Every finding on record at Linn Community Nursing Home

The facility had a census of 41 residents. Based on observation, record review, and interview, the facility failed to store, prepare, distribute, and serve food by professional standards for food service safety in one kitchen and two kitchenettes. Findings included:- On 02/23/26 at 08:35 AM, observation in the kitchen revealed a freezer with the following undated food items:A plastic bag with 4 filet steak patties.A plastic bag, approximately 1/4 full, grilled shrimpA plastic bag, approximately 1/4 full, of French fries.A plastic bag, approximately 1/4 full, chicken stripsA plastic bag approximately 1/4 full of popcorn chicken.A plastic bag full of taco meat.A plastic bag, approximately 1/4 full of tater totsA plastic bag, approximately 1/4 full of chicken patties.A plastic bag, approximately 1/4 full of breaded mushrooms.An unsealed, undated plastic bag of choriquesco. On 02/23/26 at 08:40 AM, Dietary Staff (DS) CC verified the above findings and stated she was unaware that the freezer food items needed to be labeled and dated. On 02/23/26 at 09:15 AM, observation in the small dining room kitchenette revealed DS DD (without a hair net) during the breakfast meal serving, with the bottom warming drawer open on the oven, with his head over the food items, plating food and serving them to the residents. On 02/24/26 at 11:00 AM, an observation in the large dining room kitchenette revealed DS EE, without a hairnet, opened the bottom warming drawer, had her head over the warming drawer, plating food items for the residents' noon meal. On 02/23/26 at 09:10 AM, CDM BB verified staff were not wearing hairnets in the kitchenettes during meal service and stated they are meal servers and do not have to wear hairnets. On 02/24/26 at 11:00 AM, observation in the kitchen revealed DS FF used a probed thermometer to check the temperature of smothered pork chops from the oven, then, without cleaning the probe between food items, placed it in the mixed vegetables and scalloped potatoes with the CDM overseeing the temperature checks. On 02/24/26 at 11:00 AM, CDM BB verified DS FF had not cleaned the thermometer between food items and stated she should have cleaned it. The facility's Labeling and Dating Food Policy, undated, documented staff would be trained on proper labeling and dating procedures for food items. The facility's Hair Restraints and Food Preparation Policy, undated, documented the facility would follow the 2022 FDA food code, which does not explicitly require the use of hair restraints for food service workers and does not mandate hair restraints for food preparation; however, the facility recognizes their potential benefit. The facility recommends the following: all food preparation staff involved in food preparation are encouraged to wear hair restraints, especially those with long hair or facial hair. Even if hair restraints are not worn by all staff, clean caps or hats are encouraged to minimize hair shedding. Staff with long hair must tie it back securely to prevent contact with food or food preparation surfaces.

The facility had a census of 41 residents. Based on observation, interview, and record review, the facility failed to develop a Facility Assessment to include the nursing resources necessary to care for the residents during the day-to-day operations, which has the potential to affect all residents in the facility. Findings included:- Review of the Facility Assessment revealed the document lacked specific staffing levels and number of Registered Nurses (RN), Licensed Nurses (LPN/LVN), Certified Medication Aides (CMA), and Certified Nurse Aides (CNA) needed for each unit, resident needs, and census. The assessment lacked the staffing levels required for each shift. On 02/24/26 at 09:34 AM, Administrative Nurse D reported the facility's minimum staffing pattern was two staff who could pass medications, one of which would be a licensed nurse, for both neighborhoods. Each neighborhood scheduled two CNA's (a total of four) for day and evening shifts. The night shift for both neighborhoods was scheduled with one licensed nurse and two nurse aides. Administrative Nurse D verified she participated in the Facility Assessment process and thought it was in the assessment. The facility did not provide a Facility Assessment policy, as requested.

The facility had a census of 41 residents. The sample included 12 residents with one reviewed for hospice services. Based on observation, record review, and interview, the facility failed to ensure Resident (R)9's care plan, who admitted to hospice on 02/10/26, included a plan of care and a description of the services provided, which included contact information, visit frequency, medications, and medical equipment. Findings included:- R9's Electronic Health Record (EHR) revealed a diagnosis of dementia (a progressive mental disorder characterized by failing memory and confusion). R9's Significant Change Minimum Data Set (MDS), dated [DATE], documented R9 had a Brief Interview of Mental Status (BIMS) score of 00, which indicated severe cognitive impairment. The MDS document R9 required supervision with most activities of daily living (ADL) and R9 received hospice care services. The Cognitive Loss/Dementia Care Area Assessment, (CAA), dated 02/10/26, documented R9 had dementia. R9's Care Plan, revised 02/22/26, documented R9 required supervision with most ADLs. The plan documented R9 admitted to hospice services on 02/10/26. The plan directed the staff to administer pain and other medications for comfort as the physician ordered. The care plan lacked a contact number for hospice, what supplies, equipment, and medications hospice would provide, when hospice staff would be in the building, and what care they would provide for R9. A review of R9's clinical record revealed the resident admitted to hospice care on 02/10/26. The hospice agreement, dated 08/13/24, documented Hospice and the facility would jointly develop and agree upon a coordinated plan of care. On 02/24/26 at 08:00 AM, observation revealed R9 sat at a dining room table and independently ate her breakfast meal with no signs or symptoms of pain. On 02/25/26 at 12:19 PM, Administrative Nurse D verified R9's care plan lacked information regarding what hospice services were provided to R9, such as frequency of visits, contact information/phone numbers, and medical supplies. The facility's End of Life, Palliative, and Hospice Care Policy, revised 05/02/25, documented, when possible, the hospice program staff participated in each other's team meetings to promote regular professional communication, collaboration, and an integrated plan of care on behalf of residents and families.

The facility had a census of 41 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to ensure a sanitary environment, to help prevent the potential development and transmission of communicable diseases and infections. when staff failed to change gloves when going from a dirty to clean area during incontinence care for Resident (R)15. Findings included:- On 02/24/26 at 10:00 AM, observation revealed R15 was in bed, with a urinal in place under his covers. Certified Nurse Aide (CNA) M and Licensed Nurse (LN) G entered R15's room. CNA M asked R15 if he was finished using the urinal, and he replied 'yes'. CNA M and LN G applied gloves, CNA M removed the urinal, and spilled urine on the bed pad and her gloves. CNA M then handed LN G the urinal. LN G poured the urine in the toilet and discarded her gloves and donned new gloves. CNA M provided perineal care to R15 and assisted LN G in positioning R15 on his left side, with the same soiled gloves. CNA M touched R15's bedding, oxygen tubing, and legs with the same soiled gloves. CNA M provided incontinent care to R15's buttocks, removed the wet incontinent brief and bed pad, touched the privacy curtain at the end of R15's bed, closed the lid on the incontinent wipe package, then retrieved a new incontinent brief and placed it under R15's buttocks, while wearing the same soiled gloves. CNA M assisted LN G with positioning R15 on his back, fastened the incontinent brief, touched R15's clothing and then removed and discarded the soiled gloves. On 02/24/26 at 10:30 AM, CNA M verified she had not changed her gloves after providing perineal care and stated she should have. On 02/25/26 at 11:54 AM, Administrative Nurse D stated she expected staff to change gloves after performing perineal care for a resident. The facility's Perineal Care Protocol Policy, revised 04/09/25, instructed staff to wash hands and don (put on) gloves, remove soiled brief, remove gloves, wash hands, don clean gloves, and after providing perineal care, remove gloves, wash hands or use alcohol-based hand sanitizer, and noted not to touch anything with the soiled gloves after the procedure.

The facility had a census of 37 residents. The sample included two residents. Based on observation, record review, and interview, the facility failed to report Resident (R) 1's request to not be pushed by Maintenance Staff U as witnessed by staff to the State Agency (SA) as required. This placed R1 at risk for ongoing abuse and mistreatment. Findings included: - R1's electronic Medical Record (EMR) included diagnoses of hypertension (HTN - elevated blood pressure), pain, unspecified soft tissue disorder, generalized edema (swelling resulting from an excessive accumulation of fluid in the body tissues), low back pain, muscle weakness, retention of urine, and major depressive disorder (major mood disorder that causes persistent feelings of sadness). R1's Quarterly Minimum Data Set (MDS), dated [DATE], documented that R1 had intact cognition, used a wheelchair or walker, required set up or clean up assistance with toileting hygiene, bathing, and upper body dressing. R1 also required set-up or clean-up assistance with rolling in bed, sitting to lying, and lying to sitting. The MDS further documented R1 required supervision or touch assistance with sit-to-standing, toilet transfers, walking, or using a wheelchair for 50 to 150 feet. R1 received a scheduled pain medication regimen, had pain occasionally, which occasionally interfered with day-to-day activities. R1's Care Plan, dated 03/25/25, documented daily tasks of manual wheelchair mobility, staff provide at least supervision, up to propelling R1. R1 used the wheelchair for most of her mobility to get to her destinations. The Progress Note dated 05/28/25 at 10:24 AM, documented R1 attended activities of her liking, able to walk with staff assistance using her walker, but most of the time R1 used the wheelchair to and from activities. On 07/02/25 at 12:59 PM, Certified Nurse Aide (CNA) M reported on 06/05/25 that he witnessed Maintenance Staff U pushing R1 from activities, when he heard R1 tell Maintenance Staff U to stop. CNA M asked R1 if she had needed anything. R1 stated, No, I just want him gone, not in a jovial way. CNA M turned to assist R1 back to activities when Maintenance Staff U stated, No, I got this and proceeded to wheel R1 away from the area. CNA M reported to Licensed Nurse (LN) G. CNA M reported he filled out a grievance about the event and had been informed to Let it go, but was not interviewed for what was witnessed. On 07/02/25 at 01:40 PM, Dietary Staff (DS) BB reported on 06/05/25, while in the dining room, he witnessed Maintenance Staff U pushing R1 around the building in her wheelchair, when R1 requested Maintenance Staff U several times to stop, because R1 wanted to go to the activity room. Dietary Staff BB reported Maintenance Staff U softly pushed R1 into him and another staff member, and R1 had put a foot on the ground to stop. Dietary Staff BB filed a grievance concern, but had not been interviewed or questioned about the occurrence. On 07/02/25 at 01:35 PM, Licensed Staff (LN) G reported staff had reported Maintenance Staff U had pushed R1 around the facility, with R1 objecting, wanting to go to the activity room. LN G reported that three staff had reported this, and staff filled out a grievance in writing, and LN G took it to Administrative Staff A. On 07/02/25 at 03:25 PM, Administrative Staff A reported she was told by staff that Maintenance Staff U had taken R1 and staff were unaware of R1's whereabouts. Administrative Staff A stated that when told of this, she witnessed R1 and Maintenance Staff U returning inside the building through the front doors. Administrative Staff A reported R1 and Maintenance Staff U usually sat in the front of the building. Administrative Staff A reported she later interviewed R1 in private regarding the interaction between her and the Maintenance Staff U. R1 stated it was all fun and games as both R1 and Maintenance Staff U had worked together at the facility. Administrative Staff A stated she briefly talked to staff in the hallway about the incident but had not written an investigation or talked to staff individually because R1 would not say she wanted Maintenance Staff U to stop, or other specifics related to the occurrence. Administrative Staff A stated she had not called the State Agency, nor completed a written investigation related to the staff grievance related to R1 and Maintenance Staff U. The facility's Abuse, Neglect, Exploitation policy, dated 06/05/25, documented it was policy of the facility to encourage and support all residents, staff, families, visitors, volunteers and resident representees in reporting any suspected acts or abuse, neglect, exploitation, involuntary seclusion or misappropriation of resident property from corporal punishment, involuntary seclusion and physical or chemical restraint not required to treat the resident's medical symptoms. The Administrator/designee ensures that all alleged or suspected violations involving the mistreatment, neglect, or abuse, including injuries of unknown origin and misappropriation of resident property, are investigated and reported immediately to the State Agency Complaint Hotline.

The facility had a census of 37 residents. Based on observation, record review, and interview, the facility failed to fully investigate an allegation of abuse for Resident (R) 1. This placed the resident at risk for ongoing abuse. Findings included: - R1's electronic Medical Record (EMR) included diagnoses of hypertension (HTN - elevated blood pressure), pain, unspecified soft tissue disorder, generalized edema (swelling resulting from an excessive accumulation of fluid in the body tissues), low back pain, muscle weakness, retention of urine, and major depressive disorder (major mood disorder that causes persistent feelings of sadness). R1's Quarterly Minimum Data Set (MDS), dated [DATE], documented that R1 had intact cognition, used a wheelchair or walker, required set up or clean up assistance with toileting hygiene, bathing, and upper body dressing. R1 also required set-up or clean-up assistance with rolling in bed, sitting to lying, and lying to sitting. The MDS further documented R1 required supervision or touch assistance with sit-to-standing, toilet transfers, walking, or using a wheelchair for 50 to 150 feet. R1 received a scheduled pain medication regimen, had pain occasionally, which occasionally interfered with day-to-day activities. R1's Care Plan, dated 03/25/25, documented daily tasks of manual wheelchair mobility, staff provide at least supervision, up to propelling R1. R1 used the wheelchair for most of her mobility to get to her destinations. The Progress Note dated 05/28/25 at 10:24 AM, documented R1 attended activities of her liking, able to walk with staff assistance using her walker, but most of the time R1 used the wheelchair to and from activities. On 07/02/25 at 12:59 PM, Certified Nurse Aide (CNA) M reported on 06/05/25 that he witnessed Maintenance Staff U pushing R1 from activities, when he heard R1 tell Maintenance Staff U to stop. CNA M asked R1 if she had needed anything. R1 stated, No, I just want him gone, not in a jovial way. CNA M turned to assist R1 back to activities when Maintenance Staff U stated, No, I got this and proceeded to wheel R1 away from the area. CNA M reported to Licensed Nurse (LN) G. CNA M reported he filled out a grievance about the event and had been informed to Let it go, but was not interviewed for what was witnessed. On 07/02/25 at 01:40 PM, Dietary Staff (DS) BB reported on 06/05/25, while in the dining room, he witnessed Maintenance Staff U pushing R1 around the building in her wheelchair, when R1 requested Maintenance Staff U to stop several times, because R1 wanted to go to the activity room. Dietary Staff BB reported Maintenance Staff U softly pushed R1 into him and another staff member, and R1 had put a foot on the ground to stop. Dietary Staff BB filed a grievance concern but had not been interviewed or questioned about the occurrence. On 07/02/25 at 01:35 PM, Licensed Staff (LN) G reported staff had reported Maintenance Staff U had pushed R1 around the facility, with R1 objecting, wanting to go to the activity room. LN G reported that three staff had reported this, and staff filled out a grievance in writing, and LN G took it to Administrative Staff A. On 07/02/25 at 03:25 PM, Administrative Staff A reported she was told by staff that Maintenance Staff U had taken R1 and staff were unaware of R1's whereabouts. Administrative Staff A stated that when told of this, she witnessed R1 and Maintenance Staff U returning inside the building through the front doors. Administrative Staff A reported R1 and Maintenance Staff U usually sat in the front of the building. Administrative Staff A reported she later interviewed R1 in private regarding the interaction between her and the Maintenance Staff U. R1 stated it was all fun and games as both R1 and Maintenance Staff U had worked together at the facility. Administrative Staff A stated she briefly talked to the staff in the hallway about the incident but had not written an investigation or talked to the staff individually because R1 would not say she wanted Maintenance Staff U to stop, or other specifics related to the occurrence. Administrative Staff A stated she had not called the State Agency, nor completed a written investigation related to the staff grievance related to R1 and Maintenance Staff U. The facility's Abuse, Neglect, Exploitation policy, dated 06/05/25, documented it was policy of the facility to encourage and support all residents, the staff, families, visitors, volunteers and resident representees in reporting any suspected acts or abuse, neglect, exploitation, involuntary seclusion or misappropriation of resident property from corporal punishment, involuntary seclusion and physical or chemical restraint not required to treat the resident's medical symptoms. The Administrator/designee ensures that all alleged or suspected violations involving the mistreatment, neglect, or abuse, including injuries of unknown origin and misappropriation of resident property, are investigated and reported immediately to the State Agency Complaint Hotline.

