders), and anticonvulsant (a drug that is used to prevent or treat seizures or convulsions by controlling abnormal electrical activity in the brain) medications. R6‘s Care Plan, dated 05/15/25, directed staff to administer medications as ordered. R6's plan of care directed staff to monitor for side effects and effectiveness, initiated 07/12/19. The “Physician Order,” dated 07/12/19, directed staff to administer Sertraline (antidepressant medication), 50 milligrams (mg) by mouth daily, related to major depressive disorder, single episode. The Consultant Pharmacist's review on 05/05/25 recommended a gradual dose reduction (GDR) of sertraline or a rationale explaining the decision for continuing the sertraline. No physician response was documented. On 08/19/25, upon request, the consultant pharmacist sent to the facility the February 2025 “Medication Regimen Review,” which recommended a GDR, rationale, or risk versus benefit statement for sertraline. On 08/19/25 at 09:15 AM, Licensed Nurse (LN) H administered medications to R6. He took them whole in pudding with water. On 08/19/25 at 03:55 PM, Administrative Nurse D stated the pharmacist consultant had forgotten to send the February 2025 Medication Regimen Reviews to the facility. She verified R6’s physician would not have received the February 2025 recommendation. Administrative Nurse D verified the physician had not responded to the 05/05/25 recommendation. She verified that the pharmacist consultant sends the monthly reviews to the facility, and she sends them on to each specific physician. She verified the physicians would not have received the February 2025 reports. The facility’s “Pharmacy Services” policy, dated April 2019, stated the consultant pharmacist would provide specific activities related to medication regimen review, including: a documented review of the medication regimen of each resident at least monthly, or more frequently under certain conditions, based on applicable federal and state guidelines. Appropriate communication of information to prescribers and facility leadership about potential or actual problems related to any aspect of medications and pharmacy services, including medication irregularities, and pertinent resident-specific documentation in the medical record, as indicated. The policy documented regular review of the emergency medication supply, review of medication storage areas at least monthly, and medication carts at least quarterly, for proper storage and labeling of medications, cleanliness, and expired medications, and providing the facility with written or electronic reports and recommendations related to all aspects of medication and pharmaceutical services review.

The facility had a census of 34 residents. Based on observation, interview, and record review, the facility failed to ensure medications were secure when a medication cart was left unlocked and unattended, failed to label and date insulin (a hormone that lowers the level of glucose in the blood) pens when opened, and failed to remove expired medication from use. This deficient practice placed residents at risk of receiving ineffective medication.Findings included:- On 08/18/25 at 09:32 AM, the facility's west medication cart contained:An insulin flex pen without a name or an opened date. A bottle of Aspirin (non-steroidal anti-inflammatory drug- NSAID), 81 milligram (mg) pills, expired 08/2024. Systane (eye lubricant) eye drops, expired 06/2025. Dulcolax (laxative) pills,100 mg, expired 04/2023. On 08/18/25 at 09:45 AM, the facility's east medication cart contained: Two unlabeled, undated insulin pens.A bottle of melatonin (sleep aide) 3 mg pills, expired April 30, 2024.Artificial tears, expired 03/2023.On 08/20/25 at 12:25 PM, the facility's medication room emergency medication kit (E-Kit) had two expired medications: Lidocaine (pain reliever) jelly 2% with expiration date of 07/31/25. Epinephrine (used to treat severe allergic reactions, cardiac arrest, and other conditions) auto-injector 0.3 mg expired 07/31/25. On 08/18/25 at 08:40 AM, Certified Medication Aide (CMA) T verified that the medications in the west medication cart had expired. On 08/18/25 at 09:45 AM, Licensed Nurse (LN) G verified the unlabeled insulin pens and expired medications in the facility's east medication cart.On 08/20/25 at 12:10 PM, Administrative Nurse D verified that staff were to ensure the medication cart was locked when they left it. Staff were to check for and remove expired medications. Staff were to label and date insulin pens when opened.On 08/20/25 at 12:25 PM, CMA RR verified the expiration dates on the E-kit paperwork.On 08/20/25 at 01:20 PM, Administrative Nurse D opened the E-kit and verified that the lidocaine jelly and epinephrine pen were expired. The facility's Medication Labeling and Storage policy, dated February 2023, stated that drawers, cabinets, rooms, or carts containing medications and biologicals would be locked when not in use, and carts would not be left unattended if open and potentially available to others. The policy stated medication labels would include the resident's name and expiration date. The facility's Administering Medications policy, dated February 2023, stated insulin pens would be clearly labeled with the resident's name. Staff would check the medical label for the expiration date, and when opening a multi-dose container, record the date opened on the container.

The facility identified a census of 34 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to ensure staff secured and protected the privacy and confidentiality of Resident (R) 24's medical record. This placed this resident at risk for impaired right to confidentiality.Findings included:- On 08/19/25 at 08:08 AM, an observation revealed that facility staff left R24's point of care (POC) information of the Electronic Medical Record (EMR) open and visible on the east medication cart laptop. On 08/19/25 at 08:09 AM, Certified Medication Aide (CMA) R stated the screen should not be left unlocked with resident information open.On 08/20/25 at 09:02 AM, Licensed Nurse (LN) G stated that the medication cart and the laptop screen should always be locked when away from the cart.On 08/20/25 at 12:15 PM, Administrative Nurse D stated she would expect any nursing staff to lock any screen on the laptop, and the medication cart should always be locked as well when a staff member was not in direct sight of the cart.The facility's undated Protected Health Information (PHI), Management and Protection of policy documented that PHI shall not be used or disclosed except as permitted by current federal and state laws.

The facility identified a census of 34 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 38's care plan was revised with interventions to reflect his current level of staff assistance her required after a recent hospital stay and on hospice care. The facility failed to update R2's care plan with interventions related to the need for 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). This placed R38 and R2 at risk for delayed or missed care.Findings included:- The Electronic Medical Record (EMR) for R2 had diagnoses of Alzheimer's disease (a progressive mental deterioration characterized by confusion and memory failure), chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), hemiparesis/hemiplegia (weakness and paralysis on one side of the body), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). The “Quarterly Minimum Data Set” (MDS), dated [DATE], documented R2 had severely impaired cognition. R2 was dependent upon staff for all activities of daily living, had a Stage 2 (partial-thickness skin loss into but no deeper than the dermis, including intact or ruptured blisters), and was on received Hospice (specialized care that mainly aims to provide comfort and dignity to the patients, by providing physical comfort and emotional, social, and spiritual support for people nearing the end of life) services. R2’s “Care Plan,” dated 07/17/25, initiated on 07/12/23, documented R2 had actual skin impairment due to dry skin and limited mobility. The care plan directed staff to follow policies/protocols for the prevention and treatment of skin breakdown, monitor, and report any changes in skin status. The care plan lacked documentation. R2 was on Enhanced Barrier Precautions (EBP- infection control interventions designed to reduce transmission of resistant organisms, which employ targeted gown and glove use during high contact care) and lacked direction to staff on what personal protective equipment (PPE- gowns, face shields, and/or eyeglasses/goggles, and gloves) to use. The” Physician’s Order,” dated 07/22/25, directed staff to apply Opti foam (a brand of foam wound dressing designed to absorb fluid and protect wounds) to her Stage 2 pressure ulcer, change the dressing every seven days and as needed, and discontinue when healed. On 08/20/25 at 10:15 AM, Licensed Nurse (LN) G and LN H sanitized their hands and donned clean gloves. LN G stated R2 had recently gotten a small open area on her coccyx. LN H got on the side of the bed closest to the wall, and LN G was on the opposite side. R2 had bilateral heel protectors on, and LN G pulled down her pants, checked her incontinence brief, and stated she had a bowel movement (bm). R2’s heel protectors and pants were removed due to LN G had gotten BM on her pants while she was providing personal care. Both LN G and LN H removed their soiled glove and donned clean gloves. LN G and LN H assisted R2 onto her left side so that LN H could perform wound care. LN H removed the old dressing, used gauze to cleanse the wound, placed the wound cleanser on the bed, and measured the wound. LN H put Opti foam on R2’s wound, assisted with a clean brief, and still had on soiled gloves. LN H verified that she should have changed her gloves after she cleansed the wound. LN H stated that she had discussed with Administrative Nurse D that R2 needed to be on EBP, and she had not done it yet. LN H stated, it was on her list and would do it right away. On 08/20/25 at 11:00 AM, Certified Nurse Aide (CNA) N stated she did not know that R2 required EBP and that she had never worn a gown while she provided care to R2, only gloves. On 08/20/25 at 12:20 PM, Administrative Nurse D stated R2 should be on EBP due to her open area and that staff should have changed her gloves after she cleaned R2’s wound. Administrative Nurse D further stated she would review the care plan and make sure the EBP information was on the care plan. The facility’s “Care Plans, Comprehensive Person-Centered” policy, dated 03/22, documented a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the physical, psychosocial, and functional needs was developed for each resident. The interdisciplinary team reviewed and updated the care plan when there has been a significant change in the resident's condition, at least quarterly, and when a resident has been readmitted to the facility from a hospital stay. - The “Medical Diagnosis” tab of R38’s Electronic Medical Record (EMR) documented diagnoses of paraplegia (paralysis characterized by motor or sensory loss in the lower limbs and trunk), hypertension (HTN- elevated blood pressure), pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as the result of pressure, or pressure in combination with shear and/or friction) of the sacral region (area between the posterior hip bones), and osteomyelitis (local or generalized infection of the bone and bone marrow). R38’s “Significant Change Minimum Data Set (MDS)” dated 08/13/25 documented he had a Brief Interview for Mental Status (BIMS) score of seven, which indicated moderately impaired cognition. R38 required substantial to being dependent on staff for his activities of daily living (ADL) cares. R38 had an indwelling catheter (tube placed in the bladder to drain urine into a collection bag) and an ostomy (surgical opening from an area inside the body to the outside). R38 had a Stage 4 (a deep pressure wound that reaches the muscles, ligaments, or even bone) pressure ulcer. R38 was on Hospice services. R38’s “Functional Abilities Care Area Assessment (CAA)” dated 08/15/25 documented he was a [AGE] year-old male admitted on hospice with osteomyelitis of the sacral and sacrococcygeal (area located at the base of the spine) region. R38 presented with a pressure ulcer, Stage 4 of the sacral region (left buttocks), chronic paraplegia, and multiple comorbidities. R38 has severe cognitive impairment. R38’s Care Plan, last revised 08/15/25, directed staff for his activities of daily living (ADL) cares: for bathing, he had been getting showers one to two times per week. The Care Plan documented R38 used a shower chair and a sit-to-stand (device to assist with going from a seated position to standing) for transfers, and R38 shaved himself daily independently. The Care Plan directed staff that on occasion, R38 would get up in his wheelchair and he could independently propel himself. The Care Plan directed staff that, due to the R38’s inability to safely ambulate, stair climbing, and walking would not be routinely assessed or documented by direct care staff. The Care Plan documented these activities posed a safety risk and are not within the resident's current functional capabilities. The Care Plan directed staff R38 liked to reposition himself and would request help if needed, dressing, and R38 could dress himself. The Care Plan documented R38 wore a shirt only and a brief, but R38 did not wear pants. The Care Plan documented R38 was able to eat independently with set-up help only, was on a regular diet, and preferred high protein. The Care Plan documented R38 was able to do his own oral care with set-up help only. The Care Plan documented R38 required the assistance of one staff member with personal hygiene. The Care Plan documented R38 had his own wipes and were kept in his room. R38 was incontinent of bowel and does not use the toilet. R38 would tell you when he needs to be changed. The Care Plan documented R38 used a bedpan for bowel movements; he has a metal bedpan and a plastic one. R38 required a mechanical lift full lift with two assist. R38 refused to get up in his wheelchair or recliner most time. R38 often moved and turned himself fast and often bangs his arms around on the side rails and headboard while doing so. R38 requests that staff move out of the way while moving himself. R38 had a hospital stay from 07/22/25 to 08/07/25. Upon R38’s return from the hospital, he was placed on hospice services. R38’s care plan was not revised and updated to reflect his current ADL care needs as indicated from his Significant Change MDS on 08/13/25. On 08/20/25 at 12:15 PM, Administrative Nurse D stated that R38’s care plan should have been updated with his most current level of care needed after his return from the hospital. Administrative Nurse D stated she had gotten behind on the updates on the care plans, and she took responsibility for that. The facility’s “Care Plans, Comprehensive Person-Centered” policy, dated March 2022, documented the comprehensive, person-centered care plan was developed within seven days of the completion of the required MDS assessment, and no more than 21 days after admission. The interdisciplinary team (IDT) reviewed and updated the care plan when there had been a significant change in the resident’s condition; when the desired outcome was not met; when the resident had been readmitted to the facility from a hospital stay; and at least quarterly, in conjunction with the required quarterly MDS assessment.

