Every finding on record at Maple Heights Nursing & Rehabilitative Center

The facility identified a census of 50 residents. The sample included three residents with three residents reviewed for hot liquid safety. Based on observations, record review, and interviews, the facility failed to ensure an environment free from accident hazards when on 02/15/26 Dietary Staff CC provided cognitively impaired Resident (R) 1 with coffee in a lidded cup, without obtaining the temperature of the coffee prior to giving it to her, and R1 spilled the coffee on herself. After the spill, the staff obtained the temperature of the coffee, which was 151 degrees Fahrenheit. R1 sustained second degree burns from the hot liquid spill. Findings included:- R1 admitted to the facility on [DATE]. R1's Electronic Medical Record (EMR) documented diagnoses of generalized muscle weakness, dementia (a progressive mental disorder characterized by failing memory and confusion), dysphagia (difficulty swallowing), and cognitive communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness). R1's Quarterly Minimum Data Set (MDS) dated [DATE], documented R1 had a Brief Interview for Mental Status (BIMS) score of eight which indicated moderate cognitive impairment. R1 required set up or clean-up assistance with eating. R1 had a mechanically altered diet. R1's Significant Change MDS dated 02/26/26, documented R1 had a BIMS score of three which indicated severe cognitive impairment. R1 was independent with eating. R1 had a mechanically altered diet. The Cognitive Loss/Dementia Care Area Assessment (CAA) dated 02/26/26, documented R1 had a BIMS of three. The Nutritional Status CAA dated 02/26/26, documented R1 readmitted to the facility after a hospitalization for burns. R1 had second-degree burns to her right and left lower limbs. R1 continued with a regular diet with soft, bite sized texture and thin liquids. R1's 10/18/24 Care Plan documented R1 was alert to self only, due to dementia, but she was familiar with her surroundings. The Care Plan documented the following interventions: Initiated 10/18/24, Resolved 02/23/26: R1 had some increased weakness, and she could have regular mugs without lids for hot liquids per her request. R1 had no history of spillage or other issues related to the matter. R1's 10/29/25 Care Plan documented R1 had a swallowing problem related to dysphagia. The plan documented the following interventions: Initiated 01/19/26, Resolved 02/19/26: Dietary and nursing staff provided all hot liquids in a hydro-jug, non-spill cup. Initiated 01/26/26, Created on 02/23/26: R1 refused hydro-jug, non-spill thermal cup. Staff provided all hot liquids in a mug with a lid. Initiated 02/19/26, Revised 03/09/26: Staff used a mug with a lid for all hot liquids or non-spill thermal mug if R1 agrees. Staff placed a clothing protector on R1's chest and lap area during meals. R1 only drank hot liquids at the table or with staff supervision. Initiated 02/21/26: Per family request, staff placed two ice cubes in R1's hot liquid beverages and soups. R1's EMR documented the following: A Hot Liquids Safety Evaluation dated 04/12/25, documented R1 had upper extremity weakness and loss or reduced mobility. The evaluation documented an intervention for a cup with a lid. A diet order, dated 11/25/25 and discontinued 02/20/26, revealed R1 had a regular diet with soft and bite-sized texture and thin liquids. The order instructed staff to provide a mug with a lid for all hot liquids or a non-spill thermal mug if she agreed; staff placed a clothing protector on R1's chest and lap area during meals; and R1 only drank hot liquids at the table or with staff supervision. A Nurses Note on 02/15/26 at 10:15 AM, documented at 09:40 AM staff alerted the nurse that R1 spilled hot coffee on herself in the dining area. The nurse performed an immediate assessment and noted erythema (redness or inflammation of the skin) from below R1's belt line to her groin. R1 appeared tired and repeatedly stated she was tired. R1 reported pain in her groin and bilateral thighs, stating it hurt. R1 had blistering present on her medial/inner thighs, consistent with a burn injury. The facility notified the on-call provider and received orders to send R1 to the emergency room (ER) for further evaluation and treatment. The facility notified R1's representative who agreed to the transfer. R1 departed from the facility with Emergency Medical Services (EMS) at 10:05 AM. A Nurses Note on 02/15/26 at 11:45 AM, documented at 11:36 AM, the ER nurse called the facility to report they were transferring R1 to the Burn Center Hospital. The facility notified R1's representative. An Emergency Department