The facility had a census of 38 residents. The sample included 12 residents, with four reviewed for accidents. Based on observation, record review, and interview the facility failed to ensure an environment free from accident hazards for cognitively impaired Resident (R) 35. On 05/23/24 at approximately 10:07 AM, Dietary Staff (DS) BB let R35 out the exit door by the main dining room, which led to the patio. DS BB then returned to dietary tasks without ensuring additional supervision for R35. The patio area contained a gate that was unlocked and R35 exited the patio area through the unlocked gate. At approximately 10:39 AM, Maintenance Staff U saw R35 on a bench by the front door reading a newspaper and when he went out the door, R35 walked back inside the facility. At approximately 01:12 PM, another resident asked DS BB to go outside, and DS BB stated they would have to check with the charge nurse to see if the resident could go outside. When DS BB asked the charge nurse, DS BB mentioned letting R35 outside earlier. The staff did not know R35 was outside of the facility without staff supervision until approximately 3.5 hours later. Staff found R35 in her room in her recliner, as R35 had made her way back to her room. The facility's failure to provide adequate supervision to ensure an environment free from accident hazards placed R35 in immediate jeopardy. The facility additionally failed to provide interventions for R12 to prevent falls. This placed R12 at risk for fall-related injury. Findings included: - R35's Electronic Medical Record (EMR) documented R35 had diagnoses of osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain), dementia (a progressive mental disorder characterized by failing memory, and confusion), and a history of falling. R35's Quarterly Minimum Data Assessment, (MDS) revised 04/03/24 documented R35 had a Brief Interview of Mental Status (BIMS) score of nine, which indicated severe cognitive impairment. The MDS documented R35 used a walker for mobility and required supervision with ambulation. R35's Care Plan revised 04/22/24, instructed staff to make sure R35 had her walker with her when ambulating. The care plan documented R35 needed to focus on stabilizing herself when she stood up. R35 was unsafe when she walked by herself, and needed reminders for her safety, especially to use her walker. The care plan documented R35's wander/elopement risk assessment concluded she was at moderate risk due to being new to the facility and having poor short-term cognition. The Facility's Incident Report dated 05/23/24 documented Dietary Staff (DS) BB last saw R35 at 10:07 AM when she let R140 back in the facility and R35 went out the patio door behind him. DS BB told R35 she could not go outside without permission, however R35 continued outside. R35 exited the patio through an unlocked gate, then walked around on the sidewalk with her front-wheeled walker to the front door area of the facility at approximately 10:39 AM. R35 sat on a bench by the front door, and read the newspaper. The report documented Maintenance Staff (MS) U went out the front door and R35 grabbed the door before it closed and went into the facility. The report documented that at 01:12 PM R27 asked DS BB if she could go outside on the patio. DS BB went to the charge nurse to ask if R27 could go outside and mentioned to the charge nurse at that time that R35 was outside. The report noted the charge nurse immediately started looking for R35 and notified Administrative Staff E and Administrative Nurse D. Other staff were notified as well and staff searched for R35. At approximately 01:17 PM staff observed R35 in her room. Observation on 06/03/24 at 09:32 AM revealed an unlocked gait located at the end of a sidewalk, approximately 50 feet outside the dining room exit leading to the patio. The other gait was secured with a zip tie. The surveyor opened the unlocked gait, but the staff did not respond. During an interview on 06/03/24 at 09:32 AM, DS BB stated she let R35 go out on the patio on 05/23/24 because she thought it was safe. DS BB stated she did not know the gate was unlocked. During an interview on 06/03/24 at 09:51 AM, Administrative Nurse D verified the gate straight from the exit door to the patio was unlocked and stated it should be locked. Administrative Nurse D stated the patio gates do not alarm when they are opened and went on to say the facility was trying to get someone to come and put alarms on them. Administrative Nurse D verified the unlocked gate was the one R35 used to leave the building unsupervised on 05/23/24. The facility's Accident Prevention Policy, revised 05/06/24, documented that all staff members of the facility would ensure that each resident's environment remained as free from accident hazards as possible, and each resident would receive adequate supervision and assistive devices to prevent accidents. On 06/03/24 at 02:43 PM, the administrative staff were provided the IJ template and notified the facility's failure to provide a safe environment and supervision for R35 placed the resident in immediate jeopardy. The facility provided an acceptable plan for removal on 06/03/24 at 04:06 PM which included the following corrective actions: Updated Elopement and Elopement Risk Policies The facility started a sign-off sheet to include charge nurses' verification that a resident was able to go outside the facility without staff or a family member. Staff participated in an elopement drill on 05/28/24. R35's care plan was updated on 05/23/24. Initiated daily maintenance cheeks of the patio gates to make sure they are secured. R35 received 15-minute checks. Updated R35's wander/elopement risk assessment which shows moderate risk for elopement. The surveyor verified the removal of the immediacy and implementation of the corrective actions while on site on 06/04/24 at 11:26 AM. The deficient practice remained at a D scope and severity. 37450 - R12's Electronic Medical Record (EMR), documented diagnoses of spinal stenosis (degenerative condition of the spine that could cause weakness and loss of use of extremities), cognitive-communication deficit, a need for assistance with personal care, restlessness, agitation (feeling of aggravation or restlessness brought on by a provocation or a medical condition), pain, Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), and urinary tract infection. The Quarterly Minimum Data Set (MDS), dated [DATE], documented R12 had moderately impaired cognition as assessed by staff. R12 had no delirium (sudden severe confusion, disorientation, and restlessness), psychosis (any major mental disorder characterized by gross impairment in reality perception), or exhibited behaviors. R12 had no functional range of motion impairment and did not use of mobility aids. R12 required substantial to maximal assistance with functional abilities and mobility. R12 was frequently incontinent of urine and bowel. R12 received scheduled pain medication and non-medication interventions for pain. The MDS further documented R12 had two or more falls with no injuries. The Fall Care Area Assessment (CAA), dated 02/07/24, documented R12 falls could be serious and could lead to death, and finding root causes could aid in prevention, and addressing the root causes with interventions would aid in reducing the risk for further occurrence and injuries associated with a fall. R12's Safety Care Plan dated 05/20/24 documented R12 was a high fall risk due to some of the medication R12 took, a fall history, and an unsteady gait. The Progress Note and Care Plan review revealed: On 06/22/23 at 10:35 PM, R12 had a fall with his knees on the floor and his upper body was leaning on his bed. The care plan instructed staff to leave the resident's door open. On 09/15/23 at 04:03 PM, staff assisted R12 with a chair in the dining room when R12's knee gave out. Staff broke the fall with R12 landing on a staff member's foot. The care plan documented R12 had a restorative program but may need more therapy. On 10/16/23 at 08:14 PM, the nurse was called to R12's room and found the resident lying on the floor with gripper socks on and the right foot with grippers on the top of the foot. R12 reported he reached for the wheelchair and the wheelchair rolled away from him. The care plan instructed staff to ensure gripper socks were worn correctly. On 11/08/23 at 04:53 AM, R12 was wandering around the facility when he came through the front doors, near the office, tripped on the rug, and landed on the floor. The care plan lacked intervention related to the 11/08/23 fall. On 12/02/23 at 08:33 PM, a resident reported R12 was sitting on the floor of the dining room. The care plan lacked any intervention related to the 12/02/23 fall. On 01/18/24 at 02:08 PM, documented R12 had a fall and was lying on his right side next to a recliner. The care plan lacked any intervention related to the 01/18/24 fall. On 02/01/24 at 03:00 PM, R12 was watching a staff member at the bird cage when R12 crossed his leg and lost his balance. Staff attempted to stop R12's fall by grabbing R12's arms. The care plan intervention instructed staff to know R12 was incontinent, and that the resident's toileting plan had been adjusted. On 02/28/24 at 01:04 PM, documented R12 waved at a visitor, lost his balance, fell back against a wall, slid down, and landed on the floor. The care plan instructed staff R12 had fatigue and his gait and balance were more unstable. The physician had been notified with a request for acetaminophen to help with sleep. On 03/19/24 at 07:00 PM, R12 fell in the lobby and landed on his side. The care plan lacked any intervention related to the 03/19/24 fall. On 04/14/24 at 09:35 PM, R12 was found sitting on the floor in front of the dresser in his room. The care plan lacked any intervention related to the 04/14/24 fall. On 05/01/24 at 11:20 PM, R12 slid out of a wheelchair onto the floor. The care plan directed staff to ensure a gripper pad was in place on the wheelchair seat. On 06/03/24 at 09:05 AM, observation revealed R12 ambulated independently, without an assistive device, slightly leaning forward, arms hanging along his sides. Staff approached him and guided him to a chair in the commons area of the facility. On 06/04/24 at 08:31 AM, Certified Nurse Aide (CNA) O stated R12 wandered throughout the facility and staff tried to keep an eye on him, ensure he was wearing proper footwear, and maintain his toileting program. On 06/05/24 at 11:55 AM, Administrative Nurse D stated all resident falls should have care plan interventions to prevent further falls. Administrative Nurse D verified R12 lacked interventions for falls on 11/08/23, 12/02/23, 01/18/23, 02/01/24, 03/19/24, and 04/14/24. The facility's Fall Prevention Protocol, dated 05/07/24, documented that the effectiveness of the facility fall reduction program will be evaluated on a monthly basis by the Quality Assurance and Performance Improvement (QAPI) committee. Outcome indicators include the number of falls, the severity of fall-related injuries, and the effectiveness of implemented care plan interventions. The facility failed to adequately prevent R12's falls due to a lack of preventative interventions for five of 11 falls experienced which placed R12 at risk for injuries due to falling.

The facility had a census of 38 residents. The sample included 12 residents. Based on observation, interview, and record review the facility failed to store foods and ensure proper dishwashing in a manner to prevent food-borne illness. This placed the residents at risk for foodborne illness. Findings included: - On [DATE] at 09:22 AM, during the initial kitchen tour, observation revealed the following: The stainless-steel double-door refrigerator with a freezer on the bottom lacked a thermometer in the refrigerator section. The freezer section had seven opened, unsealed, unlabeled bags of frozen foods. The thermometer on the door shelf was not working. The walk-in freezer had boxes of homestyle portion chicken, frozen pasta, white shrimp, diced strawberries, and peach pies stored on the freezer floor. The white refrigerator in the hallway entry with a freezer in the top portion that had seven containers of an expired frozen product with a label that read Must be used by [DATE]. On [DATE] at 10:48 AM, observation in the facility kitchen revealed the walk-in freezer lacked an independent backup thermometer. The facility dishwashing machine used detergent pellets and sensors for heating and amounts of chemicals to disperse. The dishwashing logs documented the following: [DATE] through [DATE] temperatures ,d+[DATE] degrees F (Fahrenheit) with 200 parts per million (ppm) sanitizers. [DATE] through [DATE], no temperatures were recorded. [DATE], [DATE], and [DATE] the documentation lacked sanitizer or temperatures recorded. The facility's Weekly Water Temperature Log documented April kitchen water heater weekly checks, which measured ,d+[DATE] F, May checks measured ,d+[DATE] F, and June checks measured 118 F. On [DATE] at 09:22 AM, Dietary Staff DD verified the undated bags of frozen foods, the lack of an independent thermometer in cold storage, and the expired foods. Dietary Staff DD verified the boxes on the floor and stated the delivery came the day before and the employee could not lift so she was trying to get them put away today as she got time. Dietary Staff DD verified the expiration dates and stated the activity department put those in there and they should have been thrown away. On [DATE] at 10:21 AM, Dietary Staff CC verified staff should not store boxes of food on the freezer floor. Staff was to label and date food when opened, ensure working backup thermometers in each cold storage unit and dispose of expired foods. On [DATE] at 01:25 PM, Dietary Staff CC verified staff should have checked the temperature and chemical sanitation twice, daily. He verified the missing documentation and stated the dishwasher used chemical sanitation with low-temperature detergent. The facility's Dietary Purchases, Receipt, and Storage policy, dated [DATE], stated the Dining Services Manager was responsible for receiving and storing all food and supplies in a proper area. Ordering procedures require weekly inventories and there will be a complete inventory of all consumable items weekly by the Dining Services Manager. Staff would check refrigerators daily for any expired food and dispose of it daily. The facility failed to store foods and ensure proper dishwashing in a manner to prevent food-borne illness related to unsealed, undated bags of frozen food, food stored on the freezer floor, no backup thermometers for cold storage, and the dishwashing log lacked monitoring of chemical or temperatures for three days in [DATE]. This placed the residents at risk for foodborne illness.