The facility had a census of 34 residents. The sample included 13 residents, with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to obtain a stop date for Resident (R) 10's as needed (PRN) Ativan (an antianxiety medication class of medication that calms and relaxes people). The facility failed to ensure an appropriate indication for R17's Seroquel (an antipsychotic) and failed to document a physician's rationale and the risks versus benefits for the Seroquel use. The facility further failed to obtain a gradual dose reduction (GDR) for R6. This placed the residents at risk for unnecessary psychotropic (alters perception, mood, consciousness, cognition, or behavior) medications and related complications.Findings included:- The Electronic Medical Record for R10 documented diagnoses of vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), bipolar disorder (a major mental illness that causes people to have episodes of severe high and low moods), and major depressive disorder (major mood disorder that causes persistent feelings of sadness). The” Significant Change Minimum Data Set” (MDS), dated [DATE], documented R10 had intact cognition. R10 required supervision with bathing and was independent with all other activities of daily living. The MDS further documented R10 received antipsychotic (a class of medications used to treat major mental conditions), antidepressant (a class of medications used to treat mood disorders), and antianxiety (a class of medications used to calm and relax people). The “Quarterly MDS,” dated 05/23/25, documented R10 had intact cognition. R10 required supervision with showers and dressing and was independent with all other activities of daily living. R10 received antipsychotic, antidepressant, and antianxiety medications daily. R10’s “Care Plan” dated 08/04/25, initiated on 07/14/25, documented R10 was at risk for complications from medications with Black Box Warning (BBW- highest safety-related Warning that medications can have assigned by the Food and Drug Administration), and directed staff to administer medications as ordered by the physician, monitor for side effects, and the pharmacist would review her medications monthly. The” Physician’s Order,” dated 02/23/25, directed staff to administer Ativan (an antianxiety medication), 1 milligram (mg), by mouth every four hours, PRN, for restlessness and anxiety. The order lacked a stop date for the PRN medication. On 08/19/25 at 08:00 AM, Licensed Nurse (LN) H administered R10’s medications without issue or concern. On 08/20/25 at 12:15 PM, Administrative Nurse D stated R10’s Ativan should have a stop date and be reassessed by the physician. Upon request, a policy for Psychotropic Medication Use was not provided by the facility. - The Electronic Medical Record for R17 documented diagnoses of Alzheimer's disease (a progressive mental deterioration characterized by confusion and memory failure), hypertension (high blood pressure), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest).The “Annual Minimum Data Set” (MDS), dated [DATE], documented R17 had severely impaired cognition. R17 required substantial staff assistance for toileting, hygiene, and personal hygiene. R17 was independent with eating, dressing, mobility, transfers, and ambulation. The MDS further documented R17 received antidepressant (a class of medications used to treat mood disorders) and antianxiety (a class of medications used to calm and relax people) medication daily. The “Quarterly Minimum Data Set (MDS),” dated 06/20/25, documented R17 had severely impaired cognition. R17 required supervision from staff for personal hygiene, eating, oral care, dressing, and set up assistance with mobility and transfers. The MDS further documented R17 received antipsychotic (a class of medications used to treat major mental conditions), antidepressant, and antianxiety medication daily. R17’s “Care Plan” dated 07/02/25, initiated on 02/12/24, directed staff to converse with R17 while providing care, encourage activities, encourage family involvement, and facilitate resident interaction. The update, dated 01/15/24, documented R17 was at risk for adverse reactions from medications with Black Box Warning (BBW- the highest safety-related Warning that medications can have assigned by the Food and Drug Administration) and directed staff to monitor for signs and symptoms of side effects from the medications. The care plan update, dated 01/16/24, directed staff to cue, reorient, and supervise as needed and use task segmentation to support short-term memory deficits. The care plan update, dated 04/07/25, directed staff to consult with the pharmacy and physician to consider dosage reduction when clinically appropriate, at least quarterly. The “Physician’s Order,” dated 01/27/25, directed staff to administer Seroquel (an antipsychotic medication), 12.5 milligrams (mg), by mouth, at bedtime, for anxiety and agitation. The medication was increased to twice per day on 03/07/25. On 08/19/25 at 08:30 AM, Certified Medication Aide (CMA) R administered R17’s medication with a lot of encouragement and discussion. CMA R stated R17 had periods of crying and, at times, aggression. CMA R further stated that staff provided 1:1 care, took her to activities, and she had as-needed anxiety medication. On 08/20/25 at 10:20 AM, Licensed Nurse (LN) H stated R17 had a lot of anxiety and at times she seems to be afraid to be alone. LN H further stated that staff provided a lot of 1:1 activities with her to help with the anxiety. On 08/20/25 at 12:15 PM, Administrative Nurse D stated the physician needed to provide an ongoing indication or risk versus benefit for her Seroquel. Administrative Nurse D verified that agitation was not an appropriate diagnosis for the Seroquel use. Upon request, a policy for Antipsychotic Medication Use was not provided by the facility. - R6‘s “Electronic Medical Record” included diagnoses of diabetes mellitus (DM- when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin) and major depressive disorder (major mood disorder which causes persistent feelings of sadness). R6‘s “Quarterly Minimum Data Set” (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate cognitive impairment, and no mood issues or behaviors. The MDS documented R6 required substantial staff assistance with most activities of daily living. The MDS documented R6 received insulin (a hormone that lowers the level of glucose in the blood), antidepressant (a class of medications used to treat mood disorders), and anticonvulsant (a drug that is used to prevent or treat seizures or convulsions by controlling abnormal electrical activity in the brain) medications. R6‘s Care Plan, dated 05/15/25, directed staff to administer medications as ordered. R6's plan of care directed staff to monitor for side effects and effectiveness, initiated 07/12/19. The “Physician Order,” dated 07/12/19, directed staff to administer Sertraline, 50 milligrams (mg) by mouth daily, related to major depressive disorder, a single episode. The Consultant Pharmacist's review on 05/05/25 recommended a gradual dose reduction (GDR) of sertraline or a rationale explaining the decision for continuing the sertraline. No physician response was documented. On 08/19/25, upon request, the consultant pharmacist sent to the facility the February 2025 “Drug Regimen Review,” which recommended a GDR, rationale, or risk versus benefit statement for sertraline. On 08/19/25 at 09:15 AM, Licensed Nurse (LN) H administered medications to R6. He took them whole in pudding with water. On 08/19/25 at 03:55 PM, Administrative Nurse D stated the pharmacist consultant had forgotten to send the February 2025 drug regimen reviews to the facility. She verified R6’s physician would not have received the February 2025 recommendation. Administrative Nurse D verified the physician had not responded to the 05/05/25 recommendation. Upon request, the facility did not provide a policy for Psychotropic drugs. The facility’s “Pharmacy Services” policy, dated April 2019, stated the consultant pharmacist will provide specific activities related to medication regimen review, including: A documented review of the medication regimen of each resident at least monthly, or more frequently under certain conditions, based on applicable federal and state guidelines. Appropriate communication of information to prescribers and facility leadership about potential or actual problems related to any aspect of medications and pharmacy services, including medication irregularities, and pertinent resident-specific documentation in the medical record, as indicated. Providing the facility with written or electronic reports and recommendations related to all aspects of medication and pharmaceutical services review.