The facility had a census of 38 residents. Based on interviews and record review, the facility failed to implement a water management program for Legionella disease (Legionella is a bacterium spread through mist, such as from air-conditioning units for large buildings. Adults over the age of 50 and people with weak immune systems, chronic lung disease, or heavy tobacco use are most at risk of developing pneumonia caused by Legionella). This placed the residents in the facility at risk for infectious disease. Findings included: - The facility's Water Temperature Check Log documented checks of laundry, kitchen, common areas, and resident rooms weekly. The facility did not have documentation of Legionella preventative measures including identification of risk areas and actions taken to mitigate risk. During an interview on 06/04/24 at 03:10 PM, Maintenance Staff V verified the facility lacked a map of water distribution and dead-end or little-used faucets despite one whole resident hall was not used. Maintenance Staff V confirmed there was no documentation of disinfection of shower heads. During an interview on 06/04/24 at 03:13 PM the facility's Infection Control Preventionist CC verified the facility did not have the required documentation to show follow through with the water management plan to prevent Legionella or another waterborne pathogen. The facility's Water Management Policy, dated 01/17/24, stated the minimum standards included: suitable Legionella risk assessments. Description of building water systems. Identification of where Legionella could grow and spread. Action plan for preventing or controlling the risk. Implementation, management, monitoring, and recording of precautions to include regular inspections, microbiological monitoring, temperature checks, and flushing where appropriate. The facility failed to implement a water management program to manage waterborne pathogens placing the residents who reside in the facility at risk of contracting Legionella pneumonia.

The facility had a census of 38 residents. The sample included 12 residents with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported an unapproved indication for use, the lack of target behaviors and side effect monitoring, and lack of patient-specific rationale describing why a gradual dose reduction (GDR) was contraindicated for the use of psychotropic (alters mood or thoughts) medications for Resident (R) 6, R13, R22, and R21. This placed the residents at risk for unnecessary medication side effects. Findings included: - R6's Electronic Medical Record (EMR), documented diagnoses of altered mental status, slurred speech, kidney failure, anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). R6's Quarterly Minimum Data Set (MDS), dated [DATE], documented R6 had severe cognitive impairment with no signs or symptoms of delirium (sudden severe confusion, disorientation, and restlessness) or psychosis (any major mental disorder characterized by gross impairment in reality perception). R6 had behavioral symptoms not directed toward others, which occurred one to three days during the observation period. R6 was dependent on staff for functional abilities and mobility. The MDS further documented R6 received an antipsychotic (class of medications used to treat major mental conditions that cause a break from reality), antianxiety (class of medications that calm and relax people), antidepressant (class of medications used to treat mood disorders), and opioid (a medication used to treat pain) medications. A GDR was documented as clinically contraindicated on 03/22/24. R6's Care Plan, dated 05/28/24, documented R6 received a high alert medication of divalproex (a mood stabilizer), Lexapro (an antidepressant), lorazepam (an antianxiety), Norco (medication used to treat pain), and olanzapine (an antipsychotic); staff was to monitor for adverse side effects. The care plan lacked resident-specific targeted behaviors and monitoring related side effects from the use of high-alert medications. The Physician Orders directed staff to administer the following: Divalproex Sodium Delayed-Release 250 milligrams (mg) tablet daily for disorientation 04/06/23 Lexapro 10 mg daily for anxiety disorder 03/05/22 Zyprexa 2.5 mg daily for altered mental status and anxiety disorder 04/06/23 Lorazepam 0.5 mg two times a day for anxiety disorder 03/04/22 The CP monthly medication regimen reviews (MRR) documented a recommendation for a GDR for Lexapro and Zyprexa on 02/28/24 and a GDR recommendation for lorazepam on 03/31/24. The Progress Note on 03/10/24 at 10:41 AM, documented R6 continued to holler out since waking in the morning. Scheduled medications were administered as ordered and R6 continued to holler out for mom at times, otherwise just hollered. The resident denied pain and when asked if he needed anything he would say no. The Progress Note on 03/22/24 at 03:05 PM, documented R6's physician declined the GDR for Lexapro and Zyprexa. The MRR reviewed from 05/31/23 through 05/31/24 lacked evidence the CP identified and reported the lack of side effects and targeted behaviors monitoring and lacked evidence the CP reported the unapproved indication and associated risks for Zyprexa. A review of R6's clinical record lacked evidence the physician documented the specific benefits versus the risks for R6's continuation of the antipsychotic medication. On 06/03/24 at 10:29 AM, observation revealed R6 sat in a Broda chair ( special wheelchair with the ability to tilt and recline) dressed for the day. R6 had ongoing verbalizations and hollering that were not words. Licensed Nurse (LN) G administered the ordered medications without difficulties. LN G inquired if R6 wanted breakfast and the resident declined but accepted the offer of a glass of chocolate milk. On 06/04/24 at 02:46 PM, LN H reported physician orders in the EMR alerted staff to the type of medications the residents received with black box warnings. The EMR was specific with diagnoses but lacked specific targeted behaviors the resident exhibited. LN H reported the certified nurse aides (CNA) would alert the nurse of behaviors and the nurse would document in the progress notes. On 06/04/24 at 03:20 PM, Administrative Nurse D verified the use of psychotropic medication lacked specific targeted behaviors, symptom monitoring for adverse side effects, and lack of risk versus benefit statement by the physician. Administrative Nurse D verified she was aware of the unapproved indication related to the use of R6's antipsychotic medication, and said the consultant pharmacist had not included that in the monthly reviews. The facility's Consultant Pharmacist Services Provider Requirements, dated 06/05/24, documented the consultant pharmacist provides pharmaceutical care services, including but not limited to reviewing the medication regimen (drug regimen review) of each elder in the healthcare center at least monthly incorporating federally mandated standards of care in addition to other applicable professional standards, and documenting the review and findings in the elder's clinical record. Communicating potential or actual problems detected related to medication therapy orders to the responsible physician and the Director of Nursing. The facility failed to ensure the CP identified and reported the lack of an approved indication for the use of an antipsychotic as well as inadequate monitoring and/or rationale for the continued use of psychotropic medications for R6. This placed R6 at risk of unnecessary psychotropic medications and related side effects. - R13's Electronic Medical Record (EMR) documented diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), pain, sleep disorder, heart failure, weakness, and major depressive disorder (major mood disorder which causes persistent feelings of sadness)with psychotic (any major mental disorder characterized by gross impairment in reality perception) features. R13's Quarterly Minimum Data Set (MDS), dated [DATE], documented R13 had intact cognition. R13 had no signs or symptoms of delirium (sudden severe confusion, disorientation, and restlessness) or psychosis (any major mental disorder characterized by gross impairment in reality perception), and exhibited no behaviors. R13 required set up or clean up assistance with functional abilities and supervision or touch assistance with mobility. The MDS further documented the use of an antianxiety (a class of medications that calm and relax people), an antidepressant (a class of medications used to treat mood disorders), a hypnotic (a class of medications used to induce sleep), diuretic (medication to promote the formation and excretion of urine), and opioid (a medication used to treat pain) medication. R13's Care Plan, dated 05/21/24, documented the use of high-alert medications including zolpidem (a hypnotic), duloxetine (an antidepressant), furosemide (a diuretic), Norco (medication to treat pain), trazodone (an antidepressant); staff were to monitor for adverse side effects. The care plan lacked resident-specific targeted behaviors and specific side effect monitoring with the use of high-alert medications. The Physician Orders directed staff to administer the following : Zolpidem 5 milligrams (mg) one time a day related to a sleep disorder 02/03/23 Duloxetine 60 mg one time a day for major depressive disorder, single episode, severe with psychotic features 12/13/23 Trazodone 100 mg one time a day related to a sleep disorder 02/03/23 Buspirone 5 mg two times a day for anxiety disorder 12/27/21 Depakote delayed release 250 mg two times a day for depression 02/29/24 The Progress Note dated 04/06/24 at 08:53 PM, documented R13 stood in the doorway of her room where another resident hollered and R13 stated to the other resident Oh shut up. On 04/24/24 the Pharmacy Recommendation requested the physician to consider a GDR for duloxetine, trazodone, buspirone, and a trial discontinuation of zolpidem. The physician declined the GDR and trial discontinuation of zolpidem. The physician declined the GDRs based on the listed reason that it would impair the resident's function or cause psychiatric instability by exacerbating an underlying condition or disorder. The denials did not record a patient-specific rationale describing why or how a GDR was likely to impair function or cause psychiatric instability in R13. The MRR reviewed from 05/31/23 through 05/31/24 lacked evidence the CP identified and reported the lack of side effects and targeted behaviors monitoring for R13's psychotropic medications. On 06/04/24 at 02:46 PM, LN H reported physician orders in the EMR alerted staff to the type of medications the residents received with black box warnings. The EMR was specific with diagnoses but lacked specific targeted behaviors the resident exhibited. LN H reported the certified nurse aides (CNA) would alert the nurses of behaviors and the nurse would document them in the progress notes. On 06/04/24 at 03:20 PM, Administrative Nurse D verified the lack of specific target behaviors and symptom monitoring for adverse side effects, as well as the lack of risk versus benefit statements by the physician. The facility's Consultant Pharmacist Services Provider Requirements, dated 06/05/24, documented the consultant pharmacist provides pharmaceutical care services, including but not limited to reviewing the medication regimen (drug regimen review) of each elder in the healthcare center at least monthly incorporating federally mandated standards of care in addition to other applicable professional standards, and documenting the review and findings in the resident's clinical record. Communicating potential or actual problems detected related to medication therapy orders to the responsible physician and the Director of Nursing. The facility failed to ensure the CP identified and reported the inadequate monitoring and/or rationale for the continued use of psychotropic medications for R13. This placed R13 at risk of unnecessary psychotropic medications and related side effects. - R22's Electronic Medical Record (EMR) documented diagnoses of hypertension (elevated blood pressure), mild cognitive impairment, muscle weakness, chronic pain, and dementia (progressive mental disorder characterized by failing memory, and confusion) with psychotic (any major mental disorder characterized by gross impairment in reality perception) disturbance. R22's Quarterly Minimum Data Set (MDS), dated [DATE], documented R22 had intact cognition. R22 had no delirium (sudden severe confusion, disorientation, and restlessness), but did have delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue) and verbal behaviors directed toward others which occurred daily, and other behavioral symptoms not directed at others occurred four to six days of the observation period. R22 required set up or clean up assistance with functional abilities and mobility; the resident was always continent of urine and bowel. The MDS further documented R22 received non-medication interventions for pain and received a diuretic ( medication used to promote the formation and excretion of urine). R22's Care Plan dated 04/24/24, documented high-alert medications of valproate and olanzapine. The Physician Orders directed staff to administer olanzapine (an antipsychotic) 2.5 milligrams (mg) two times a day related to dementia with psychotic disturbance. The Consultant Pharmacist Evaluation of Drug Regimen dated 04/30/24, noted an increase in olanzapine. The CP's evaluation lacked information regarding the unapproved indication for the use of the antipsychotic. On 06/04/24 at 12:45 PM, Certified Nurse Aide (CNA) O stated that R22 continued to have behaviors following readmission to the facility. CNA O stated R22 could be unpredictable, but CNA O would try to talk to the resident or allow the resident time to calm down before approaching. On 06/04/24 at 02:46 PM, LN H reported physician orders on the EMR alerted staff to the type of medications the residents received with black box warnings. The EMR was specific with diagnoses but lacked specific targeted behaviors the resident exhibited. LN H reported the certified nurse aides (CNA) would alert the nurses of behaviors and the nurse would document them in the progress notes. On 06/04/24 at 03:20 PM, Administrative Nurse D verified she was aware of the unapproved indication related to the use of R22's antipsychotic medication, and said the consultant pharmacist had not included that in the monthly reviews. The facility's Consultant Pharmacist Services Provider Requirements, dated 06/05/24, documented the consultant pharmacist provides pharmaceutical care services, including but not limited to reviewing the medication regimen (drug regimen review) of each elder in the healthcare center at least monthly incorporating federally mandated standards of care in addition to other applicable professional standards, and documenting the review and findings in the elder's clinical record. Communicating potential or actual problems detected related to medication therapy orders to the responsible physician and the Director of Nursing. The facility failed to ensure the CP identified and reported the lack of an approved indication for the use of an antipsychotic for R22. This placed R22 at risk of unnecessary psychotropic medications and related side effects. 32358 - R21's Electronic Medical Record (EMR) documented that R21 had diagnoses of major depressive disorder (a major mood disorder that causes persistent feelings of sadness), Parkinson ' s disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness), and insomnia (inability to sleep). R21's Quarterly Minimum Data Set (MDS), dated [DATE], documented R21 had a Brief Interview of Mental Status (BIMS) score of 11, which indicated moderate cognitive impairment. The MDS documented R21 received an antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) antidepressant (a class of medications used to treat mood disorders) and antianxiety medications during the observation period. R21's Care Plan, revised 04/22/24, documented R21 received Pristiq (a medication used to treat depression and instructed staff to monitor R21 for specific side effects. The care plan documented R21 received Seroquel (antipsychotic) for bipolar disorder (a major mental illness that causes people to have episodes of severe high and low moods) and instructed staff to monitor R21 for specific side effects. The Physician Order, dated 10/11/23, instructed staff to administer R21 Seroquel extended-release (XR) tablet one time a day for behaviors. The Consultant Pharmacist's (CP) monthly medication regimen reviews (MRR) revealed the following: On 03/24/24 the CP recommended a GDR for Pristiq 50 milligrams (mg), Abilify 2 mg, and Seroquel 100 mg, daily. The physician declined the recommendations because the GDR was clinically contraindicated as indicated by the resident's target symptoms returned or worsened after the most recent GDR attempt within the facility and a GDR attempt at this time would likely impair the individual's function or cause psychiatric insatiability by exacerbating an underlying medical condition or psychiatric disorder. A review of the MRR revealed the CP did not identify or report the inadequate monitoring for targeted behaviors for R21's psychotropic medications and or the unapproved indication for Seroquel. A review of R21's clinical record lacked evidence of targeted behavior monitoring related to R21's psychotropic medications. On 06/03/24 at 11:55 AM, observation revealed R21 sat in a wheelchair at the dining room table and visited politely with another resident at her table. On 06/04/24 at 03:20 PM, Administrative Nurse D verified the CP had not alerted the facility of the unapproved indication for Seroquel and/or specific targeted behaviors they should be monitoring for or the symptoms of adverse reactions for R21's psychotropic medications. The facility's CP Services Provider Requirements Policy, revised 06/05/24, documented the CP would communicate potential or actual problems detected related to medication therapy orders to the responsible physician and the director of nursing. The CP failed to identify and report the unapproved indication for use for R21's Seroquel and inadequate monitoring of targeted behaviors for R21's psychotropic medications. This placed the resident at risk for unnecessary psychotropic medications and related side effects.

The facility had a census of 38 residents. Based on the interview and record review, the facility failed to offer pneumococcal (type of bacterial infection) immunizations for four of the six residents sampled for immunizations: Residents (R) 13, R25, R12, and R24. This placed the residents at risk for complications related to pneumococcal pneumonia. Findings included: - R13's Electronic Health Record (EHR) documentation indicated R13 received one Pneumovax dose on 04/07/16. The facility lacked documentation R13 was offered or refused any further pneumococcal vaccinations. R13's Physician Order dated 03/26/21, directed staff to administer the pneumococcal vaccine per facility policy. R25's EHR documentation indicated R25 received one Pneumovax dose on 12/05/19. The facility lacked documentation R25 was offered or refused any further pneumococcal vaccinations. R25's EHR documented an admitting diagnosis of pneumonia and a Physician Order dated 02/23/22 that directed staff to administer the pneumococcal vaccine per facility policy. R12's EHR documentation indicated R12 received one Pneumovax dose on 09/24/19. The facility lacked documentation R12 was offered or refused any further pneumococcal vaccinations. R12's Physician Order dated 03/23/23, directed staff to administer the pneumococcal vaccine per facility policy. R24's EHR documentation indicated R24 received one Pneumovax dose on 11/19/15. The facility lacked documentation that R24 was offered or refused any further pneumococcal vaccinations. R24's Physician Order dated 08/10/21 directed staff to administer the pneumococcal vaccine per facility policy. During an interview on 06/04/24 at 01:14 PM, Administrative Nurse E verified four of the six reviewed residents had not received a second pneumonia immunization since admission to the facility and the facility had not screened the residents for eligibility for a second pnuemovax. During an interview on 06/04/24 at 03:00 PM, Administrative Nurse D stated the facility had not made a list of residents eligible to receive a second pneumococcal vaccination. She verified the residents reviewed were older than 65. She stated all the information was in their EHR. She stated the pharmacy would perform the vaccinations after they (the pharmacy) reviewed for eligible residents. During an interview on 06/05/24 at 09:42 AM, Administrative Nurse D verified the facility should have offered residents the physician-ordered pneumococcal vaccination according to facility policy. The facility's Influenza and Pneumonia Immunization Policy dated 01/04/24, stated all current and newly admitted residents would be offered the Pneumovax injection as desired by the resident and approved by the primary care physician after investigation related to current immunization status. The Centers for Disease Control and Prevention (CDC) recommends two pneumococcal vaccines for all adults [AGE] years or older. PCV13 followed by a dose of PPSV23 at least one year later. If PPSV23 is done- a dose of PCV13 will be administered at least one year later. Each resident's immunization status would be determined, if possible, prior to vaccination and documented in the resident's clinical record. Prior to offering the vaccination each resident or their representative would receive current education regarding the benefits and potential side effects of the immunization. Pneumococcal vaccines are offered and administered by the county Health Department or the resident's physician. The clinical record would include the education provided and whether the vaccine was received or refused. The facility failed to offer R13, R25, R12, and R24 the physician ordered pneumococcal immunization. This placed the residents at risk for complications related to pneumococcal pneumonia.

The facility had a census of 38 residents. The sample included 12 residents with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 6, R13, R22, and R21 had approved indications and adequate monitoring for the use of psychotropic (alters mood or thought) medications. This placed the residents at risk of receiving unnecessary psychotropic medications. Findings included: - R6's Electronic Medical Record (EMR), documented diagnoses of altered mental status, slurred speech, kidney failure, anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). R6's Quarterly Minimum Data Set (MDS), dated [DATE], documented R6 had severe cognitive impairment with no signs or symptoms of delirium (sudden severe confusion, disorientation, and restlessness) or psychosis (any major mental disorder characterized by gross impairment in reality perception). R6 had behavioral symptoms not directed toward others, which occurred one to three days during the observation period. R6 was dependent on staff for functional abilities and mobility. The MDS further documented R6 received an antipsychotic (class of medications used to treat major mental conditions that cause a break from reality), antianxiety (class of medications that calm and relax people), antidepressant (class of medications used to treat mood disorders), and opioid (a medication used to treat pain) medications. A GDR was documented as clinically contraindicated on 03/22/24. R6's Care Plan, dated 05/28/24, documented R6 received a high alert medication of divalproex (a mood stabilizer), Lexapro (an antidepressant), lorazepam (an antianxiety), Norco (medication used to treat pain), and olanzapine (an antipsychotic); staff was to monitor for adverse side effects. The care plan lacked resident-specific targeted behaviors and monitoring related side effects from the use of high-alert medications. The Physician Orders directed staff to administer the following: Divalproex Sodium Delayed-Release 250 milligrams (mg) tablet daily for disorientation 04/06/23 Lexapro 10 mg daily for anxiety disorder 03/05/22 Zyprexa 2.5 mg daily for altered mental status and anxiety disorder 04/06/23 Lorazepam 0.5 mg two times a day for anxiety disorder 03/04/22 The CP monthly medication regimen reviews (MRR) documented a recommendation for a GDR for Lexapro and Zyprexa on 02/28/24 and a GDR recommendation for lorazepam on 03/31/24. The Progress Note on 03/10/24 at 10:41 AM, documented R6 continued to holler out since waking in the morning. Scheduled medications were administered as ordered and R6 continued to holler out for mom at times, otherwise just hollered. The resident denied pain and when asked if he needed anything he would say no. The Progress Note on 03/22/24 at 03:05 PM, documented R6's physician declined the GDR for Lexapro and Zyprexa. The MRR reviewed from 05/31/23 through 05/31/24 lacked evidence the CP identified and reported the lack of side effects and targeted behaviors monitoring and lacked evidence the CP reported the unapproved indication and associated risks for Zyprexa. A review of R6's clinical record lacked evidence the physician documented the specific benefits versus the risks for R6's continuation of the antipsychotic medication. On 06/03/24 at 10:29 AM, observation revealed R6 sat in a Broda chair ( special wheelchair with the ability to tilt and recline) dressed for the day. R6 had ongoing verbalizations and hollering that were not words. Licensed Nurse (LN) G administered the ordered medications without difficulties. LN G inquired if R6 wanted breakfast and the resident declined but accepted the offer of a glass of chocolate milk. On 06/04/24 at 02:46 PM, LN H reported physician orders in the EMR alerted staff to the type of medications the residents received with black box warnings. The EMR was specific with diagnoses but lacked specific targeted behaviors the resident exhibited. LN H reported the certified nurse aides (CNA) would alert the nurse of behaviors and the nurse would document in the progress notes. On 06/04/24 at 03:20 PM, Administrative Nurse D verified the use of psychotropic medication lacked specific targeted behaviors, symptom monitoring for adverse side effects, and lack of risk versus benefit statement by the physician. Administrative Nurse D verified she was aware of the unapproved indication related to the use of R6's antipsychotic medication. The facility's Psychotropic Medication Use policy, dated 06/03/24, documented that the need for psychotropic medication will be monitored, as well as when the resident has received optional benefits from the medication and when the medication dose can be lowered or discontinued. The physician's order for a psychotropic drug will include both a qualifying diagnosis for the drug and a list of specific target behaviors that the staff will monitor during the drug administration. The continued use in accordance with current standards of practice and the physician has documented the clinical rationale for why any attempted dose reduction would be likely to impair the resident's function or cause psychiatric disorder or instability by exacerbating an underlying medical or psychiatric disorder: or the resident's target symptoms returned or worsened after the most recent GDR attempted dose reduction at that time would be likely to impair the resident. Licensed nurses will be aware of the potential side effects of psychotropic medications and report any side effects to the resident's attending physician. The facility failed to ensure R6 had an approved indication for the use of an antipsychotic as well as adequate monitoring and/or rationale for the continued use of psychotropic medications for R6. This placed R6 at risk of unnecessary psychotropic medications and related side effects. - R13's Electronic Medical Record (EMR) documented diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), pain, sleep disorder, heart failure, weakness, and major depressive disorder (major mood disorder which causes persistent feelings of sadness)with psychotic (any major mental disorder characterized by gross impairment in reality perception) features. R13's Quarterly Minimum Data Set (MDS), dated [DATE], documented R13 had intact cognition. R13 had no signs or symptoms of delirium (sudden severe confusion, disorientation, and restlessness) or psychosis (any major mental disorder characterized by gross impairment in reality perception), and exhibited no behaviors. R13 required set up or clean up assistance with functional abilities and supervision or touch assistance with mobility. The MDS further documented the use of an antianxiety (a class of medications that calm and relax people), an antidepressant (a class of medications used to treat mood disorders), a hypnotic (a class of medications used to induce sleep), diuretic (medication to promote the formation and excretion of urine), and opioid (a medication used to treat pain) medication. R13's Care Plan, dated 05/21/24, documented the use of high-alert medications including zolpidem (a hypnotic), duloxetine (an antidepressant), furosemide (a diuretic), Norco (medication to treat pain), trazodone (an antidepressant); staff were to monitor for adverse side effects. The care plan lacked resident-specific targeted behaviors and specific side effect monitoring with the use of high-alert medications. The Physician Orders directed staff to administer the following : Zolpidem 5 milligrams (mg) one time a day related to a sleep disorder 02/03/23 Duloxetine 60 mg one time a day for major depressive disorder, single episode, severe with psychotic features 12/13/23 Trazodone 100 mg one time a day related to a sleep disorder 02/03/23 Buspirone 5 mg two times a day for anxiety disorder 12/27/21 Depakote delayed release 250 mg two times a day for depression 02/29/24 The Progress Note dated 04/06/24 at 08:53 PM, documented R13 stood in the doorway of her room where another resident hollered and R13 stated to the other resident Oh shut up. On 04/24/24 the Pharmacy Recommendation requested the physician to consider a GDR for duloxetine, trazodone, buspirone, and a trial discontinuation of zolpidem. The physician declined the GDR and trial discontinuation of zolpidem. The physician declined the GDRs based on the listed reason that it would impair the resident's function or cause psychiatric instability by exacerbating an underlying condition or disorder. The denials did not record a patient-specific rationale describing why or how a GDR was likely to impair function or cause psychiatric instability in R13. The MRR reviewed from 05/31/23 through 05/31/24 lacked evidence the CP identified and reported the lack of side effects and targeted behaviors monitoring for R13's psychotropic medications. On 06/04/24 at 02:46 PM, LN H reported physician orders in the EMR alerted staff to the type of medications the residents received with black box warnings. The EMR was specific with diagnoses but lacked specific targeted behaviors the resident exhibited. LN H reported the certified nurse aides (CNA) would alert the nurses of behaviors and the nurse would document them in the progress notes. On 06/04/24 at 03:20 PM, Administrative Nurse D verified the lack of specific target behaviors and symptom monitoring for adverse side effects, as well as the lack of risk versus benefit statements by the physician. The facility's Psychotropic Medication Use policy, dated 06/03/24, documented that the need for psychotropic medication will be monitored, as well as when the resident has received optional benefits from the medication and when the medication dose can be lowered or discontinued. The physician's order for a psychotropic drug will include both a qualifying diagnosis for the drug and a list of specific target behaviors that the staff will monitor during the drug administration. The continued use in accordance with current standards of practice and the physician has documented the clinical rationale for why any attempted dose reduction would be likely to impair the resident's function or cause psychiatric disorder or instability by exacerbating an underlying medical or psychiatric disorder: or the resident's target symptoms returned or worsened after the most recent GDR attempted dose reduction at that time would be likely to impair the resident. Licensed nurses will be aware of the potential side effects of psychotropic medications and report any side effects to the resident's attending physician. The facility failed to ensure tR13 had adequate monitoring and/or rationale for the continued use of psychotropic medications. This placed R13 at risk of unnecessary psychotropic medications and related side effects. - R22's Electronic Medical Record (EMR) documented diagnoses of hypertension (elevated blood pressure), mild cognitive impairment, muscle weakness, chronic pain, and dementia (progressive mental disorder characterized by failing memory, and confusion) with psychotic (any major mental disorder characterized by gross impairment in reality perception) disturbance. R22's Quarterly Minimum Data Set (MDS), dated [DATE], documented R22 had intact cognition. R22 had no delirium (sudden severe confusion, disorientation, and restlessness), but did have delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue) and verbal behaviors directed toward others which occurred daily, and other behavioral symptoms not directed at others occurred four to six days of the observation period. R22 required set up or clean up assistance with functional abilities and mobility; the resident was always continent of urine and bowel. The MDS further documented R22 received non-medication interventions for pain and received a diuretic ( medication used to promote the formation and excretion of urine). R22's Care Plan dated 04/24/24, documented high-alert medications of valproate and olanzapine. The Physician Orders directed staff to administer olanzapine (an antipsychotic) 2.5 milligrams (mg) two times a day related to dementia with psychotic disturbance. The Consultant Pharmacist Evaluation of Drug Regimen dated 04/30/24, noted an increase in olanzapine. The CP's evaluation lacked information regarding the unapproved indication for the use of the antipsychotic. On 06/04/24 at 12:45 PM, Certified Nurse Aide (CNA) O stated that R22 continued to have behaviors following readmission to the facility. CNA O stated R22 could be unpredictable, but CNA O would try to talk to the resident or allow the resident time to calm down before approaching. On 06/04/24 at 02:46 PM, LN H reported physician orders on the EMR alerted staff to the type of medications the residents received with black box warnings. The EMR was specific with diagnoses but lacked specific targeted behaviors the resident exhibited. LN H reported the certified nurse aides (CNA) would alert the nurses of behaviors and the nurse would document them in the progress notes. On 06/04/24 at 03:20 PM, Administrative Nurse D verified she was aware of the unapproved indication related to the use of R22's antipsychotic medication, and said the consultant pharmacist had not included that in the monthly reviews. The facility's Psychotropic Medication Use policy, dated 06/03/24, documented that the need for psychotropic medication will be monitored, as well as when the resident has received optional benefits from the medication and when the medication dose can be lowered or discontinued. The physician's order for a psychotropic drug will include both a qualifying diagnosis for the drug and a list of specific target behaviors that the staff will monitor during the drug administration. The continued use in accordance with current standards of practice and the physician has documented the clinical rationale for why any attempted dose reduction would be likely to impair the resident's function or cause psychiatric disorder or instability by exacerbating an underlying medical or psychiatric disorder: or the resident's target symptoms returned or worsened after the most recent GDR attempted dose reduction at that time would be likely to impair the resident. Licensed nurses will be aware of the potential side effects of psychotropic medications and report any side effects to the resident's attending physician. The facility failed to ensure R22 had an approved indication for the use of an antipsychotic. This placed R22 at risk of unnecessary psychotropic medications and related side effects. 32358 - R21's Electronic Medical Record (EMR) documented that R21 had diagnoses of major depressive disorder (a major mood disorder that causes persistent feelings of sadness), Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness), and insomnia (inability to sleep). R21's Quarterly Minimum Data Set (MDS), dated [DATE], documented R21 had a Brief Interview of Mental Status (BIMS) score of 11, which indicated moderate cognitive impairment. The MDS documented that R21 received an antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) antidepressant (a class of medications used to treat mood disorders) and antianxiety medications during the observation period. R21's Care Plan, revised 04/22/24, documented R21 received Pristiq (a medication used to treat depression and instructed staff to monitor R21 for specific side effects. The care plan documented R21 received Seroquel (antipsychotic) for bipolar disorder (a major mental illness that causes people to have episodes of severe high and low moods) and instructed staff to monitor R21 for specific side effects. The Physician Order, dated 10/11/23, instructed staff to administer R21 Seroquel extended-release (XR) tablet one time a day for behaviors. The Consultant Pharmacist's (CP) monthly medication regimen reviews (MRR) revealed the following: On 03/24/24 the CP recommended a GDR for Pristiq 50 milligrams (mg), Abilify 2 mg, and Seroquel 100 mg, daily. The physician declined the recommendations because the GDR was clinically contraindicated as indicated by the resident's target symptoms returned or worsened after the most recent GDR attempt within the facility and a GDR attempt at this time would likely impair the individual's function or cause psychiatric insatiability by exacerbating an underlying medical condition or psychiatric disorder. A review of the MRR revealed the CP did not identify or report the inadequate monitoring for targeted behaviors for R21's psychotropic medications and or the unapproved indication for Seroquel. A review of R21's clinical record lacked evidence of targeted behavior monitoring related to R21's psychotropic medications. On 06/03/24 at 11:55 AM, observation revealed R21 sat in a wheelchair at the dining room table and visited politely with another resident at her table. On 06/04/24 at 03:20 PM, Administrative Nurse D verified the CP had not alerted the facility of the unapproved indication for Seroquel and/or specific targeted behaviors they should be monitoring for or the symptoms of adverse reactions for R21's psychotropic medications. The facility's Psychotropic Medication Use policy, dated 06/03/24, documented that the need for psychotropic medication will be monitored, as well as when the resident has received optional benefits from the medication and when the medication dose can be lowered or discontinued. The physician's order for a psychotropic drug will include both a qualifying diagnosis for the drug and a list of specific target behaviors that the staff will monitor during the drug administration. The continued use in accordance with current standards of practice and the physician has documented the clinical rationale for why any attempted dose reduction would be likely to impair the resident's function or cause psychiatric disorder or instability by exacerbating an underlying medical or psychiatric disorder: or the resident's target symptoms returned or worsened after the most recent GDR attempted dose reduction at that time would be likely to impair the resident. Licensed nurses will be aware of the potential side effects of psychotropic medications and report any side effects to the resident's attending physician. The facility failed to ensure an approved indication for use for R21's Seroquel and adequate monitoring of targeted behaviors for R21's psychotropic medications. This placed the resident at risk for unnecessary psychotropic medications and related side effects.