The facility had a census of 34 residents. The sample included 13 residents, with one reviewed for respiratory care. Based on observation, record review, and interview, the facility failed to provide adequate respiratory care and services for Resident (R) 10 when staff failed to store their oxygen tubing and cannula (a medical device used to deliver supplemental oxygen through the nostril) and nebulizer (a medical device that converts liquid medication into a fine mist, allowing it to be inhaled into the lungs) mask in a sanitary manner when not in use. This placed the resident at risk for an infection.Findings included:- The Electronic Medical Record for R10 documented diagnoses of chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), bipolar disorder (a major mental illness that causes people to have episodes of severe high and low moods), and major depressive disorder (major mood disorder that causes persistent feelings of sadness).The Significant Change Minimum Data Set (MDS), dated [DATE], documented R10 had intact cognition. R10 required supervision with bathing and was independent with all other activities of daily living. The MDS further documented R10 received antipsychotic (a class of medications used to treat major mental conditions), antidepressant (a class of medications used to treat mood disorders), and antianxiety (a class of medications used to calm and relax people) medications. The MDS documented R10 did not require supplemental oxygen.The Quarterly MDS, dated 05/23/25, documented R10 had intact cognition. R10 required supervision with showers and dressing, and was independent with all other activities of daily living. R10 received antipsychotic, antidepressant, and antianxiety medications daily. The MDS further documented R10 received supplemental oxygen.R10's Care Plan dated 08/04/25, initiated on 03/03/25, directed staff to monitor for signs or symptoms of respiratory distress and report to the physician as needed. The care plan further directed staff to administer oxygen via nasal cannula at 2 liters per minute at all times.The Physician's Order, dated 09/15/24, directed staff to administer Oxygen at 2 liters to keep her saturation above 90%.The Physician's Order, dated 12/04/24, directed staff to administer ipratropium-albuterol (medication to help control symptoms of lung diseases) 0.5 - 2.5 (3) milligrams (mg)/3 milliliters (ml), one vial, inhaled, twice a day for COPD.On 08/18/25 at 09:56 AM, R10's oxygen tubing and cannula were unbagged and draped over the lamp beside her recliner. Further observation revealed the nebulizer mask was unbagged and lying on the table by the recliner.On 08/19/25 at 08:00 AM, R10's nebulizer mask was unbagged and lying on the table by the recliner and was visualized by Licensed Nurse (LN) H.On 08/19/25 at 08:10 AM, LN H stated the oxygen tubing and canula, as well as the nebulizer mask, should always be bagged when not in use. LN H further stated R10 put the tubing over the lamp as her preference and that it should be care planned to do so.On 08/20/25 at 11:01 AM, Certified Nurse Aide (CNA) N stated that when R10 left her room, she personally made sure the tubing was bagged, as they had been provided with bags to store the tubing in.On 08/20/25 at 12:15 PM, Administrative Nurse D stated that the oxygen tubing, as well as the nebulizer mask, should be in a bag when not in use. The facility's Departmental (Respiratory Therapy)-Prevention of Infection policy, dated 11/11, directed staff to keep the oxygen cannula, tubing, and nebulizer mask in a plastic bag when not in use.

The facility identified a census of 34 residents. The sample included 13 residents, with two residents sampled for hospice care. Based on observation, record review, and interview, the facility failed to ensure there was a collaboration of care between Resident (R) 2 and R38's hospice provider and the facility which included the information on what hospice would provide the residents. This placed R2 and R38 at risk of inadequate end-of-life care. Findings included:- The Electronic Medical Record (EMR) for R2 had diagnoses of Alzheimer's disease (a progressive mental deterioration characterized by confusion and memory failure), chronic obstructive pulmonary disease (COPD-a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), hemiparesis/hemiplegia (weakness and paralysis on one side of the body), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). The “Significant Change Minimum Data Set” (MMDS), dated [DATE], documented R2 had severely impaired cognition. R2 was dependent upon the staff for activities of daily living. The MDS documented R2 received Hospice (specialized care that mainly aims to provide comfort and dignity to the patients, by providing physical comfort and emotional, social, and spiritual support for people nearing the end of life) services. The” Quarterly MDS,” dated 07/1/25, documented R2 had severely impaired cognition. R2 was dependent upon the staff for activities of daily living. The MDS documented R2 received Hospice services. R2’s “Care Plan” dated 07/17/25, initiated on 04/22/25, documented R2 received hospice services and directed staff to keep the environment quiet and calm, observe for pain, and administer medications as ordered. The care plan lacked instruction on the services provided by hospices, including the frequency of support visits, supplies and medical equipment provided by hospice, medications covered by hospice, and the address of the chosen hospice. Review of R2's clinical record revealed the resident was admitted to hospice care on 04/11/25. On 08/19/25 at 12:40 PM, R2 sat in a reclined Broda (specialized wheelchair with the ability to tilt and recline), with her eyes closed. On 08/20/25 at 10:15 AM, Licensed Nurse (LN) G stated R2 received hospice services, the nurse came twice per week, as well as a nurse aide. On 08/20/25 at 12:15 PM, Administrative Nurse D stated she would review the care plan to make sure the appropriate information was on the care plan. The facility’s “Hospice Program” policy, dated 07/17, documented that the facility and hospice company would coordinate care provided to the residents. The facility would communicate with hospice representatives to ensure quality of care for the resident and family. The coordinated care plans for the resident receiving hospice services would include the most recent hospice plan of care as well as the care and services provided by the facility. - The “Medical Diagnosis” tab of R38’s Electronic Medical Record (EMR) documented diagnoses of paraplegia (paralysis characterized by motor or sensory loss in the lower limbs and trunk), hypertension (HTN- elevated blood pressure), pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as the result of pressure, or pressure in combination with shear and/or friction) of the sacral region (area between the posterior hip bones), and osteomyelitis (local or generalized infection of the bone and bone marrow). R38’s “Significant Change Minimum Data Set (MDS)” dated 08/13/25 documented he had a Brief Interview for Mental Status (BIMS) score of seven, which indicated moderately impaired cognition. R38 required substantial to being dependent on staff for his activities of daily living (ADL) cares. R38 had an indwelling catheter (tube placed in the bladder to drain urine into a collection bag) and an ostomy (surgical opening from an area inside the body to the outside). R38 had a Stage 4 (a deep pressure wound that reaches the muscles, ligaments, or even bone) pressure ulcer. R38 was on Hospice services. R38’s “Functional Abilities Care Area Assessment (CAA)” dated 08/15/25 documented he was a [AGE] year-old male admitted to hospice with osteomyelitis of the sacral and sacrococcygeal (area located at the base of the spine) region. R38 presented with a pressure ulcer, Stage 4 of the sacral region (left buttocks), chronic paraplegia, and multiple comorbidities. R38 has severe cognitive impairment. R38’s Care Plan, revised on 08/15/25, directed staff that R38 had a terminal prognosis related to osteomyelitis and was on hospice services. The Care Plan directed staff to consult with the physician and social services to have hospice care for the resident in the facility. The Care Plan directed staff to keep the environment quiet and calm. The Care Plan directed staff to keep linens clean, dry, and wrinkle-free. The Care Plan directed staff to keep the lighting low and familiar objects close. The Care Plan directed staff to observe R38 closely for signs of pain, to administer pain medications as ordered, and to notify the physician immediately if there was breakthrough pain. The Care Plan directed staff to work cooperatively with the hospice team to ensure the resident's spiritual, emotional, intellectual, physical, and social needs are met. The Care Plan directed staff to work with nursing staff to provide maximum comfort for the resident. The Care Plan lacked staff direction on the durable medical equipment (DME), supplies, and medications provided by hospice. The Care Plan lacked staff direction on what hospice staff would visit and how often those visits would be. R38’s “Misc.” tab of the EMR was a scanned “Referral Order” dated 08/06/25 for a referral for hospice care. R38’s “Misc.” tab of the EMR had a scanned “Facility Notification of Hospice Admission/Change” document with an effective date of 08/07/25. R38’s “Misc.” tab of the EMR documented the “Hospice Certification and Plan of Care” dated for the period of 08/07/25 to 11/04/25. The plan of care documented the frequency/duration of hospice staff visits; orders of discipline and treatments; goals; DME and supplies; functional limitations; safety measures; activities permitted; nutritional requirements; advance directives; mental statuses; allergies; medications; the hospice physician information; and the order description. On 08/18/25 at 11:35 AM, R38 laid on his back on his low air loss mattress (a specialized type of medical mattress designed to prevent and treat pressure ulcers). Staff were preparing to provide care for R38. On 08/20/25 at 09:02 AM, Licensed Nurse (LN) G stated that Administrative Nurse D typically updated the care plans for residents, but the floor nurses could also update the care plans. LN G stated the care plan should list all the hospice information on it.On 08/20/25 at 12:15 PM, Administrative Nurse D stated that when R38 returned to the facility on hospice, his care plan should have been updated to include all the hospice information, which included what equipment, medications, and supplies that hospice provided. Administrative Nurse D stated R38’s care plan should also contain the information on what hospice staff would visit and how often. The facility “Hospice Program” policy, dated July 2017, documented the coordinated care plans for residents receiving hospice services would include the most recent hospice plan of care as well as the care and services provided by the facility to maintain the resident’s highest practicable physical, mental, and psychosocial well-being.

The facility had a census of 34 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to ensure that Resident (R)1 had a physician's order and was assessed for the ability to safely self-administer medications left at the bedside. This placed R1 at risk for improper use of medications and related side effects.Findings included:- The Electronic Medical Record (EMR) for R1 documented diagnoses of chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), edema (swelling resulting from an excessive accumulation of fluid in the body tissue), chronic pain, anxiety (mental or emotional reaction characterized by apprehension uncertainty, and irrational fear), hypertension (high blood pressure), and atrial fibrillation (rapid, irregular heartbeat).The admission Minimum Data Set (MDS), dated [DATE], documented R1 had moderately impaired cognition. R1 required supervision with bathing, and was independent with dressing, toileting, hygiene, eating, mobility, transfers, and oral care. The MDS further documented R1 received anticoagulant (a class of medication used to prevent the blood from clotting), diuretic (a medication to promote the formation and excretion of urine), and opioid (a class of controlled drug used to treat pain) medication.R1's Care Plan dated 07/22/25 directed staff to administer medications as ordered and monitor for side effects, administer supplemental oxygen as ordered to keep oxygen saturation (percentage of oxygen in the blood) above 90%.The Self-Administration of Medications Assessment, dated 07/28/25, documented R1 required assistance for all medications, including inhalants.R1's EMR lacked a physician's order that allowed R1 to keep medications at her bedside and self-administer.The Physician's Order, dated 07/22/25, directed staff to administer Breztri Aerosphere (an inhaler used for the maintenance treatment of COPD), 160-9-4.8 mcg (micrograms), two puffs, twice a day for COPD.On 08/19/25 at 09:00 AM, observation revealed Licensed Nurse (LN) H went into R1's room to administer her Breztri inhaler. When she opened the box, the inhaler was not in it. R1 stated, The inhaler is over here, and pointed to the table next to her recliner. LN H stated, I will have to get an order for the inhaler to be left in your room; it cannot be left in your room without it. R1 took the inhaler and self-administered 2 puffs into her mouth.On 08/20/25 at 12:20 PM, Administrative Nurse D stated that there should be an order before any medication can be left at a resident's bedside, and there also needs an assessment to make sure the resident can self-administer medication.The facility's Self-Administration of Medications policy, dated 02/21, documented that the residents have the right to self-administer medications if the interdisciplinary team (IDT) had determined that it was clinically appropriate and safe for the resident to do so. The policy further documented, as part of the evaluation comprehensive assessment, the IDT assesses each resident's cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for the resident.