The facility had a census of 38 residents. The sample included 12 residents. Based on observation, record review, and interview the facility failed to assess Resident (R) 22 for trauma-informed care needs to eliminate or mitigate triggers that may cause re-traumatization of the resident. This placed R22 at risk for impaired quality of life. Findings included: - R22's Electronic Medical Record (EMR) documented diagnoses of hypertension (elevated blood pressure), mild cognitive impairment, muscle weakness, chronic pain, and dementia (progressive mental disorder characterized by failing memory, and confusion) with psychotic (any major mental disorder characterized by a gross impairment in reality perception) disturbance. R22's Quarterly Minimum Data Set (MDS), dated [DATE], documented R22 had intact cognition. R22 had no delirium (sudden severe confusion, disorientation, and restlessness), but did have delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue) and verbal behaviors directed toward others which occurred daily, and other behavioral symptoms not directed at others occurred four to six days of the observation period. R22 required set up or clean up assistance with functional abilities and mobility; the resident was always continent of urine and bowel. The MDS further documented R22 received non-medication interventions for pain and received a diuretic ( medication used to promote the formation and excretion of urine). R22's Care Plan dated 04/24/24, documented the resident received a high-alert medication of valproate (antiepileptic drug), and olanzapine (antipsychotic). The Progress Note dated 04/24/24 at 09:08 AM, documented R22 left the facility and the receiving behavioral health unit was called with a report. The Progress Note dated 04/26/24 at 03:25 PM, documented R22 returned to the facility from the behavioral health unit. The Progress Note dated 05/16/24 at 03:09 PM, documented that staff discussed R22's conflict and name-calling of another resident in the dining room. R22's EMR lacked evidence the facility assessed R22 for a history of trauma to identify potential mental health needs. On 06/03/24 at 11:59 AM R22 finished lunch and independently returned to her room using a wheeled walker. On 06/04/24 at 12:45 PM, Certified Nurse Aide (CNA) O stated R22 continued to have behaviors following readmission to the facility. CNA O stated R22 could be unpredictable, but CNA O would try to talk to the resident or allow the resident time to calm down before approaching. On 06/05/24 at 11:15 AM, Administrative Nurse D stated she had not done a trauma assessment and said the assessment would have been done by social services. On 06/05/24 at 11:27 AM, Social Service X reported she had not completed a trauma-informed care assessment for R22, although she does ask residents about past traumas. Social Service X stated trauma-informed care should be included in the care plan, which would be helpful to staff to manage behavioral symptoms. The facility's Trauma Informed Care policy, dated 06/05/24, documented that the facility ensures that residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of proactive and accounting for each resident's experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident. Within forty-eight (48) hours of admission an initial screening for a history of trauma and determine if a resident has trauma-related symptoms. The facility failed to assess R22 for trauma-informed care needs to eliminate or mitigate triggers that may cause re-traumatization of the resident. This placed the resident at risk for unmet care emotional and psychosocial needs.

The facility had a census of 38 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to provide Resident (R) 17 or his representative with written information regarding the facility bed hold policy when R17 transferred to the hospital. This placed the resident at risk of not being permitted to return and resume residence in the nursing facility. Findings included: - R17's Electronic Medical Record (EMR) documented R17 had diagnoses of congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid) and acute (condition characterized by a relatively sudden onset of symptoms that are usually severe) upper respiratory infection (infections of parts of the body involved in breathing, such as the sinuses, throat, airways or lungs). R17's Quarterly Minimum Data Set (MDS), dated [DATE], documented R17 had a Brief Interview of Mental Status (BIMS) score of zero, which indicated severely impaired cognition. The MDS documented the resident was dependent on staff for most activities of daily living (ADL). R17's Care Plan, revised 04/22/24, documented that staff put oxygen on R17 at night at two liters a minute via nasal cannula because R17 had trouble breathing when he laid flat. The Nurse's Note, dated 12/30/23 at 10:37 PM, documented R17 admitted to the hospital. A review of R17's clinical record lacked evidence the facility provided the resident or representative with the bed hold policy upon transfer to the hospital. On 06/03/24 at 11:56 AM, observation revealed R17 sat in a wheelchair at the west kitchenette counter, with no signs or symptoms of respiratory distress. On 06/05/24 at 08:07 AM, Administrative Nurse D stated she was responsible for providing the bed hold policy to residents when they transferred to the hospital. Administrative Nurse D verified the lack of evidence that R17 or his representative received the bed hold policy when R17 transferred to the hospital on 12/30/23. The facility's Bed Hold Policy, revised 01/03/24, documented that before this facility transfers a resident to a hospital or the resident goes on therapeutic leave, the facility would provide written information to the resident and or resident representative that specifies the duration of the state bed-hold policy during which the resident is permitted to return and resume residency in the facility; the reserve bed payment policy in the state plan; the facility polices regarding bed-hold period, which is consistent with the law permitting the resident to return. The facility failed to provide R17 or his representative with the bed hold policy when R17 was transferred to the hospital. This placed the residents at risk of not being permitted to return and resume residence in the nursing facility.

The facility had a census of 38 residents. The sample included 12 residents with one reviewed for discharge. Based on record review, and interview, the facility failed to complete a discharge summary for Resident (R) 39, which included a recapitulation (a concise summary of the resident's stay and course of treatment in the facility) summary of the resident's stay in the facility. This placed the resident at risk of unidentified and unmet care needs. Findings included: - The Electronic Medical Record (EMR), documented R39 admitted to the facility on [DATE] and documented diagnoses of idiopathic peripheral neuropathy (no identifiable cause for weakness, numbness, and pain from nerve damage, usually in the hands and feet), enterocolitis (disease of the digestive tract) due to clostridium (C-diff: contagious bacteria characterized by foul-smelling frequent loose bowel movements), edema (swelling), vomiting, calculus (area of thickened and sometimes hardened skin that forms as a response to repeated friction, pressure, or other irritation) of kidney, anemia (inadequate number of healthy red blood cells to carry adequate oxygen to body tissues), urinary tract infection, abdominal pain, and pain in the left leg. R39's Care Plan, dated 02/05/24, documented R39 wanted to return to live in the community. The Physician Order, dated 03/18/24, documented a phone order to discharge R39 back to her apartment with the same medication orders. The Progress Note dated 03/18/24 at 03:29 PM, documented R39 informed the nurse a family member was picking her up to take R39 to her apartment. The family member and R39 left the facility at 01:20 PM with medications and instructions. The Discharge Summary Course in Nursing Home documented R39 went home to her apartment. R39's EMR lacked a recapitulation of the resident's stay. On 06/05/24 at 08:00 AM, Administrative Nurse D verified the discharge summary lacked a recapitulation of R39's stay. The facility's Admission, Transfer and Discharge policy, dated 01/03/24, documented the clinical record documentation including the provision of and response to medical treatment and care, and changes in the resident's condition by the resident's chosen attending physician. The resident's functional status at the time of admission and at the time of discharge as well as progress notes that are reported at the time of observation and that describe significant changes in the resident's condition. The facility failed to develop a recapitulation of the resident's stay for R39. This placed the resident at risk for unidentified and unmet care needs.

The facility had a census of 37 residents. The sample included 12 residents with no COVID-19 ((an acute respiratory illness capable of producing severe respiratory complications including death) positive residents identified. Based on observation, record review and interview the facility failed to identify high community transmission rates for COVID-19 and failed to ensure facility staff wore masks to protect COVID-19 transmission for the 37 residents residing in the facility. Findings included: - On 01/24/23 at 08:30AM, upon entrance into the facility observation revealed facility staff did not wear masks to prevent COVID-19 transmission in the resident care and resident common areas. On 01/24/23 at 08:35AM, Administrative Nurse D verified that facility staff were not wearing masks. On 01/24/23 at 09:45AM, Administrative Nurse D stated the facility checks every Thursday regarding the transmission rate for COVID-19 and then makes the decision if facial coverings/masks were required. The Centers for Disease Control and Prevention (CDC) COVID-19 Data Tracker (https://covid.cdc.gov/covid-data-tracker) documented Washington county transmission rate on 01/24/23 as High. Further review of the time lapse shows the Washington county community transmission level was high on 01/19/23 (the previous Thursday). The website states community levels are updated weekly on Thursdays however transmission levels used by health care facilities are updates daily. The Centers for Medicare and Medicaid Services (CMS) memo QSO-20-39-NH revised on 09/23/22 directs If the nursing home ' s county COVID-19 community transmission is high, everyone in a healthcare setting should wear face coverings or masks. The undated facility policy, COVID-19 Community Transmission, stated when levels are high, source control is recommended for everyone in a healthcare setting, When community levels are high masks should be worn in the healthcare setting. The facility staff failed to wear masks to prevent COVID-19 transmission and infection, placing the 37 residents residing in the facility at risk for COVID-19 infection.

The facility had a census of 37 residents. The sample included 12 residents. Based on observation, record review, and interview the facility failed to distribute and serve food in accordance with professional standards for food service safety for the 37 residents who resided in the facility and received their food from the facility kitchen, when the facility failed to ensure clean and sanitary food prep and storage areas, and failed to wear hairnets in the two kitchenettes, while dishing up food for the residents meals. This placed the 37 residents at risk for foodborne illness. Findings included: - 01/24/23 at 9:00 AM observation revealed the following in the kitchen: The white refrigerator located next to the entrance door of the kitchen had dried red liquids stain approximately two inches (in) wide underneath the two bottom drawers at the bottom of the fridge and the door shelves had numerous different size brownish black dried liquid stains. The freezer above the white refrigerator had numerous specks of different size food particles on all shelves. The silver refrigerator located to the left of the ovens had numerous size specs of food items on each shelf. The bottom freezer drawer had unpackaged individual French fries and other specs of food. On 01/24/23 at 11:48 AM, observation revealed Dietary Staff (DS) DD dishing up resident meals in the west kitchenette without a hair net. DS DD verified she did not have a hair net on and stated she thought if she had her hair up pulled up she did not need a hairnet. On 01/24/23 at 12:10 PM, observation revealed DS EE in the east kitchenette dishing up residents noon meals without a hair net. DS EE had hair pulled back in a pony tail behind her head. DS CC verified she did not have a hair net on and stated the she did not have to wear one if she had her hair up. On 01/25/23 at 07:33 AM, observation revealed DS CC preparing food in north kitchenette with approximately one in. of her hair below the hair net by her ears. On 01/25/23 at 07:34 AM, observation revealed DS EE in the east kitchenette dishing up food for the residents food items, without a hairnet. On 01/30/23 at 08:40 AM, observation revealed DS in west kitchenette with hair braided in one pony tail down the back of her head, without a hair net, dishing up resident's food items for breakfast meal. On 01/25/23 at 08:30 AM, DS BB stated dietary staff did not have to wear a hairnet in the kitchenette when serving residents meals only when preparing them. 01/26/23 08:38 AM, Consultant Staff (CS) GG stated she would expect staff to wear a hair net when physically cooking resident meals but if they are in the kitchenette serving food to residents, they should have their clean hair and should pull it back. On 01/25/23 at 10:30 AM, observation revealed the following findings in the kitchen: The silver bottom freezer drawer had a open bag of chicken patties and sweet potato fries, verified by DS FF, who stated they should not be open and discarded the items. DS BBB walked into the kitchen prep area without a hair net, DS FF verified the finding and told her that she needed to wear a hair net in the kitchen. The oven hood was greasy inside and the outside had numerous different size streaks of brown greasy substance all across the front of the oven hood. The mopboard and wall located across from three sink by dishwasher had numerous areas of different size reddish brown substance. approximately 3-4 ft from the dishwasher entrance door. Five ceiling vents had brownish gray substance approximately 2-4 inches around them. The pipes underneath the dishwasher had brownish gray substance running from the garbage disposal to the dishwasher. On 1/25/23 at 11:28 AM, DS BB verified the above findings in the kitchen and stated the company who cleaned the oven hood was last here in October and staff clean the oven hood monthly but had not cleaned this month. DS BB stated staff have a daily cleaning schedule. On 1/30/23 at 1:30 PM, DS BB stated the gray substance around the ceiling vents were dust particles and staff clean the areas when they clean the vents. The Kitchen Daily Cleaning Schedule,undated, documented tasks for the dietary staff to conduct daily. The facility's Food Preparation and Handling Policy, undated, documented all food items, while being prepared, will be protected against contamination from dust, flies, rodents, and other vermin, unclean utensils and work surfaces, unnecessary handling , coughs and sneezes, flood in drainage and overhead leakage, and any other possible source of contamination . The kitchen and equipment would be kept clean, neat, orderly , and well maintained all food service staff would wear hairnets when cooking or preparing food. Staff do not need to wear hairnets when distributing foods to residents at the dining tables or when assisting residents to dine. All food handlers would ensure their hair was clean and long hair was tied back when handling food. The facility failed to store, prepare, and serve food in accordance with professional standards for food service safety for the 37 residents who resident in the facility and received their food from the facility kitchen. This placed the 37 residents at risk for foodborne illness.

The facility had a census of 37 residents. The sample included 12 residents. Based on observation, record review and interview the facility failed to exercise safe needle (sharp) practice after Resident (R) 3 received an intramuscular injection (an injection in a muscle). This placed R3 and others in the affected area at risk for accidental needle sticks. Findings included: - On 01/25/23 at 01:10PM, observation revealed Licensed Nurse (LN) G entering R3's room with a syringe. Further observation revealed R3 laying on her bed on her left side. LN G pulled back the resident's blanket on the bed and exposed her right hip area. LN G put on clean gloves and used an alcohol wipe and cleansed a small are on R3's right hip area. LN G injected Rocephin (an antibiotic) into R3's hip. LN G then covered R3 with the blanket and moved his hands all around the bed. On 01/25/23 at 01:10PM, LN G stated he was looking for the cap for the syringe, and stated he lost the cap, but he guessed the staff could get the cap when they got the resident back out of bed. On 01/25/23 at 01:15PM, observation revealed LN G ambulated out of R3's room down hallway with the uncapped (non -safety) syringe with an exposed needle, out to the medication cart by the nurses desk then placed the syringe in the sharps container. On 01/25/23 at 01:20PM, Administrative Nurse D stated her expectation when a staff nurse administers an injection is the sharps container should be brought with the nurse to discard the syringe. Administrative Nurse D also stated the cap of the syringe should not have been left in R3's bed. The facility's Administering Intramuscular Medications, policy dated 01/13/23, stated the facility will ensure that each elder receives proper and appropriate treatment and care during an injection. All syringes are to be discarded in a sharps container. The facility's Accident Prevention, policy dated 12/29/22, stated all staff will ensure that each elder's environment remains free from accident hazards. The facility failed to provide a safe environment for R3, placing her at risk for injury as well as others in the affected area.

The facility had a census of 37 residents. The sample included 12 residents. Based on observation, record review and interview the facility failed to treat Resident (R) 3 with respect and dignity by not providing privacy during an intramuscular (IM-an injection in a muscle) injection. This placed the resident at risk for an undignified life. Findings included: - On 01/24/23 at 12:15PM, observation revealed R3 seated in a wheelchair at the dining table. Further observation revealed Licensed Nurse (LN) H pulled up R3's clothing to expose her left hip area. LN H administered an IM injection into R3's left hip at the dining table. Further observation revealed eight other residents seated in the dining room. On 01/25/23 at 01:20PM, Administrative Nurse D stated the expectation of the facility was to provide dignity for all residents. Administrative Nurse D stated R3 should have been taken to a private area for the nurse to administer the injection into R3's hip. The Dignity policy, dated 01/04/23, stated the facility will promote care for elders of the facility in a manner and in an environment that maintains and enhances each elder's dignity and respect in full recognition of the elder's individuality. The facility failed to provide dignity for R3, placing the resident at risk for an undignified life.

The facility had a census of 37 residents. The sample included 12 residents. Based on observation, record review and interview the facility failed to identify, assess and respond to alteration in Resident (R) 13's skin condition. This placed the resident at risk for delay in intervention to prevent further injury and unidentified care needs. Findings included: - R13's Electronic Medical Record (EMR) documented she had diagnoses of heart failure (a chronic condition in which the heart doesn't pump blood as well as it should) and dementia (a disorder affecting thinking and social systems that interferes with daily functioning). R13's Annual Minimal Data Set (MDS), dated [DATE], documented the resident had a Brief Interview of Mental Status (BIMS) score of six, which indicated severely impaired cognition. The MDS documented the resident required extensive assistance with bed mobility and transfers. The MDS further documented no skin issues. The Care Area Assessment (CAA) dated 12/06/22, documented R13 required extensive assistance and staff were to keep the resident safe during care. R13's Daily Task Care Plan, dated 12/19/22, instructed the staff to use a full body lift with assist of two staff for all transfers. R13's left arm did not move so staff were to be careful during cares. R13's Preferences Care Plan, dated 12/19/22, documented R13 always cold and prefered to dress warmly. R13's Skin Care Plan, dated 12/19/22, instructed staff to keep her arms inside the sling when transferring with a full body lift to keep R13 safe and injury free. The Weekly Skin assessment dated [DATE] documented a skin tear to R13's right elbow with a measurement of 0.1 centimeters (cm) by 2.0 cm. with no other skin issues. The Weekly Skin Assessmenst, dated 01/06/23, 01/13/23 and 01/20/23, documented no skin impairment. On 01/24/23 at 11:33AM, observation revealed R13 sat in a high backed wheelchair at the dining table. Further observation revealed R13 wore a short-sleeved shirt. She had numerous purple and dark brown areas clearly visible on both forearms. On 01/25/23 at 01:15PM, observation of Certified Nurse Aide (CNA) M and CNA N in R13's room revealed R13 seated in her high-backed wheelchair. CNA M placed a full lift sling behind the resident's back; CNA N attached the sling to the full body lift and raised the resident up out of her chair. Observation revealed R13's arms were outside of the sling as she was transferred to her bed. R13's arms were bumping against the full body lift during the transfer. On 01/25/23 at 01:20PM, CNA M stated R13 bumps her arms a lot when she was transferred with the lift. CNA M stated she was to report to the charge nurse any changes in a resident's skin. On 01/25/23 at 01:30PM, Licensed Nurse (LN) G stated weekly skin assessments were done for R13 then staff documented if there were any changes. LN G stated he was not aware R13 had any skin issues on her forearms. On 01/25/23 at 02:00PM, Administrative Nurse D stated the nurses complete weekly skin assessment for R13. Administrative Nurse D stated the last weekly skin assessment was completed for R13 on 01/20/23 and no skin impairment were documented. Administrative Nurse D stated her expectation of staff was to report any new skin issues and the nurse to assess and document those skin changes. On 01/25/23 at 03:15PM, Nurses Note documented R13 with bruising on both forearms. Documented the following measurements of skin impairment: Left upper extremity, a 3.3cm x 3.5cm purple bruise to the Left wrist. 1.0cm x 0.8cm brown bruise to the top of resident's left hand, 0.5cm x 1.0cm brown bruise to the top of her Left hand, a 1.0cm x 1.0cm scab to the top of her Left hand. 1.7cm x 1.7cm brown bruise to her Left inner forearm, 2.0cm x 1.2cm purple bruise to her outer forearm, 1.0cm x 1.3cm purple bruise to , 0.7cm, x 1.0cm purple bruise to the outer left forearm. 18.5cm x 14 cm light yellow area (bruise) to left forearm. 2.5cm x 3cm purple bruise to outer left forearm. 1.0cm x 1.0 4.0cm x 3.0cm purple bruise above the left elbow, 2.0cm x 2.0cm purple bruise to outer left forearm. Right upper extremity, 1.0cm x 1.5cm brown bruise to the back of her right arm. 1.0cm x 1.0cm brown bruise to the back of her right arm, 0.6cm x 0.7cm purple bruise to her outer right arm proximate to her elbow, 0.5cm x 1.0cm purple bruise to her outer right arm proximate to her right elbow. 14.5 x 10.5cm brown bruise to her inner right forearm. 1.8cm x 1.7cm purple bruise to her right upper forearm. 1.8cm x 2.7cm purple bruise to right upper arm, 3.0 x 2.0cm brown bruise to right underside forearm. 9.0cm x 10cm yellow/purple bruise to the top of resident's right hand. On 01/25/23 at 02:30PM, observation revealed LN G in R13's room measuring skin areas on her arms. LN G stated he was told to come and measure bruises on R13's arms. The Skin Integrity policy, dated 01/09/23, stated the nurse will perform a full-body assessment weekly to identify new skin issues and to update skin conditions. Observation of skin is to include erythema or any color changes to the skin. The nurse is to plan and implement preventative care to avoid complications and document. The facility failed to assess, identify, document and provide preventative measures for R13, to prevent bruises and changes in skin integrity. This placed the resident at risk for delay in intervention to prevent further injury and unidentified care needs.