The facility had a census of 32 residents. The sample included 14 residents. Based on observation, record review, and interview, the facility failed to employ a full time certified dietary manager for the 32 residents who resided in the facility and received meals form the facility kitchen. This placed the residents at risk for inadequate nutrition. Findings included: - On 12/14/23, review of the noon meal consisted of enchiladas, refried beans, whole kernel corn, garlic bread, and apple pie. On 12/14/23 at 11:20AM, observation revealed Dietary Staff BB in the kitchen overseeing the preparation of the noon meal. On 12/13/23 at 08:1AM, Dietary Staff BB verified she was not a certified dietary manager. Dietary Staff BB stated she had not started the certified dietary manager classes. On 12/14/23 at 2:00PM, Administrative Staff A verified Dietary Staff BB had no dietary manager certification. Upon request the facility did not provide a policy regarding Certified Dietary management requirements. The facility failed to employ a full time certified dietary manager for 32 residents who resided in the facility who received meals from the kitchen. This placed the residents at risk for inadequate nutrition.

The facility had a census of 32 residents. The sample included 14 residents. Based on observation, record review, and interview, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for the 32 residents who received their meals from the facility's kitchens when staff stored uncovered hamburger in two freezers. Kitchen staff failed to defrost the chest freezer and clean the outside of a chest and upright freezer. Kitchen staff failed to ensure the dishwasher sanitizing test strips were still effective. This placed the 32 residents at risk for foodborne illness. Findings included: - On [DATE] at 08:15 AM, observation in the kitchen revealed the following: The inside of the white chest freezer, located in the dry storage room, had approximately one-quarter inch ice buildup, 13 uncovered quarter-pound hamburger patties, and seven slider hamburgers in an unsealed zip-lock bag. The outside of the white chest freezer and upright freezer, located in the dry storage room, had numerous different size areas of black substance. On [DATE] at 08:30 AM, Dietary Staff (DS) CC verified the above findings, removed and discarded the hamburger patties and stated the chest freezer needed defrosted. DS CC stated staff should make sure food was stored in a sealed container in the freezers. On [DATE] at 12:00 PM, observation revealed DS BB attempted to check the dishwasher sanitization level by placing a sanitizing test strip in sanitizing cycle and the test strip failed to read on the strip. DS BB checked the expiration date on the test strips and the label read expiration date ,d+[DATE]. DS BB verified the strips were expired and stated she would order some more. On [DATE] at 12:00 PM, DS BB verified the peeling paint on the cupboards, the ice buildup inside the white chest freezer and the numerous different size areas on the two freezer doors, located in the dry storage room. DS BB stated food should be stored in a covered container or sealed bag when placed in the freezer. Upon request the facility did not provide a food storage policy. The facility's Dietary Aides Weekly Cleaning Chart documented tasks for the aides to do daily. The Cooks daily cleaning chart listed tasks for the cook to completed am/pm and weekly cleaning. The facility's Sanitization Policy, revised [DATE] documented all kitchens, kitchen areas and dining areas are kept clean. The policy documented the chemical solution is maintained at the correct concentration, based on periodic testing, at least once per shift and for the effective contact time according to manufacturer's guidelines. The facility kitchen staff failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for the 32 residents who received their food from the kitchen. This placed the 32 residents at risk for food borne illness.

The facility had a census of 32 residents. Based on observation, interview and record review, the facility failed to submit complete and accurate staffing information through Payroll Based Journaling (PBJ) as required. This deficient practice placed the residents at risk for unidentified and ongoing inadequate nurse staffing. Findings included: - The PBJ report provided by the Centers for Medicare & Medicaid Services (CMS) for Fiscal Year (YR) 2023 Quarter 2 and 3 indicated the facility did not have licensed nurse coverage 24 hours a day, seven days a week on multiple days, (Quarter 2: 5 dates, Quarter 3: 6 dates) Review of the facility licensed nurse payroll data for the dates listed on the PBJ revealed a licensed nurse on duty for 24 hours a day seven days a week. On 12/13/23 at 08:00 AM, observation revealed a licensed nurse on duty in the facility. On 12/14/23 at 12:30 PM, Administrative Staff B stated the facility's corporate office completed the PBJ report and would have access to the staff schedule from the computer. On 12/18/23 at 08:00 AM, Administrative Staff B stated the PBJ report completed by the corporate office did not show that the information sent to CMS was incorrect and that it did not show they were lacking licensed nurse coverage for the dates above. The facility's Reporting Direct Care Staffing Information (Payroll-Based Journal) policy, dated 08/22, documented complete and accurate direct care staffing information was reported electronically to CMS through the PBJ system in a uniform format specified by CMS. Staffing information was collected daily and reported for each fiscal quarter no later than 45 days after the end of the reporting quarter. The facility failed to submit accurate PBJ data which placed the residents at risk for unidentified and ongoing inadequate staffing.

The facility had a census of 32 residents. The sample included 14 residents with one reviewed for hydration. Based on observation, record review, and interview, the facility nursing staff failed to consistently monitor Resident (R) 32's fluid intake related to a physician-ordered fluid restriction. This placed R32 at risk for fluid overload. Findings included: - R32's Electronic Medical Record (EMR) documented R32 had diagnoses of heart failure, hypoxemia (abnormal deficiency in the concentration of oxygen in arterial blood) and edema (swelling resulting from an excessive accumulation of fluid in the body tissues). R32's Admission Minimum Data Set (MDS), dated [DATE], documented R32's Brief Interview of Mental Status (BIMS) score of 13 which indicated intact cognition. The MDS documented R32 required extensive staff assistance with most activities of daily living (ADLs). R32's Care Plan, revised on 09/13/23, documented R32 received a 2000 cubic centimeter (cc) fluid restriction and instructed dietary to provide R32 with 360 cc of fluid at breakfast, 480 cc at lunch and 480 cc at supper. The care plan instructed nursing staff to provide R32 270 cc from 06:00AM - 02:00PM, 270 cc from 02:00PM-10:00PM, and 140 cc from 10:00PM-06:00AM. The Progress Note, dated 10/24/23, documented R32 admitted to the hospital due to weight gain and hospital staff removed fluid from R32's body. The Physician Order, dated 12/04/23, instructed staff to provide R32 with a 2000 cc fluid restriction. The Progress note, dated 12/06/23 at 11:02 AM, documented R32 readmitted from the hospital on 12/04/23 due to fluid overload and instructed staff to continue to provide R32 with a 2000 cc fluid restriction. R32's December 2023 Medication Administration Record/Treatment Administration Record (MAR/TAR) lacked documentation on R32's fluid intake on the following days: Day shift December 05, 11,12, and 17. Evening shift December 07,09, and 15. Night shift 12/09/23 On 12/14/23 at 04:00 PM, observation revealed R32's bedside table had a pitcher on it with 200 cc of uniced water. On 12/19/23 at 10:46 AM, Dietary Staff (DS) BB stated she kept track of R32's fluid intake with meals then reported the intake to nursing and the nurses were responsible for recording it in R32's clinical record. On 12/19/23 at 10:58 AM, Administrative Nurse D verified the lack of fluid intake documentation on the above listed dates and stated nursing staff should document R32's fluid intake every shift. The facility's Encouraging and Restricting Fluids Policy, revised October 2010, instructed staff to follow specific instructions concerning fluid intake or restrictions, be accurate when recording fluid intake and record fluid intake on the intake side of the intake and output record. Record fluid intake in milters (ml) The facility failed to consistently monitor and record R32's physician ordered fluid restriction. This placed the resident at risk for fluid overload.

The facility had a census of 32 residents. The sample included 14 residents. Based on observation, record review, and interview, the facility failed to revise the care plan for Resident (R) 30 to include the Black Box Warning (BBW- highest safety-related warning that medications can have assigned by the Food and Drug Administration) for risperidone (antipsychotic medication) for staff direction to monitor for side effects from the antipsychotic medication. This placed the residents at risk due to uncommunicated care needs and adverse side effects. Findings included: - The Electronic Medical Record (EMR) for R30 documented diagnoses of frontotemporal neurocognitive disorder (occurs when nerve cells in the frontal and temporal lobes of the brain are lost), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), expressive language disorder (caused by brain damage sustained from neurological conditions), and abnormalities of gait and mobility. The Significant Change-5 Day Minimum Data Set (MDS), dated [DATE], documented R30 had moderately impaired cognition and required extensive assistance of two staff for bed mobility, dressing, and toileting. R30 required extensive assistance of one staff for transfers and personal hygiene. The MDS further documented R30 received antidepressant (class of medications used to treat mood disorders and relieve symptoms of depression) and opioid (narcotic pain medication) medication. R30 had no behaviors. The Quarterly MDS, dated [DATE], documented R30 had severely impaired cognition and required substantial assistance for toileting. personal hygiene, dressing, and ambulation. R30 had had physical, verbal, and other behaviors 1-3 days, and received anxiety and depression medication. R30's Care Plan, dated 12/04/23, initiated on 03/15/23, documented R30 received medications with a BBW but failed to have risperidone medication on the care plan and what BBW signs and symptoms to monitor for. The Physician's Order, dated 11/21/23, directed staff to administer risperidone, 0.25 mg, one by mouth, twice per day for frontotemporal neurocognitive disorder, anxiety, and depression. On 12/13/23 at 02:37 PM, observation revealed R30 ambulated down the hall with staff and required verbal cues to make sure R30 held on to her walker when she ambulated. Further observation revealed, R30 very pleasant and acknowledged other staff. On 12/18/23 at 11:04 AM, Certified Nurse Aide (CNA) O stated there have been designated staff to be one on one with the resident due to her anxiety, and her impaired vision. CNA O stated R30 and times she tried to hit staff but otherwise very pleasant. On 12/19/23 at 10:00 AM, Licensed Nurse (LN) G stated R30 had periods of anxiety and agitation and felt the medication had help with some of her anxiety. On 12/19/23 at 10:32 AM, Administrative Nurse D verified there were not interventions placed on the care plan for the risperidone and the black box warnings. The facility's Care Plans, Comprehensive Person-Centered policy, dated 03/22, documented a comprehensive, person-centered care plan that included measurable objectives and timetables to meet a resident's physical, psychosocial and functional needs was developed and implemented for each resident and are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. The facility failed revise the care plan for adverse side effects for R30's risperidone medication. This placed the resident at risk for possible side effects and decline due to uncommunicated care needs.