The facility had a census of 48 residents. The sample included 17 residents, with 5 reviewed for accidents. Based on observation, record review, and interview the facility failed to provide adequate supervision and interventions to prevent accidents for 2 of 5 sampled residents. Resident #46 who left the building through a window on 5/11/19, and 5/26/19, a moderate risk for wandering, history of falls, and severely impaired cognition, placing the resident in immediate jeopardy, and Resident #34, who had several falls without effective interventions. Findings included: - Resident #46's physician order [REDACTED]. to one or many joints characterized by swelling and pain), and muscle weakness. The annual (MDS) Minimum Data Set assessment, dated 5/8/19, documented the resident had a (BIMS) Brief Interview for Mental Status score of 6, indicating severely impaired cognition. The MDS documented the resident had wandering behavior 1 to 3 days during the 5 day look back period, required staff supervision with bed mobility, transfers, walking in the room or corridor, locomotion on and off the unit, eating, limited staff assistance with dressing, toilet use, and personal hygiene. The MDS documented the resident ambulated independently, had 1 non injury fall, and 2 or more minor injury falls. The 5/8/19 behavior (CAA) Care Area Assessment documented the resident had elevation in verbal and physical behaviors, hard to redirect , struck windows at times in an attempt to crawl out. The 5/8/19 fall CAA documented the resident high risk for falls, unsteady gait with a stoop posture, and ambulated independently with staff supervision. The 6/2/19 revised care plan documented the resident fell on [DATE], 2/28/19, 3/24/19, 3/6/19, and 9/25/19, balance unsteady at times, but able to stabilize without staff assistance. The care plan documented when the resident ambulated, he/she tended to stoop over, and required staff supervision to remind him/her of safety issues. The care plan documented the resident high risk for wandering because the resident thought he/she owned, the facility should be allowed to go where ever he/she wanted, and often searched for his/her daughters. The care plan lacked documentation the resident exited the building, without staff supervision, through room [ROOM NUMBER]'s window, on 5/11/19, instructions to staff, to keep the resident from exiting again through the same window on 5/26/19. The 2/1/19 at 2:37 PM, nurse's note documented the resident came out of his/her room, walked down the hallway, started opening the windows, and stated he/she was going to climb out. The note indicated a nurse aide intervened and the resident became angry and agitated. The 3/25/19 at 1:19 PM, nurse's note documented the nurse noted the resident exit seeking, opened windows and screens and tried to climb out of them. The 5/2/19 at 2:13 PM, nurse's note documented the resident became restless and exit seeking. The 5/2/19 at 11:13 PM, nurse's note documented the resident struck at windows at times in attempt to crawl out. The 5/11/2019 at 10:15 AM, nurse's note documented the resident had been exit seeking this morning, went into room [ROOM NUMBER], and before staff could get to the room, the resident removed one of the screens in the windows, and climbed out. The note documented Housekeeping Staff U noted the resident climbing out the window and intercepted him/her, and brought the resident back inside through the west door, and the resident went back into his/her room and laid down. The 5/14/19 note from the director of nursing documented he/she instructed staff when opening windows to leave the lower part of the window closed and open the top half for fresh air. The note documented window shims could not be placed that would stay in place, confirmed by maintenance staff. The note documented staff continued to monitor the resident, consistent staff were assigned to the resident's area, and instructed staff to encourage activities for the resident, as well as manger the resident's pain. The note documented the incident on 5/11/19 was a usual occurrence, was reviewed, but not considered an elopement. The 5/26/19 incident report documented on 5/26/19 at 5:57 PM, Nurse G received a phone call from Nurse Aide M asking for assistance with bringing the resident back inside the facility, when Nurse G picked up the phone he/she could see the resident and Nurse Aide M outside the west window. The report documented after Nurse G received the call, he/she went to the west door, opened it to let the resident and Nurse Aide M back into the building, the resident wanted to make a phone call and was informed the telephone was inside, then the resident sat on the couch right next to the door. The report documented the resident appeared calm and was cooperative with staff, Nurse Aide M reported the resident had crawled out the window in room [ROOM NUMBER], as evidenced by the open window and popped out screen. Nurse G had noted he/she closed and locked the window earlier in the shift. Nurse Aide M reported he/she found the resident attempting to get into a car parked in the parking lot approximately 20 feet from the window the resident had crawled out. The report documented the resident had been acting normal at noon, became restless at times, but was easily calmed down or redirected by staff. The report documented as the afternoon progressed, around 5:00 PM, the resident started to wander more, became more agitated, and Nurse G spent one on one time with the resident because the resident was worried about his/her family member, but by the resident was back to his/her normal self by suppertime. The report documented after supper the resident would wander for a short while, sat down and rested, and then got up and wander again. The report documented at 5:37 PM, Nurse G administered pain medication to the resident because the resident complained of hurting all over, the resident went to the couch at the west end of the hallway and sat down, and appeared to be calm and resting. The report documented the resident remained on the couch until the time of the incident. Nurse G visualized the resident last at approximately 5:55 PM and then went to answer the phone call from Nurse Aide M. The report documented Nurse G assessed the resident and documented no injury or skin impairments. The report documented staff placed a shim (a thin, often tapered piece of material (such as wood, metal, or stone) used to fill in space between things) in the window and screen. The report documented the resident had previously been visualized on 5/11/19 by staff as he/she crawled out of the same window, the intervention was to ensure the lower part of the window remained shut and if fresh air was desired, to only open the top portion of the window. The report documented the resident had been assessed as moderate risk for wandering and elopement. The report documented the resident was immediately placed on 15 minute checks and the facility continued to look into different types of window locks or secure devices to install on windows that residents have access to. The report documented staff were re-educated on elopement policy to aide in future prevention of an elopement. On 5/29/19 at 4:05 PM, Nurse Aide M stated, on 5/26/19 at approximately 5:30 PM, he/she was outside the facility on the by the north dining room doors for a quick break, and noticed the resident outside the facility trying to get into a vehicle parked in the parking lot outside room [ROOM NUMBER]. Nurse Aide M stated he/she walked up to the resident and told the resident it was a nice day, the resident replied it was, but he/she was going home. Nurse Aide M told the resident the car was locked, the resident asked Nurse Aide M if he/she had a car at the facility, and Nurse Aide M told the resident no. Nurse Aide M stated he/she asked the resident to go into the building with him/her to use the phone to see if they could get a ride, and the resident stated, oh, no, so Nurse Aide M asked the resident to go for a little walk with him/her. Nurse Aide M stated he/she had a cell phone in his/her pocked so he/she called the facility and Nurse G answered, told him/her Nurse Aide M needed help on 5 west. Nurse G asked what happened, Nurse Aide M told him/her an individual was outside the facility and wanted to go home. While escorting the resident around the building to the front entrance patio area (entrance door), and Nurse G let them in. Nurse Aide M stated Nurse G asked him/her how long the resident had been outside and he/she reported he/she did not know. During the interview, Nurse Aide M stated when he/she went to place the window screen back in room [ROOM NUMBER]'s window, when he/she barely touched the screen it would easily come out, and reported the finding to Nurse G. On 5/29/19 at 4:27 PM, observation revealed when walking straight out from room [ROOM NUMBER]'s window, approximately 20 feet, was a parking lot. Approximately 18 feet to the right of the window, was a curved dug out approximately 10 feet long by 3 feet wide with an approximately 2 foot deep drop off, without any warning devices around it, with utility pipes sticking up (verified on 5/29/19 at 4:10 PM by Nurse Aide M was there on 5/26/19 when the resident crawled out the window). Observation revealed outside the window screen was a wood shim between the screen and screen frame to hold the screen in. The wood shim was approximately 1 foot from the bottom of the screen, and measured approximately 6 (in) inches long by 1/2 in wide. On 5/30/19 at 11:15 AM, observation revealed a double window set on the north end of room [ROOM NUMBER]. The window was double locked, but could easily unlocked, opened without difficulty, when gentle pressure applied on the screen on the lower right bottom the screen came away from the window. The window to the right was the same, but the screen was not able to be easily dislodged from the frame,except it had a clip in the left lower inside corner, verified with Maintenance Staff V. Maintenance Staff V stated the screens were designed to easily give away in case of a fire, but agreed the screen where the resident had eloped from, seemed to be broken in the lower right corner. On 6/3/19 at 7:51 AM, observation revealed the resident ambulated with stand by assistance from staff, to the front office, in a stooped over position, visited with staff, then ambulated back down the hall, holding staff's hand. On 5/29/19 at 2:13 PM, Administrative Nurse D stated the resident did not actually elope because staff saw the resident go out the window on both occasions. Administrative Nurse D stated staff did not think the resident could unlock the window, and verified the shims placed the the widow had not worked. The facility's 1/8/18 Nursing Elopement policy documented the facility would provide a safe and secure environment for all elders. The policy documented all staff would notify highest ranking nursing personnel when an elder was missing. The highest-ranking nursing personnel would begin a search of unit immediately and alert all staff to report to a designated area. Upon hearing alert, staff would report to designated area. When sector search completed staff would report back to command post. The charge nurse would complete appropriate documentation including condition of the elder when last observed and would notify proper state agency. The facility failed to provide supervision for Resident #46, who left the building, without staff supervision, by crawling out a window in room [ROOM NUMBER], on 5/11/19, and 5/26/19, and failed to fix the window, placing the resident in immediate jeopardy. The facility abated the immediate jeopardy on 5/30/19 at 5:51 PM, when they completed education for all full and part time staff including competency testing and (PRN) as needed staff would not be allowed to work until they completed the education and competency testing. The risk management re-evaluated all residents with a BIMS score of 12 and below for the ability to wander or elope and updated their elopement book. The facility inspected all windows in the west hall and placed a set screw 6 inches up in room [ROOM NUMBER]'s window so the window could not be opened enough to exit. A (QA) Quality Assurance meeting held regarding the incident and included the medical director on 5/30/19. This deficient practice remains at a scope and severity of a G. - Resident #34's (POS) physician order [REDACTED]. The quarterly (MDS) Minimum Data Set assessment, dated 5/23/18, documented the resident had a (BIMS) Brief Interview for Mental Status Score of 6, indicating severely impaired cognition. The assessment documented the resident required limited assistance of 1 staff for bed mobility, supervision with set up assistance for transfers, ambulation, and locomotion on and of the unit. The assessment further documented the resident had unsteady balance, no functional limitations, wandered 1 to 3 days, had 1 non-injury fall during the 7 day look back period and received 7 days of training in walking. The annual MDS, dated [DATE], was the same as 5/23/18 assessment except the resident required extensive assistance of 1 staff for toileting, limited assistance of 1 staff for transfers, ambulation, locomotion on and off the unit, and 2 non-injury falls. The (CAA) Care Area Assessment for falls documented the resident took himself/herself to the bathroom without calling for staff assistance, had fluctuating moods, and was incontinent of urine. The 8/23/18 care plan documented the resident had poor vision and balance, wandered, could transfer independently, required 1 staff assistance with ambulation, and often used a wheelchair for long distances. The 9/10/18 care plan update directed staff to assist the resident with toileting at 3:00 AM. The 3/14/and 4/29/19 care plan updates directed staff to make sure the resident wore foot wear when he/she got out of bed but lacked individualized interventions to prevent further falls. Review of the Fall Risk Assessments, dated 6/18/18, 7/2/18, 8/9/18, 9/28/18, 1/17/19, 3/13/9, and 4/12/19 documented the resident was a high risk for falls. The 4/29/19 assessment documented the resident was a moderate risk for falls The 6/13/18 at 3:13 PM, nurse's note documented staff found the resident seated upright on the floor in his/her room. The note further documented the resident sustained [REDACTED]. The record lacked documentation of new interventions to prevent further falls. The 7/2/18 at 5:20 AM, nurse's note documented the staff witnessed the resident fall backwards, hit his/her head on the foot board of the bed, and sustained a laceration to the back of his/her head. The note documented the resident did not have any socks or shoes on, and his/her head was lying in a pool of blood. The note further documented the resident went to the local hospital and received 7 staples to the back of his/her head. The care plan lacked individualized interventions to prevent further falls. The 9/28/18 at 7:37 PM, nurse's note documented staff found the resident upright in the middle of the floor with his/her legs stretched out in front of him/her. The note further documented the resident stated he/she was walking, fell , and sustained no injury. The record lacked documentation of new interventions to prevent further falls. The 12/16/18 at 7:39 PM, nurse's note documented staff heard the resident scream, found the resident in his/her room with his/her head against the wall, back against the bed, and legs out straight at an angle. The resident was confused, had active range of motion to his/her extremities, and a small circular dark pink area on the back of his/her head. The note further documented the resident had been hospitalized for [REDACTED]. The record lacked documentation of new interventions to prevent further falls. The 1/7/19 at 7:25 AM, nurse's note documented staff stated the resident had been looking out of the window, fell to the floor and just laid there. The note documented the resident did not hit his/her head, sustained no injury, and 3 staff assisted the resident to stand. The record lacked documentation of new interventions to prevent further falls. The 3/23/29 at 12:10 PM, nurse's note documented the resident was agitated, constantly up and down, yelling at staff and not allowing staff to assist him/her. The note further documented the resident leaned against the wall, dropped to the floor and hit his/her head on the floor. The note documented staff assessed the resident and he/she had sustained no injury. The record lacked documentation of new interventions to prevent further falls. The 3/14/19 at 1:19 PM, nurse's noted documented staff found the resident half off the bed on his/her right side with his/her head at the foot of the bed. The note documented the resident had 1 shoe on and stated, I slid down to the floor. The resident did not sustain any injury and staff wheeled the resident to the dining room for monitoring. The record lacked documentation of new interventions to prevent further falls. The 4/29/19 at 8:45 PM, nurse's note documented staff found the resident seated on the floor with his/her legs stretched out in front of him/her a couple feet from the bed. The resident had 1 shoe off, his/her bedding bunched up on the floor, and his/her other shoe in the middle of the bed. Staff assisted the resident with his/her shoes and placed him/her in a recliner. The note further documented the resident sustained [REDACTED]. On 5/30/19 at 8:08 AM, observation revealed the resident at the dining room table, waiting for breakfast, and had no shoes or socks on. On 6/3/19 at 4:25 PM, observation revealed Nurse Aide P assisted the resident to stand, without the use of a gait belt (a belt used to aid in the safe movement of a patient to a standing position who has balance and mobility problems), and slowly and unsteadily ambulated the resident to his/her bed. On 6/4/19 at 9:05 AM, Licensed Nurse G stated the resident had a lot of falls and if the resident did not want his/her shoes or socks on, the shoes did not get put on. On 6/4/19 at 9:10 AM, Administrative Nurse D stated the resident had a stroke and staff do (PROM) passive range of motion with the resident. On 6/4/19 at 2:36 PM, Nurse Aide N stated staff tried putting shoes on the resident and he/she hit and kicked at them. The facility's Fall Prevention Protocol policy, dated 1/14, documented each elder residing at the facility was provided services and care that ensures that the elder's environment remains as free from accident hazards as is possible and each elder receives adequate supervision and assistive devices to prevent accidents. Every elder is assessed for the causal risk factors for falling at the time of admission, upon return from a health care facility, and after every fall in the facility. The facility failed to provide adequate supervision and implement interventions to prevent falls for Resident #34, placing the resident at risk for further falls and injury.

The facility had a census of 49 residents. The sample included 22 residents. Based upon observations, record review and interview the facility failed to implement timely and effective interventions and adequately supervise 2 (#47, #50) of 3 residents sampled for accidents. Findings included: - Resident #50's electronic record identified the resident had [DIAGNOSES REDACTED]. The resident's annual Minimum Data Set ((MDS) dated [DATE] identified the resident scored 2 (severely impaired cognition) on the Brief Interview for Mental Status, had physical behaviors, rejected care 1 to 3 days of the 7 day assessment period and had verbal behaviors 4 to 6 days of the 7 day assessment period. The resident required extensive staff assistance with bed mobility, transfers, walking in the room/corridor, locomotion on/off the unit, dressing, eating, toilet use and personal hygiene. The MDS identified the resident was not steady, was only able to stabilize with human assistance when moving from a seated to a standing position, walking, turning around and facing the opposite direction while walking, moving on and off the toilet and surface to surface transfer. The resident had no impairment in functional limitation of range of motion, utilized a wheelchair and had (1) non-injury fall since the prior assessment. The resident's Cognitive Loss/Dementia Care Area Assessment (CAA) dated 3/30/15 documented the resident had [DIAGNOSES REDACTED]. The resident's Fall CAA dated 3/30/15 documented the resident was at high risk for falls, required extensive staff assistance of 2 for ambulation and due to the resident's dementia (progressive mental disorder characterized by failing memory, confusion ) the resident attempted to ambulate without staff assistance. The resident had a high/low bed and staff kept the bed in the lowest position when the resident was in bed along with a fall mat on the floor beside the resident's bed. The resident's room was in an area where staff provided frequent visual supervision when the resident was in his/her room. Staff followed the facility's standards of care for falls and attempted to identify fall risks and put interventions in place before falls occurred. The resident's Fall Risk assessment dated [DATE], 4/22/14, 4/30/14, and 4/27/15 and 4/30/15 identified the resident was at a high risk for falls. The resident's care plan revised on 5/1/15 included the resident was at risk for falls, had impaired safety related to a right hip hemiarthroplasty (hip replacement surgery) and had several falls effective 2/26/14. On 2/9/2015 the facility educated staff on the importance of offering the resident a drink every time he/she assisted the resident. An intervention on 3/17/14 revealed the resident's gait was unsteady and required extensive staff assistance with transfers. Staff ensured the resident's bed was in a low position when he/she was in it and staff placed a floor mat next to the resident's bed. On 3/22/14 staff ensured the resident's tennis shoe strings were tied in a double knot to help reduce tripping on untied shoe strings or the resident wore shoes with straps. Effective 4/9/14 staff ensured the door to the resident's room was open at night to allow staff visible monitoring. On 4/11/2014 the resident required activities that minimized his/her potential for falls while providing diversion and distraction. 6/1/14 staff sat at the same table as the resident when the resident was in the dining room and transferred the resident to his/her recliner, chair or bed and did not leave the resident in a wheelchair as the resident did not understand to lock the brakes when he/she attempted to stand. Effective 7/1/14 at times the resident used a wheelchair for mobility and was dependent upon staff for wheelchair mobility. The resident required extensive assistance of 2 staff via a gait belt and staff walked arm in arm with the resident. On 7/10/14 staff tightened the anti-lock brake on the resident's wheelchair and maintenance staff performed a safety check each month. Effective 11/2/14 staff placed dycem (an anti-slip) material in the resident's wheelchair to prevent the resident from slipping out. 11/28/14 staff ensured the foot rest of the recliner was down when the resident sat in the recliner as the resident may try to stand. 4/6/15 the resident had a high/low bed and staff ensured the bed was positioned at a height that allowed the resident to sit with his/her hips, knees, and legs bent at a 90 degree angle when he/she sat on the edge of the bed. Review of the resident's fall log identified the resident fell 14 times from 3/8/14 to 4/27/14 and one of the falls resulted in a left hip fracture. The facility failed to do a root cause analysis to determine the reasons of his/her falls. A NN dated 4/27/2014 and timed 11:26 A.M. documented the resident walked with some paper in his/her hands, walked around another resident in a wheelchair, lost his/her balance and fell to his/ her left hip. The resident had a small reddish colored bruise next to his/her left eyebrow that measured 0.7 centimeter (cm) x 0.1 cm. The resident cried in pain when he/she stood. Staff notified the resident's physician and received a physician's orders [REDACTED]. A NN dated 4/27/2014 and timed 2:13 P.M. documented the resident was transferred to the hospital for a left hip fracture. A hospital operation report dated 4/28/14 included preoperative and postoperative [DIAGNOSES REDACTED]. The report included the resident fell and sustained a femoral neck fracture. The resident arrived to the hospital during the late evening hours on 4/27/14 and surgery was on 4/28/14. A NN dated 4/30/2014 and timed 5:46 P.M. documented the resident returned to the facility following surgical intervention for a left hip fracture. Review of the resident's fall log from 4/30/14 to 4/26/15 revealed the resident fell 19 times during this time frame. The facility failed to do a root cause analysis to determine the cause of his/her falls. A NN dated 5/1/2014 and timed 1:39 A.M. documented the resident attempted to stand up from the wheelchair, the wheelchair rolled out from under him/her and the resident fell on to the pedals of the wheelchair. Intervention included staff placed the resident in a recliner and the resident would only use the wheelchair for transportation if staff was with the resident. A NN dated 6/1/2014 and timed 10:04 P.M. documented at 9:20 P.M. the resident laid on his/her right side on the floor and the resident's feet were caught in the foot pedal of the wheelchair. Intervention included staff would not leave the resident in the wheelchair unattended. A NN dated 7/1/2014 and timed 2:01 P.M. documented the resident laid on his/her left side next to his/her wheelchair and the pedals of the wheelchair were down. A NN dated 7/4/2014 and timed 10:17 P.M. documented at 9:30 P.M. the resident sat on the floor and the resident's wheelchair was beside him/her. A NN dated 7/10/2014 and timed 9:51 A.M. documented staff assisted the resident with A.M. care. The staff went into the bathroom and left the resident unattended in his/her wheelchair and the resident fell . Intervention included staff tightened the anti-lock brake on the resident's wheelchair and maintenance would check on a monthly basis. A NN dated 11/2/2014 and timed 10:16 A.M. documented the resident sat in his/her wheelchair, the resident reached down, put the right foot pedal and slipped out of the wheelchair. The facility failed to document an intervention. A NN dated 11/28/2014 and timed 8:00 P.M. documented the resident knelt in the front end of his/her recliner. Intervention included the recliner foot rest would remain down. A NN dated 12/8/2014 and timed 11:35 A.M. documented the resident was on the floor in front of his/her recliner. The resident had removed his/her shoes and socks remained. Intervention included the resident would wear gripper socks at all times even with shoes. A NN dated 12/20/2014 and timed 3:51 P.M. documented the resident was on the floor between the foot of his/her recliner and bed. Prior to the fall the resident sat in his/her recliner with the foot of the recliner up. Interventions included staff would perform frequent visual room checks and would have an activity to do at all time. A NN dated 2/5/2015 and timed 2:20 P.M. documented the resident was on the floor with blood spots around his/her head. A NN dated 2/9/2015 and timed 4:53 A.M. documented the resident laid on the floor mat next to his/her bed. An investigation note dated 2/12/15 and timed 9:49 A.M. documented the resident fell on [DATE] at 2:20 P.M. from his/her recliner. Intervention included staff took the resident to activities outside of his/her room and the BINGO was going on at the time of his/her fall. The note also included the resident was found on his/her floor mat at 4:49 A.M. on 2/9/15. Intervention included staff offered fluids when providing cares or interacting with the resident. A NN dated 4/26/2015 and timed 6:33 P.M. documented the resident sat on the floor between his/her recliner and the roommate's chair. The resident had removed his/her shoes and only had socks on. Intervention included staff was encouraged to ambulate or do an activity with the resident. On 5/4/15 at 2:00 P.M. the resident sat in his/her recliner in his/her room. Observation revealed the foot rest of the recliner in the raised position. Further observation revealed the resident had on shoes, regular socks and not gripper socks. On 5/5/15 at 7:31 A.M. 2 staff assisted the resident from his/her room to the assisted dining room. Observation revealed the resident required extensive staff assistance with ambulation. On 5/5/15 at 9:25 A.M. the resident sat in his/her recliner in his/her room and the foot rest of the recliner in the raised position. Observation revealed the resident had on shoes and regular socks. On 5/5/15 at 1:40 P.M. the resident sat in his/her recliner in his/her room and the foot rest of the recliner in the raised position. Observation revealed the resident's wheelchair was in close proximity to the resident, no anti-lock device on the resident's wheelchair and no dycem in the seat of the wheelchair as planned. On 5/5/15 at 2:10 P.M. the resident sat sideways in his/her recliner in his/her room and the foot rest of the recliner in the raised position. The resident had removed his/her shoes and socks and the resident's wheelchair was in close proximity to the resident. Observation revealed the door of the resident's room open and 3 staff walked by the resident's room and did not assist the resident. On 5/6/15 at 3:00 P.M. the resident sat in the recliner in his/her room and the foot rest of the wheelchair was in a raised position. Observation revealed no dycem in the resident's wheelchair and no anti-lock device on the resident's wheelchair as planned On 5/6/15 at 3:20 P.M. direct care staff O confirmed there was not dycem in the resident's wheelchair and no anti-lock device on the resident wheelchair. On 5/6/15 at 3:30 P.M. licensed nurse K confirmed the resident's wheelchair was without dycem and no anti-lock device on the resident's wheelchair. He/she stated he/she was unsure if the resident should have the devices in place and would have to check the resident's care plan. On 5/5/15 at 4:04 P.M. direct care staff O stated the resident was at risk for falls. He/she stated the resident enjoyed sitting in his/her recliner and preferred the foot rest in the raised position. On 5/6/15 at 1:14 P.M. licensed nurse K stated the resident was at high risk for falls due to impaired cognition. He/she stated the foot rest of the resident's recliner was usually in the raised position due to comfort. Licensed nurse K stated the resident usually wore gripper socks unless he/she ambulated on carpet and then the resident would wear shoes. On 5/6/15 at 1:37 P.M. nursing administrative staff D stated the resident was at risk for falls and the foot rest of the resident's recliner could either be up or down per resident request. The facility's Fall Prevention Protocol revised January 2014 included the facility provided services and care that ensured the resident's environment remained as free from accident hazards as was possible and each resident received adequate supervision and assistive devices to prevent accidents. Each resident's was assessed for the causal risk factors for falling at the time of admission, upon return from health care facility and after every fall in the facility. The facility failed to implement timely and effective interventions for the severely cognitively impaired resident with a history of multiple falls and sustained a left hip fracture after a fall on 4/27/14. The facility also failed to do a root cause analysis to determine causal factors related to his/her falls and failed to follow interventions as planned. - Resident #47's quarterly Minimum Data Set ((MDS) dated [DATE] identified the resident scored 3 (severely impaired cognition), wandered 1 to 3 days of the 7 day assessment period, required extensive staff assistance with bed mobility, transfers, walking in the room/corridor, locomotion on/off the unit, dressing, toilet use and personal hygiene. The resident was not steady and was only able to stabilize with human assistance when moved from a seated to a standing position, walking, turning around and facing the opposite direction while walking and surface to surface transfers. The resident had no functional limitation in range of motion, utilized a walker and wheelchair and had 2 or more falls with (1) injury except major fall since the prior assessment. The resident's Cognitive Loss Dementia Care Area Assessment (CAA) dated 8/26/14 included the resident had a [DIAGNOSES REDACTED]. The resident's Activity of Daily Living (ADL) CAA dated 8/26/14 included the resident required visual supervision and verbal reminders to complete ADL tasks. The resident often ambulated without his/her walker, did not complete personal hygiene/incontinence tasks, change incontinence products, or toilet without staff intervention. The resident's Fall CAA dated 8/26/14 included the resident had a [DIAGNOSES REDACTED]. The resident often forgot to use his/her front wheeled walker at all times. The resident had an unsteady gait and tended to move very quickly when ambulating and transferring which added to possibility of him/her falling. The resident's Fall Risk assessment dated [DATE] identified the resident was at high risk for falls. The resident's Fall Risk assessment dated [DATE] identified the resident was at moderate risk for falls. The resident's revised care plan dated 5/1/15 addressed the resident had a self-care deficit related to dementia and required staff assistance with ADL's The resident required extensive staff assistance of one to get into and out of bed due to balance issues in the morning and at bedtime. He/she was able to reposition him/herself while in bed, needed staff to ensure that the side rail was up when he/she was in bed, to use it for positioning. The resident ambulated independently with a front wheeled walker and at times his/her gait was unsteady. Staff provided frequent visual supervision, ensured his/her walker was within reach as much as possible, and provided assistance as needed. If the resident was not feeling well the resident used his/her wheelchair. All staff were educated to stay with the resident and to radio for nursing staff if the resident ambulated with his/her walker without staff assistance (2/10/15). A family member took the resident's cane home to prevent the resident from using it when ambulating (5/26/14). Staff applied dycem (anti-slip surface) to the resident's recliner to prevent the resident from slipping out of the chair (7/28/2014). Staff assisted the resident with bed time care after the resident ate the evening meal (12/22/14). Staff educated on the importance of ensuring the resident was steady when he/she stood due to hypotension (2/9/15). Staff ensured the chairs in the lobby area were against the wall to prevent the resident from sliding when the resident sat down (5/1/15). Staff removed the resident's recliner away from his/her bed at night because the resident used it for leverage to get to a standing position (12/20/2014). Staff tried to observe the resident when he/she attempted to pick things up from the floor and assisted him/her to prevent him/her from losing his/her balance (2/22/15). Staff continued to remind the resident more frequently to use his/her walker, including in his/her room (8/11/14). Staff remained with the resident when he/she used the restroom (3/18/15). Review of the resident's fall log from 1/22/14 to 5/5/15 revealed the resident fell 57 times during this time frame. A nurse's note dated 6/27/2014 and timed 10:48 P.M. documented at 7:25 P.M. the resident was found on his/her hands and knees in his/her room with a bloody nose. The resident reported he/she ambulated without his/her walker, fell and hit his/her nose on the floor. The resident had a 1.5 centimeter (cm) by 0.5 cm skin tear on the bridge of his/her nose and a 1 cm open area on the inside of his/her upper lip. The facility failed to document an intervention. A NN dated 8/14/2014 and timed 10:04 A.M. included the resident on his/her hands and knees beside his/her bed. The resident stated he/she was in the bathroom, tried to pull up his/her pants and fell to the floor. Intervention included staff obtained a physician's orders [REDACTED]. A NN dated 9/13/2014 and timed 11:06 P.M. documented at 8:00 P.M. the resident was on his/her knees near his/her bed and tried to get up. The resident stated he/she slid out of the recliner. Interventions included staff placed gripper socks on the resident and placed dycem in his/her recliner. A NN dated 10/2/2014 and timed 1:26 P.M. documented the resident was at the laundry baskets without his/her walker, lost his/her balance and fell down. Intervention included staff would place a laundry hamper in his/her room and staff would empty it to keep the resident from carrying his/her clothing in the hallway without his/her walker. A NN dated 12/9/2014 and timed 5:58 P.M. documented the resident sat on the floor next to his/her bed. The resident's walker was on the other side of the room by the resident's recliner. Intervention include staff encouraged the resident to afternoon group activities to reduce the amount of time the resident was unsupervised in his/her room. A NN dated 12/14/2014 and timed 12:48 P.M. documented the resident sat on the bed with his/her back toward the foot of the bed. Staff did not place all of the safety measures in place when the resident changed rooms. A NN dated 12/16/2014 and timed 7:26 documented the resident sat on the floor in front of the lift chair with his/her walker in front of him/her. Staff reported he/she assisted the resident with dressing, the resident was resident was unsteady, the resident lost his/her balance and swayed backwards. Staff tried to sit the resident on the lift chair but the brakes to the lift chair were not locked, the lift chair moved away from the resident and staff and caused both the resident and the staff to fall to the floor. Intervention included the facility educated staff on the use of brakes as safety devices to help prevent fall and injuries. A NN dated 1/28/2015 and timed 8:06 A.M. documented at 6:15 A.M. the resident sat on the floor and it looked like the resident had already been to the bathroom. Intervention included staff placed the resident on a toileting schedule. A NN dated 3/18/2015 and timed 3:09 P.M. documented the resident sat on the floor between the toilet and the wall. Intervention included the facility educated staff to stay with the resident to make sure the resident was fully finished. A NN dated 5/1/2015 and timed 5:23 P.M. documented the resident went to sit down in a chair and the chair slid, the resident missed the chair and fell . Intervention included the facility educated staff to make sure chairs were pushed against the wall in a manner that they would not move. A NN dated 5/5/2015 and timed 5:03 A.M. documented at approximately 4:30 A.M. the resident sat on the floor in his/her room and leaned next to his/her recliner. The resident stated he/she was trying to go the bathroom. The note included the resident was incontinent of urine. On 5/5/14 at 7:30 A.M. the resident sat in the hallway in his/her wheelchair. On 5/5/14 at 8:22 A.M., 8:32 A.M. and 8:50 A.M. observation did not reveal dycem in the resident's recliner. On 5/5/14 at 1:40 P.M. and 2:11 P.M. the resident laid in bed. Observation revealed 1/4 inch side rail on the resident's bed but not in the upright position. Observation did not reveal a fall mat or non-skid strips on the resident's floor. On 5/5/15 at 3:13 P.M. direct care staff K stated the resident was at risk for falls. The resident had low bed but staff ensured the resident's legs were at a 90 degree angle so the resident did not slide out of the bed when he/she stood. The facility removed fall mats, the resident wore non-skid socks and staff ensured the resident's walker was within reach. Direct care staff stated staff did not remove the resident's recliner away from the resident's bed at night. On 5/5/15 at 1:04 P.M. administrative nursing staff E stated the resident was at very high risk for falls. Staff kept the resident within their vision at all times. The resident utilized a wheelchair if he/she was unsteady. He/she was unsure if the resident should have non-skid strips by his/her bed, the facility discontinued fall mats around the first of April 2015 and the resident should have dycem in his/her chair. The surveyor and the staff entered the resident's room and licensed nurse confirmed there was no dycem in the resident's recliner. On 5/5/15 at 1:30 P.M. administrative nursing staff D stated the resident had a high/low bed but staff did not lower the bed to the floor. He/she stated the resident had orthostatic blood pressure (lowered upon change of position) which contributed to the resident's falls. Administrative nursing staff D stated dycem should be in the resident's recliner. The facility's Fall Prevention Protocol revised January 2014 included the facility provided services and care that ensured the resident's environment remained as free from accident hazards as was possible and each resident received adequate supervision and assistive devices to prevent accidents. Each resident's was assessed for the causal risk factors for falling at the time of admission, upon return from health care facility and after every fall in the facility. The facility failed to implement timely and effective interventions for the severely cognitively impaired resident with a history of multiple falls and also failed to follow interventions as planned.