The facility had a census of 32 residents. The sample included 14 residents. Based on record review and interview, the facility failed to provide Resident (R)32 or his representative with written information regarding the facility bed hold policy when R32 was transferred to the hospital. This placed R32 at risk for not being permitted to return and resume residence in the nursing facility. Findings included: - R32's Electronic Medical Record (EMR) documented R32 had diagnoses of heart failure, hypoxemia (abnormal deficiency in the concentration of oxygen in arterial blood) and edema (swelling resulting from an excessive accumulation of fluid in the body tissues). R32's Admission Minimum Data Set (MDS), dated [DATE], documented R32's Brief Interview of Mental Status (BIMS) score of 13 which indicated intact cognition. The MDS documented R32 required extensive staff assistance with most activities of daily living (ADLs). R32's Care Area Assessment (CAA) did not trigger for hydration/fluid maintenance. R32's Care Plan, revised 09/13/23, documented R32 required limited staff assistance with most ADLs. The Progress Note, dated 10/24/2023 at 01:34 PM documented R32 was admitted to the hospital. Review of R32's clinical record lacked evidence the resident or representative was provided the facility bed hold policy. On 12/19/23 at 09:28 AM, Social Service X stated she was responsible for providing R32 or her representative with the bed hold policy when R32 was transferred to the hospital. Social Service X stated she mailed the bed hold policy to R32's representative but had not received it back and lacked documentation regarding when she mailed the form. On 12/19/23 at 10:10 AM, Administrative Nurse D stated social service staff was responsible for providing the bed hold policy to R32 or her representative when R32 was transferred to the hospital. Administrative Nurse D stated she expected staff to follow up in two to three days if they had not received the signed bed hold policy back. The facility's Bed-Holds and Returns Policy, revised March of 2022, documented all residents/representatives would be provided written information regarding the facility bed-hold policies, which address holding or reserving a resident's bed during periods of absence (hospitalization or therapeutic leave). The facility failed to provide R32 or his representative with the bed hold policy when R32 was transferred to the hospital. This placed the resident at risk for not being permitted to return and resume residence in the nursing facility.

The facility had a census of 32 residents. The sample included 14 residents. Based on observation, record review, and interview, the facility failed to include two sampled residents, Resident (R) 1 and R14, in the development and planning of the residents' care plan. This placed the residents at risk of impaired care and decreased autonomy. Findings included: - The Electronic Medical Record (EMR) for R1 documented diagnoses of diabetes mellitus type 2 (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), dementia with other behavioral disturbance (progressive mental disorder characterized by failing memory, confusion), auditory hallucinations (sensing things while awake that appear to be real, but the mind created), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), migraines ( a recurrent, throbbing headache that typically affects one side of the head and is often accompanied by nausea and disturbed vision), psychosis (any major mental disorder characterized by a gross impairment in reality testing), acute kidney failure (inability of the kidneys to excrete wastes, concentrate urine and conserve electrolytes), and delirium due to known physiological condition (sudden severe confusion, disorientation and restlessness). The Annual Minimum Data Set (MDS), dated [DATE], document R1 had intact cognition and was independent with toileting, oral care, personal hygiene, and eating. R1 required supervision with bathing and ambulation. The MDS further documented it was very important to R1 to have her family involved in discussions about her care. R1's Care Plan, dated 10/26/23, directed staff to encourage R1 to do as much for herself as she could, and assist as needed. R1 slept in, late at times until noon, and her breakfast may be served in her room per choice. The plan further directed when she had migraine headaches, she may not come out of her room for several days, and she preferred medications in the dining room with meals. R1's Care Plan Conference Summary, dated 02/22/23, 05/17/23, and 11/01/23 documented family and resident not present. On 12/13/23 at 04:40 PM, observation revealed R1 was in her room watching television. She wore pajamas as she laid in bed. On 12/13/23 at 04:43 PM, R1 stated she knew what the care plan meeting was but had never been invited or participated in the care plan process. R1 stated she would attend if invited. On 12/18/23 at 01:28 PM, Social Service X stated she gave the residents care plan letters and reminded them about the meetings during her MDS interviews. Social Service X stated R1 did not attend the meetings and her family was not able to come to them as they worked during the time the meetings were held. Social Service X further stated she did not document in the EMR when she invited the resident or family to the meetings. On 12/19/23 at 09:58 AM, Administrative Nurse D verified the facility did not document in the EMR if a resident was invited, only if they attended. The facility's Care Plans, Comprehensive Person Centered policy, dated 03/22, documented the interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, developed and implemented a comprehensive, person-centered care plan for each resident and had the right to participate in the planning process, request meetings, request revisions to the plan of care, and see the car plan and sign it after significant changes are made. The resident was informed of his or her right to participate in his or her treatment and provided advance notice of care planning conferences. The facility failed to include R1 in the development and planning of the resident's care plan placing her at risk for impaired care and autonomy. - The Electronic Medical Record (EMR) for R14 documented diagnoses of dysphagia (swallowing difficulty), hypertension (high blood pressure), flaccid hemiplegia affecting right dominant side (paralysis of one side of the body), and diabetes mellitus type 2 (DM-when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R14 had moderately impaired cognition, and required extensive assistance of two staff for bed mobility, transfers, dressing and toileting; R14 did not ambulate. The MDS further documented it was very important to R14 to have his family involved in discussions about his care. R14's Care Plan, dated 09/11/23, directed staff to cue R14 to gather items to brush his teeth, allow him to pick out his clothing, cue through the process of dressing, and assist with a gait belt and one staff for transfers. R14's Care Plan Conference Summary, dated 03/22/23, documented family and resident were not present. On 12/13/23 at 09:38 AM, R14 reported he had lived at the facility for four years and had never participated in a care plan meeting. R14 reported he did not know what the meeting was for. On 12/18/23 at 01:28 PM, Social Service X stated she gave the residents care plan letters and reminded them about the meetings during her MDS interviews. Social Service X stated R14 did not attend the meetings. She also stated she did not document in the EMR when she invited the resident or family to the meetings. On 12/19/23 at 09:58 AM, Administrative Nurse D verified the facility did not document in the EMR if a resident was invited, only if they attended. The facility's Care Plans, Comprehensive Person Centered policy, dated 03/22, documented the interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, developed and implemented a comprehensive, person-centered care plan for each resident and had the right to participate in the planning process, request meetings, request revisions to the plan of care, and see the car plan and sign it after significant changes are made. The resident was informed of his or her right to participate in his or her treatment and provided advance notice of care planning conferences. The facility failed to include R14 in the development and planning of the resident's care plan placing him at risk for impaired care and autonomy.

The facility had a census of 32 residents. The sample included 14 residents. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 1 had a physician's order and was assessed for the ability to safely self-administer medications left at the bed side. This placed R1 at risk for improper use of medication and related side effects. Findings included: - The Electronic Medical Record (EMR) for R1 documented diagnoses of diabetes mellitus type 2 (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), dementia with other behavioral disturbance (progressive mental disorder characterized by failing memory, confusion), auditory hallucinations (sensing things while awake that appear to be real, but the mind created) , anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), migraines (a recurrent, throbbing headache that typically affects one side of the head and is often accompanied by nausea and disturbed vision), psychosis (any major mental disorder characterized by a gross impairment in reality testing), acute kidney failure (inability of the kidneys to excrete wastes, concentrate urine and conserve electrolytes), gastro esophageal reflux (GERD-backflow of stomach contents to the esophagus), and delirium due to known physiological condition (sudden severe confusion, disorientation and restlessness. The Annual Minimum Data Set (MDS), dated [DATE], document R1 had intact cognition and was independent with toileting, oral care, personal hygiene, and eating. R1 required supervision with bathing and ambulation. The MDS further documented R1 received antipsychotic (medications used to treat psychosis and other mental emotional conditions), antidepressant (medications used to treat mood disorders and relieve symptoms of depression), antiplatelet (medication that prevent blood clots from forming), and a hypoglycemic (medication used to help reduce the amount of sugar present in the blood). R1's Care Plan, dated 10/26/23, initiated on 02/14/20, documented R1 was at risk for complications from medications with Black Box Warning (BBW- highest safety-related warning that medications can have assigned by the Food and Drug Administration), and directed staff to administer medications as ordered by the physician, monitor for side effects and effectiveness, and report as needed any adverse reactions to the physician. The Physician's Orders, dated 01/14/20, directed staff to administer, lisinopril (blood pressure medication), 40 milligrams (mg), one by mouth, daily for hypertension (high blood pressure), amlodipine (blood pressure medication), 5 mg, one by mouth, daily, for hypertension, and magnesium oxide, one 400 mg, by mouth twice per day, for nutritional supplement. The Physician's Order, dated 03/23/20, directed staff to administer Cymbalta DR (an antidepressant), 60 mg, one by mouth, daily, for depression (persistent feelings of sadness). The Physician's Order, dated 12/11/20, directed staff to administer metformin HCI extended release (ER) (anti-diabetic), 500 mg, one by mouth twice per day for diabetes. The Physician's Order, dated 04/20/21, directed staff to administer pantoprazole sodium (acid reducer), 40 mg, one by mouth daily for GERD. The Physician's Order, dated 07/29/21, directed staff to administer Ultram (pain medication), 50 mg, every six hours as needed for pain. The Physician's Order, dated 12/14/21, directed staff to administer aspirin (anti-inflammatory), 81 mg, two by mouth daily for a healed fracture. The Physician's Order, dated 09/09/22, directed staff to administer Colace caplet (stool softener), 100 mg, one by mouth daily in the morning for hard stools. The Physician's Order, dated 02/22/23, directed staff to administer Ritalin (stimulant), 5 mg, one by mouth in the morning for energy. R1's EMR lacked a physician's order which allowed R1 to keep medications at her bedside and self-administer. R1's EMR lacked evidence the facility assessed R1 for the ability to safely self-administer medication. On 12/14/23 at 09:15 AM, observation revealed Licensed Nurse (LN) G asked R1 several times to sit up in bed so she could take her medication. R1 stated she did not want to take her pills right then, so LN G placed the pills on her bedside table and left R1's room. LN G stated she would return later to make sure the resident took the medication. LN G said she often left the medication on R1's bedside table to take later. At 09:30 AM, observation revealed R1 sat on the side of her bed and took her medication. On 12/19/23 at 09:58 AM, Administrative Nurse D stated R1 probably had a self-administration assessment somewhere down in a box in the basement but verified R1 had not been assessed recently. The facility's Self-Administration of Medications policy, dated 02/21, documented the residents have the right to self-administer medications if the interdisciplinary team (IDT) had determined that it was clinically appropriate and safe for the resident to do so. The policy further documented, as part of the evaluation comprehensive assessment, the IDT assess each resident's cognitive and physical abilities to determine whether self-administering medications are safe and clinically appropriate for the resident. The facility failed to ensure R1 had a physician order and the ability to safely self-administer medications prior to leaving medications at the bedside. This placed the resident at risk for improper use of medication and related side effects.

The facility had census of 32 residents. The sample included 14 residents with one reviewed for hospitalization . Based on observation, record review, and interview, the facility failed to provide a written notice for a facility-initiated transfer to Resident (R32) or her representative within a practicable time when R32 was transferred to the hospital. This placed the resident at risk for uninformed care choices. Findings included: - R32's Electronic Medical Record (EMR) documented R32 had diagnoses of heart failure, hypoxemia (abnormal deficiency in the concentration of oxygen in arterial blood) and edema (swelling resulting from an excessive accumulation of fluid in the body tissues). R32's Admission Minimum Data Set (MDS), dated [DATE], documented R32's Brief Interview of Mental Status (BIMS) score of 13 which indicated intact cognition. The MDS documented R32 required extensive staff assistance with most activities of daily living (ADLs). R32's Care Area Assessment (CAA) did not trigger for hydration/fluid maintenance. R32's Care Plan, revised 09/13/23, documented R32 required limited staff assistance with most ADLs. The Progress Note, dated 10/24/2023 at 01:34 PM documented R32 was admitted to the hospital. Review of R32's clinical record lacked evidence the resident or representative was provided written notice. On 12/14/23 at 10:35 AM, observation revealed R32 sat in a wheelchair in her room. On 12/19/23 at 09:28 AM, Social Service X stated she was responsible for providing R32 or her representative with written notice of R32's transfer to hospital. Social Service X stated she mailed the transfer information to R32's representative but had not received it back and lacked documentation regarding when she mailed the form. On 12/19/23 at 10:10 AM, Administrative Nurse D stated social service staff was responsible for providing transfer information to R32 or her representative when R32 was transferred to the hospital. Administrative Nurse D stated she expected staff to follow up in two to three days if they had not received the signed form back. Upon request the facility did not provide a policy regarding written notification of resident transfers to hospital. The facility failed to provide R32 or her representative written notice regarding R32's transfer to the hospital. This placed the resident and/or her representative at risk of uninformed care choices.

The facility had a census of 32 residents. The sample included 14 residents, with five reviewed for falls, Based on observation, record review, and interview, the facility failed to evaluate effectiveness of fall interventions and change or modify the interventions which were ineffective at preventing falls for Resident (R) 19. This placed the resident at risk for further falls and injury. Findings included: - The Electronic Medical Record (EMR) for R19 documented diagnoses of weakness, epilepsy (a brain disorder characterized by repeated seizures), congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), transient ischemic attack (TIA- temporary episode of inadequate blood supply to the brain), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), and pain. The Quarterly- 5 Day Medicare Minimum Data Set (MD, dated 12/29/23, documented R19 had intact cognition and required supervision and one staff assistance for dressing, toileting, and personal hygiene. R19 required supervision and one staff assistance for bed mobility, transfers, ambulation, and eating. R19 had unsteady balance, no functional impairment, and had no falls. The Quarterly MDS, dated [DATE], documented R19 had intact cognition and required supervision with transfers. R19 was independent with eating, oral hygiene, personal hygiene, and had no functional impairment. The MDS recorded R19 had no falls. The Fall Risk Assessments, dated 12/27/22, 01/03/23, 01/10/23, 01/11/23, 01/21/23, 02/20/23, 03/05/23, 04/07/23, 05/09/23, 06/02/23, 07/02/23, 10/02/23, and11/12/23, documented R19 was a high risk for falls. R19's Care Plan, dated 10/12/23, initiated on 08/14/20, directed staff to keep items frequently used by R19 within reaching distance. The update on 08/28/20, directed staff to move her phone closer to her. The update, dated 12/23/21, directed staff to put gripper socks on the resident when in bed. The update, dated 01/03/23, directed staff to remind R19 that staff need to be present when she transferred. The update, dated 01/10/23, directed staff to ensure R19's call light was within reach and encourage the resident to use it for assistance. The update, dated 01/11/23, directed staff to place nonskid strips in front of her recliner. The update, dated 02/20/23, directed staff to place nonskid strips in front of her sofa. The update, dated 03/05/23, documented staff reeducated R19 on the importance of using her call light for assistance. The update, dated 03/29/23, directed staff to move her phone next to her couch or chair. The update, dated, 04/07/23, directed staff to place signs in her room to remind her to call for assistance when getting up. The update, dated 05/09/23, directed staff to remind the resident to call for assistance when she transferred. The update, dated 06/02/23, directed staff to have gripper socks or shoes on at all times while resident was in her recliner or wheelchair. The update, dated, 11/10/23, directed staff to explain and assist R19 when transferred to make sure she was ready to move and stable when staff is. The update, dated 11/15/23, directed staff to place gripper socks on R19 at night. The update, dated 12/01/23, directed staff to place a fall mat beside R19's bed. The Fall Investigation, dated 01/10/23 at 06:24 PM, documented staff heard a soft thud and found R19 in her room, on her right side, with her feet between the walker wheels, able to move all extremities, and had no injuries. The note further documented R19 was assisted up by three staff members and a gait belt. The Fall Investigation, dated 02/20/23 at 07:44 PM, documented R19 yelled for help and staff found her on the floor leaning next to her sofa. R19 stated she got tired of sitting in the chair and had transferred herself from her wheelchair to her sofa. The noted further documented R19 had been educated several times to ask for assistance and to wait until someone came to transfer her. The resident did not sustain any injuries and was assisted by two staff and gait belt to her wheelchair. The Fall Investigation, dated 03/05/23 at 06:31 PM, documented staff heard R19 scream for assistance and found her seated on the floor between her recliner and wheelchair. R19 stated she fell while she transferred herself to her wheelchair. R19 was assisted by two staff and gait belt to her recliner and did not sustain any injuries. The Fall Investigation, dated 04/07/23 at 06:20 PM, documented R19 tried to transfer herself to her wheelchair, fell and hit her head. The investigation further documented R19 had a hematoma (solid swelling of clotted blood within the tissues) on the back of her head and a skin tear on her right forearm and was assisted up by staff and placed in her recliner. The Fall Investigation, dated 05/09/23 at 09:00 AM, documented staff found R19 in her room on the floor in front of her recliner. R19 had the wheelchair within reach in front of her and stated she tried to sit in her recliner and missed the chair. R19 did not sustain any injuries and was able to move all extremities as previous. The Fall Investigation, dated 06/02/23 at 02:10 PM, documented staff found R19 on the floor, on her right side, in front of her recliner. The fall was unwitnessed; R19 had no injury and stated she had tried to take herself to the bathroom. The investigation further documented two staff assisted R19 up with a gait belt and placed her in her wheelchair. The Fall Investigation, dated 11/10/23, documented staff assisted R19 to transfer from her wheelchair to her bed, and her hand slipped off the bed rail and she fell to the floor. The Fall Investigation, dated 12/01/23 at 10:06 AM, documented staff found R19 on the floor between her bed and wheelchair with both legs extended outward towards her end table with her right arm resting on her bed. The investigation further documented R19 did not sustain any injury; she had her call light within reach, but it was not activated. R19 was able to move all extremities and assisted up by staff. On 12/19/23 at 10:17 AM, observation revealed Certified Nurse Aide (CNA) N placed a gait belt around R19's waist, used her left hand under the gait belt to try to lift R19 from her wheelchair to her recliner. Further observation revealed R19 needed cueing during the transfer to stand up and pivot into the recliner as R19's legs were bent, and CNA N had to use extensive assistance to transfer her. On 12/19/23 at 09:54 AM, Licensed Nurse (LN) G stated R19 was supposed to call for assistance when she wanted to transfer but did not remember to use her call light. LN G said R19 got antsy and did it herself which usually resulted in a fall. LN G further stated staff had placed three signs in R19's room for reminders, and the resident had a low bed, and had been reeducated multiples to call for assistance. On 12/19/23 at 10:20 AM, CNA N stated R19 received therapy for transfers and strengthening and required a lot of reeducation not to transfer alone as she did not remember to call for assistance. On 12/19/23 at 10:32 AM, Administrative Nurse D stated she had run out of interventions to prevent falls for R19 and verified there were repetitive interventions on R19's Care Plan. The facility's Falls and Fall Risk, Managing policy, dated 03/18, documented staff identified interventions related to the residents specific risks and causes to try to prevent the resident from falls and to minimize complications from falls. Care plan interventions were chosen only after data gathered, proper sequencing of events, careful consideration of the relationship between the resident's problem areas ad their causes, and relevant clinical decision making. The staff, with the input of the attending physician, would implement a resident-centered fall prevention plan to reduce the specific risk factors for each resident at risk or with a history of falls. The facility failed to evaluate effectiveness of fall interventions and change or modify the interventions which were ineffective at preventing falls for R19. This placed the resident at risk for further falls and injury.

The facility had a census of 35 residents. The sample included 12 residents with three reviewed for nutrition and hydration. Based on observation, record review, and interview, the facility failed to provide necessary nutritional assessments and treatment for [REDACTED]. Findings included: - R21's Physician order [REDACTED]. mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin). The Annual Minimum Data Set (MDS), dated [DATE], documented the resident had moderately impaired cognition, verbal behaviors directed toward others, and rejection of care one to three days during the look back period that significantly interfered with the resident's care. The MDS documented the resident required limited assistance of one staff for Activities of Daily Living (ADLs), had loss of liquid and solids from his mouth when eating and drinking, 70 inches tall, weighed 127 pounds (lbs), and received a mechanically altered therapeutic diet. The Nutritional Status Care Area Assessment (CAA), dated 07/24/20, documented on 01/12/20 the resident weighed 129.6 lbs, 07/05/20 weighed 127.1 lbs, and received a diabetic, mechanical soft diet with nectar consistency fluids. The Nutrition Care Plan, dated 08/12/19, documented the resident at risk for nutritional deficit related to a history of weight loss, and directed staff to provide Carnation Instant Breakfast (CIB) three times a day, double portions, and monitor any signs of swallowing difficulties, holding food in mouth, making several attempts at swallowing, and refusing to eat. The care plan further directed staff to monitor, record, and report to the physician as needed any signs and symptoms of muscle wasting, significant weight loss of three lbs in one week, more than five percent weight loss in one month, and greater than 10 percent in six months. The care plan directed staff to provide diet as ordered and registered dietician to evaluate and make diet change recommendations as needed. The Diabetic Mellitus Care Plan, dated 08/12/19, directed staff to offer the resident substitutes for food not eaten. The Physician Order, dated 05/13/19, directed staff to serve the resident a mechanical soft textured diabetic diet with nectar thick liquids and Ensure liquid (nutritional supplement) one can two times a day. The Physician Order, dated 05/20/19, directed staff to offer the resident CIB twice daily. The Physician Order, dated 06/06/19, directed staff to increase the resident's carbohydrates with meals. R21's Vital Sign Log-Weights recorded the following weights: 03/01/20 136.6 lbs. 04/05/20 127.5 lbs. 05/03/20 124.4 lbs. 05/24/20 122.1 lbs. (7.5% weight loss) 05/31/20 123.6 lbs. 06/21/20 123.6 lbs. 07/05/20 127.1 lbs. 07/12/20 123.9 lbs. 07/19/20 117.5 lbs. 07/26/20 120.6 lbs. (5% weight loss in 30 days) 08/09/20 120.5 lbs. 08/16/20 121.5 lbs. 08/23/20 119 lbs. 08/31/20 119 lbs. (10% weight loss in 180 days) The Mini Nutritional Assessment, dated 01/04/20, recorded the resident weighed 129.3 lbs, no decrease in food intake or weight loss, Body Mass Index (BMI) less than 19 (normal range is 18.5 to 24.9), and at risk of malnutrition. The Mini Nutritional Assessment, dated 04/04/20, recorded the resident weighed 127.8 lbs, no decrease in food intake, no weight loss, BMI less than 19, and at risk for malnutrition. The Mini Nutritional Assessment, dated 07/06/20, recorded the resident weighed 127.1 lbs, moderate decrease in food intake, weight loss between 2.2 lbs and 6.6 lbs, BMI less than 19, and malnourished. The Nutritional Risk Assessment, dated 07/16/20, recorded the resident weighed 123.9 lbs, BMI 17.8, low body weight, physical appearance thin, and not able to list food favorites. The dietary manager reported good intakes of CIB supplements, weight slowly trending downward the last 180 days, and intakes 0 to 50%. The assessment recorded the resident required supplements to meet caloric needs, discontinue the Ensure (which the resident did not prefer) and increase the CIB to three times a day. The Progress Note, dated 09/03/20, recorded the resident had a recent notable weight loss, rarely finished a full meal, ate approximately 20 to 30% of meals, refused Ensure but would take CIB three times a day. Note sent to physician along with weight charting via fax. On 09/02/20 at 12:30 PM, observation revealed R21 ate a few bites of(NAME)noodles, small bowl of peaches, and drank half of his CIB. Observation revealed the resident independently propelled himself out of the dining room to his room. On 09/02/20 at 04:32 PM, observation revealed R21 sat in his room and ate a pastry snack. On 09/02/20 at 04:55 PM, observation revealed R21 sat in the dining room, a regular portion meal of cheeseburger casserole, slice of bread and butter, CIB, and baked cinnamon apples in front of him. Observation revealed the resident sat with his left hand on his head, as if to holding it up, and fed himself a few bites of his meal, staff members stopped and encouraged the resident to eat, no one offered alternatives, and resident left the room without eating anything else. On 09/03/2020 at 08:20 AM, Dietary Staff (DS) DD reported the resident received CIB with his meals and sometimes the staff offered him shakes. DS DD reported staff offered the resident soups if he did not eat well, because the resident did not like to chew a lot. DS DD reported dietary staff recorded the resident's food and liquid intake at meals and the nursing department recorded the information into the electronic charting system. On 09/03/20 at 04:41 PM, Consultant (C) GG reported the dietary manager reported concerns to her, she was available by phone, and had remote access to the computer charting system due to the COVID (a mild to severe respiratory illness caused by a coronavirus that is transmitted chiefly by contact with infectious material) precautions. C GG reported the dietary manager informed her the resident had a weight loss but could not remember when she was notified. The last nutrition note was in April 2020. On 09/08/2020 at 08:54 AM, Administrative Nurse D reported the dietary aides documented the meal intakes and no food or fluid intakes were recorded in the electronic record for review. Administrative Nurse D stated the dietary department was responsible for giving the resident Ensure supplement and nursing staff checked it off in the treatment record. Administrative Nurse D verified the nursing department had not recorded the amount of supplement the resident ingested or intake of mealtime percentages. The facility Nutrition (Impaired) Unplanned Weight Loss Clinical Protocol policy, dated September 2017, documented the staff will report to the physician significant weight gains or losses or any abrupt or persistent changes from baseline appetite or food intake. The staff and physician will identify pertinent interventions based on identified causes and overall resident condition, prognosis, and wishes. The physician and staff will monitor nutritional status, and individual's response to interventions and possible complications of such interventions. The facility failed to accurately monitor R21's meals and nutritional supplement intake resulting in a 10.26% weight loss in six months, placing the resident at risk for further weight loss and nutritional problems.

The facility had a census of 29 residents. The sample included 14 residents. Based on observation, record review and interview the facility failed to provide the necessary treatment and services to promote healing of a facility acquired Stage 2 pressure ulcer (partial thickness loss of dermis, presenting as a shallow wound) and prevent the development of a new Stage 2 pressure ulcer for 1 of 1 sampled resident. (#11) Findings included: - Review of Resident #11's physician order [REDACTED]. The quarterly (MDS) Minimum Data Set assessment, dated 01/17/18, recorded the resident had a (BIMS) Brief Interview for Mental Status score of 00 (severe cognitive impairment) exhibited verbal behaviors, and rejected cares. The resident required extensive to total staff assistance with bed mobility, transfers, toileting and personal hygiene, had an indwelling urinary catheter, and was frequently incontinent of bowel. The MDS further recorded the resident was at risk for the development of pressure ulcers, currently had no pressure ulcer, had a pressure reducing device on the bed and chair, and a repositioning/turning program. The 09/08/17 admission (CAA) Care Area Assessment for pressure ulcers recorded the resident was at risk for the development of pressure ulcers due to limited mobility caused by the [MEDICAL CONDITION], and currently had an Stage 2 pressure ulcer on his/her right buttock. The 11/11/17 Braden Assessment recorded a score of 15 (at risk to develop pressure ulcers). The 01/17/18 care plan recorded the resident was at risk for the development of pressures ulcers and directed staff to reposition the resident and avoid exposure to moisture. The care plan also directed staff to report skin breakdown to the physician, assess and monitor existing open areas, and report worsening wounds/open areas to the physician. The care plan lacked evidence of nutritional interventions and the use of a ROHO cushion (air cell cushion provides proper positioning and redistributes pressure to prevent skin breakdown for immobile individuals, who spend significant time seated) in the resident's recliner and wheelchair. The 01/22/18 nursing skin assessment recorded the resident had a 1.7 (cm) centimeter by 1.0 cm shear (produced by pressure or friction) wound on the left buttock. The resident's medical record lacked evidence of any assessments of the resident's pressure ulcers after 01/22/18. The 01/22/18 physician's orders [REDACTED]. The (MONTH) (YEAR) (TAR) Treatment Administration Record documented, from 01/22/18 to 02/01/18, staff recorded the initials mx (monitored) every day on the pressure ulcer flowsheet. Continued review of the TAR flowsheet lacked evidence staff assessed the resident's pressure ulcer for description, measurements, change in condition, drainage, or infection. Continued review of the flowsheet revealed no documentation of the new pressure ulcer observed by the surveyor on 01/31/18. The 01/24/18 (RD) Registered Dietician Progress Notes recorded the resident had a recent hospitalization and weight loss, and the resident needed an average meal intake of 100% to maintain his/her weight and protein levels. Continued review of the progress note revealed no documentation of nutritional interventions to promote wound healing. Review of the resident's medical record lacked evidence staff notified the physician that the existing Stage 2 pressure ulcer on the upper left buttock was not healing or the development of a new Stage 2 pressure ulcer on the upper left buttock. On 01/30/18 at 2:02 PM, observation revealed the resident's ROHO cushion (air cell cushion provides proper positioning and redistributes pressure to prevent skin breakdown for immobile individuals, who spend significant time seated) was deflated on the resident's unoccupied wheelchair seat. On 01/30/18 at 4:47 PM, observation revealed the resident, seated in a wheelchair with the ROHO cushion in place, at the dining room table. On 01/31/18 at 9:15 AM, observation revealed the resident, seated on a commode, with the sit to stand lift used to assist the resident to maintain his/her balance. Continued observation revealed Nurse G and Nurse Aide M used the lift to assist the resident to stand to provide the pressure ulcer treatment. Continued observation revealed the resident's upper left buttock near the coccyx (small triangular bone near the base of the spine) had 2 pressure ulcers: upper open area measured approximately 1.0-1.5 cm in diameter (Nurse G verified this was a new open area) and lower open area measured approximately 1.5-2.0 cm in diameter (Nurse G verified this was the existing pressure ulcer on the TAR). Continued observation revealed the area surrounding the resident's 2 pressure ulcers had purple colored skin and Nurse G applied zinc oxide ointment on the pressure ulcers. Continued observation revealed the resident said ouch, when Nurse G cleaned the pressure ulcers and applied zinc oxide ointment. On 01/31/18 at 9:25 AM, Nurse G stated the resident spent a lot of time seated in his/her recliner and wheelchair, staff ensured a cushion was in place, and repositioned the resident every 2 hours. Nurse G stated the resident had a history of [REDACTED]. Nurse G stated staff had not used PUSH Tool (PUSH Tool was developed by the National Pressure Ulcer Advisory Panel (NPUAP) as a quick, reliable tool to monitor the change in pressure ulcer status over time) to monitor the resident's pressure ulcers and that was the reason for lack of assessment documentation on the resident's medical record. Nurse G stated staff should notify the physician if the resident's pressure ulcer was not healing or a new pressure ulcer developed. Nurse G stated he/she was not aware if staff notified the (RD) Registered Dietician about the resident's skin issue or if the resident had nutritional interventions to promote wound healing. On 01/31/18 at 10:15 AM, Nurse Aide M stated the resident required extensive staff assistance with repositioning, transfers and had a history of [REDACTED]. Nurse Aide M stated the resident spent a lot of time, seated in his/her recliner or wheelchair, and staff ensured the cushion was in place. Nurse Aide M stated staff reported the resident's ROHO cushion was deflated several days ago and staff continued to use the ineffective cushion, until the new cushion arrived. On 01/31/18 at 10:30 AM, Nurse Aide N stated the resident required extensive staff assistance for repositioning and staff used a sit to stand lift to transfer the resident. Nurse Aide N stated the resident had a history of [REDACTED]. Nurse Aide N stated staff reported the resident's ROHO cushion was not inflated to the charge nurse, several weeks ago, and staff continued to use the deflated cushion in the resident's recliner and wheelchair. On 01/31/18 at 1:01 PM, Dietary Staff BB stated the resident had not received nutritional interventions to promote wound healing. On 02/01/18 at 11:25 AM, Administrative Nurse D stated the facility did not have a wound nurse, but nurses should assess the resident's pressure ulcer and document on the TAR to appropriately monitor the pressure ulcer. Administrative Nurse D stated staff should notify the physician and RD about worsening or new pressure ulcers to ensure appropriate wound treatment and nutritional interventions were in place. Administrative Nurse D stated staff identified the ROHO cushion was deflated and a new cushion was ordered. On 02/06/18 at 9:10 AM, Registered Dietician GG stated staff had not informed him/her or the facility's dietary manager about the resident's pressure ulcers. Registered Dietician GG further stated the resident had recent weight loss and needed nutritional interventions to promote wound healing. The facility's (YEAR) Pressure Ulcer Policy directed staff to identify residents at risk to develop pressure ulcers and implement necessary interventions to prevent or heal pressure ulcers. The policy directed staff to notify the physician and RD to ensure appropriate treatment and nutritional interventions to prevent and/or heal pressure ulcers. The facility failed to provide the necessary treatment and services to promote healing of a facility acquired Stage 2 pressure ulcer and prevent the development of a new Stage 2 pressure ulcer for cognitively impaired dependent Resident #11, identified at risk for pressure ulcers.

The facility had a census of 29 residents. The sample included 14 residents. Based on observation, record review and interview the facility failed to ensure adequate pain management for 1 of 14 sampled residents, who had a fall with a head injury and [MEDICAL CONDITION]. (#13) Findings included: - Review of Resident #13's physician order [REDACTED]. The quarterly (MDS) Minimum Data Set assessment, dated 12/11/17, recorded the resident had a (BIMS) Brief Interview for Mental Status score of 15 (cognitively intact). The resident was independent with bed mobility and transfers, had impaired balance, and was unable to walk. The resident received (prn) as needed pain medications and the resident had no pain during the 7 day look back assessment period. The 06/12/17 annual (CAA) Care Area Assessment for falls recorded the resident was at risk for falls due to his/her [MEDICAL CONDITION], use of a mobility device, and not asking for staff assistance. The 12/20/17 care plan recorded the resident was at risk for falls related to his/her [MEDICAL CONDITION] and use of mobility devices. The care plan recorded the resident was cognitively intact and able to make his/her needs known. The facility's 01/23/18 at 9:30 AM, fall report recorded the resident became dizzy, lost his/her balance, and fell , while transferring from his/her bed to the wheelchair. The report recorded the resident stated he/she struck his/her head, during the fall, and staff noted bruising and swelling on the resident's forehead. The report further recorded the resident complained of right hip pain and staff sent the resident to the (ER) emergency room for an evaluation and x-ray. The 01/23/18 Radiology Report recorded the resident had no [MEDICAL CONDITION] and the resident returned to the facility. The facility's Neurological Assessment flow sheet (assessment of sensory and motor responses, especially reflexes, to determine whether the nervous system is impaired), dated 01/23/18, recorded the resident was alert and oriented, and complained of right hip pain on 01/23/18 at 12:00 PM, 1:00 PM and 2:00 PM. Continued review of the flow sheet revealed no documentation of the resident's pain assessment from 01/23/18 at 2:00 PM until 01/25/18 at 2:00 PM (48 hours), when staff sent the resident to the emergency room for severe pain and emesis (vomit). The 01/23/18 physician's orders [REDACTED]. The (MONTH) (YEAR) (MAR) Medication Administration Record [REDACTED]. Review of the MAR indicated [REDACTED] 01/23/18 at 8:30 PM, [MEDICATION NAME] administered and at 9:45 PM the resident's pain was better. 01/24/18 at 12:30 AM, [MEDICATION NAME] administered and at 1:30 AM the resident had no complaints of pain. 01/24/18 at 9:00 AM, [MEDICATION NAME] administered with no results recorded. 01/24/18 at 9:00 PM, medication refused. 01/25/18 at 3:00 AM, medication refused. 01/25/18 at 9:00 AM, medication refused. review of the resident's medical record revealed [REDACTED]. Continued review of the resident's medical record lacked evidence staff notified the physician about the resident's uncontrolled pain, during this time period. The 01/25/18 Hospital Transfer Report recorded the resident had a fall on 01/23/18, and hit his/her head and right hip. The report recorded the resident has had no pain relief since the fall and now had dark emesis with coffee ground consistency and foul odor. The report also recorded the resident complained of pain all over his/her body, and the resident was unable to move, due to increased pain with movement. The 01/26/18 Hospital Transfer Report recorded the resident had a fall on 01/23/18, and x-ray to the resident's right hip did not reveal an injury. The report recorded the resident had increased pain since the fall. The last [MEDICATION NAME] was administered on 01/24/18 at 9:00 AM (32 hours prior to the resident's transfer to the hospital), and the resident vomited for more than 24 hours. The 01/26/18 hospital admission record documented the resident fell out of bed on 01/23/18, landed on his/her right hip and head, and prior imaging did not reveal a fracture. The admission record documented the resident had increased right frontal headache pain and right hip pain since the fall. The admission record documented the resident had severe right hip pain, that radiated into his/her knee and developed bilious emesis (forcible ejection of vomit containing bile (greenish/brown fluid secreted in the liver). The admission record documented the resident's head (CT) Computed Tomography scan (test that uses x-ray technology to make multiple cross-sectional views of organs and bones) revealed no acute injuries and the resident's CT pelvis scan revealed a displaced [MEDICAL CONDITION]. On 01/30/18 at 10:50 AM, observation revealed the resident returned from the hospital, seated in a wheelchair, and propelled by staff. On 01/31/18 at 9:25 AM, Nurse G stated the resident was alert and oriented, and could accurately report his/her pain. Nurse G stated the resident had a fall, the x-ray was negative for a fracture and the resident complained of worsening right hip pain. Nurse G stated the facility obtained a physician's orders [REDACTED]. Nurse G further stated nursing staff should assess residents for changes in condition and/or pain after falls and notify the physician to ensure the resident's pain was managed. On 01/31/18 at 10:30 AM, Nurse Aide N stated the resident was alert and oriented, and able to accurately report his/her pain. Nurse Aide N stated the resident complained of increased right hip pain, especially with movement, and the resident began to refuse cares due to the pain. Nurse Aide N further stated he/she reported the resident's worsening pain to the nurse. On 01/31/18 at 11:19 AM, Nurse Aide O stated the resident was alert, always involved in his/her cares and could accurately report his/her pain. Nurse Aide O stated the resident complained of severe hip pain for 2 days after the fall and the resident began vomiting the day before he/she discharged to the hospital. Nurse Aide O further stated he/she reported the resident's pain to the nurse several times a day and was told the resident refused pain medications. On 02/01/18 at 8:38 AM, Nurse Aide P stated the resident could accurately report his/her pain and was always involved in his/her cares. Nurse Aide P stated the resident complained of severe right hip pain that increased with movement, did not want staff to touch him/her due to the hip and leg pain and refused [MEDICAL TREATMENT] (the clinical purification of blood). Nurse Aide P further stated the resident's pain was reported to the nurse, and the nurse stated several times the resident refused pain medication due to his/her nausea and vomiting. On 02/01/18 at 9:17 AM, Nurse H stated the resident was alert and oriented and able to accurately report his/her changes in condition and/or pain. Nurse H stated the resident complained of worsening hip pain and headaches, and refused the prn [MEDICATION NAME] at times due to nausea and vomiting. Nurse H stated he/she was not aware if nursing staff notified the physician of the resident's worsening pain and a need for a change in pain medication, or if staff assessed and recorded the resident's status prior to discharge to hospital. Nurse H further stated the resident refused his/her scheduled [MEDICAL TREATMENT] treatment and the [MEDICAL TREATMENT] staff told the facility to send the resident to the hospital. On 02/01/18 at 11:12 AM, Administrative Nurse D stated nursing staff should complete post fall assessments and notify the physician of worsening changes in condition or pain. Administrative Nurse D stated nursing staff should closely monitor the resident's pain level and notify the physician if the resident's pain was not managed by their current pain medications. On 02/06/18 at 10:32 AM, Physician's Nurse HH stated the facility notified the physician about the resident's pain, on 01/24/18, and the physician told the facility, he/she would assess the resident at [MEDICAL TREATMENT] and prescribe a stronger pain medication, if needed. Physician's Nurse HH stated the resident refused [MEDICAL TREATMENT] on 01/24/18, and the next day (01/25/18) the physician ordered the facility to transfer the resident to the hospital for evaluation. The facility's (YEAR) Pain Policy directed staff to provide prompt assessments and treatments to manage the resident's pain. The policy directed staff to notify the physician as needed to ensure the resident's pain was controlled. The facility failed to ensure adequate pain management for Resident #13, who had a fall with a head injury and [MEDICAL CONDITION].