Note on 02/15/26, documented R1 ate breakfast that morning and spilled her coffee in her lap. She finished eating breakfast and staff took her to the shower to clear her up, when they noticed significant firmness in her lap with peeling skin, believed to be second-degree burns. R1's skin assessment revealed 3% total body surface area (TBSA-the percentage of body surface affected by partial or full-thickness burns), partial thickness (potentially painful burn that affects the first and second layer of the skin) burns to her inner groin area, and bilateral medial (inner) thighs. An admission History and Physical Examination note on 02/15/26, documented R1 presented to the burn center with partial thickness scald burns to her bilateral thighs and perineum (the area between the anus and the genitalia) after spilling 157-degree F coffee in her lap that morning at breakfast. The facility's reportable investigation documented on 02/15/26 at 09:40 AM, R1 sat in the dining room for breakfast. The kitchen staff and nursing staff heard R1 holler out and Dietary Staff BB looked out of the serving window to see coffee on the floor. Dietary Staff BB asked Certified Nurse Aide (CNA) M, who assisted another resident with breakfast, to check on R1. CNA M got up and observed coffee on R1's lap, then started to pat it dry. CNA M asked Dietary Staff BB to call for a nurse in charge to assess R1. Licensed Nurse (LN) G arrived and began his assessment. LN G's assessment revealed redness and blistering to R1, so LN G called the on-call provider and requested R1 to be sent to the ER for evaluation. R1 transferred to the ER for evaluation and the ER later notified the facility they transferred R1 to a burn center for further evaluation. The burn center treated R1 for second-degree burns and a new onset of atrial flutter (a heart arrhythmia where the upper chambers of the heart, beat too quickly) with bradycardia (low heart rate, less than 60 beats per minute). The investigation conclusion noted: After investigation, the facility felt the incident was accidental and was caused by R1's health condition. R1 told the nurse she was tired, and her blood pressure was low. R1 had a lid on her coffee cup per her care plan but when she dropped the cup, the lid came off. R1 had no history of dropping her coffee prior to that incident. In a notarized witness statement on 02/15/26, Dietary Staff CC stated R1 asked him to refill her coffee mug. He went to the kitchen and brought the coffee pot to the table. Dietary Staff CC stated he filled her cup and took it over to the counter to put sweetener in it. He put the lid on and sat the cup on the table for R1. On 03/19/26 at 11:50 AM, R1 sat in her wheelchair at a dining room table. She wore a clothing protector and had a thermal coffee mug with a lid and straw positioned in front of her on the table. On 03/19/26 at 11:52 AM, Dietary Staff DD filled a coffee cup with coffee from an automatic machine in the serving room. Dietary Staff DD obtained the temperature of the coffee and noted the temperature to be 134.9 degrees Fahrenheit (F). On 03/19/26 at 10:12 AM, Administrative Nurse D stated Dietary Staff BB obtained the temperature of what remained in R1's coffee cup on 02/15/26, after the spill, and reported the temperature was 151 degrees F. On 03/19/26 at 11:52 AM, Dietary Staff BB stated on 02/15/26, she served residents from the serving room and heard R1 holler. She stated she looked up and noticed coffee on the floor. Dietary Staff BB told CNA M, who was behind R1, to check on R1. She stated she obtained the temperature of the coffee that remained in R1's cup and noted the temperature as 151 degrees F. Dietary Staff BB stated staff put ice in R1's coffee and she used a cup with a lid. She stated staff obtained the temperature of every cup and did not send it out if it was over 135 degrees F. She stated she thought Dietary Staff CC obtained the temperature of R1's first cup of coffee but did not check the second cup. She stated she expected staff to obtain the temperature of every hot liquid cup and not to send the cup out if it was over 135 degrees F. On 03/19/26 at 12:51 PM, Dietary Staff EE stated only dietary passed drinks at mealtimes, and they had a list to follow that directed who received lids on their cups. She stated staff filled up a cup from the automatic coffee machine then obtained the temperature to make sure it was below 135 degrees F. On 03/19/26 at 12:52 PM, Dietary Staff DD stated she looked on the list to see how they took their hot liquids, and she obtained the temperature of every cup from the automatic coffee machine to make sure it was below 135 degrees F. She stated R1 liked sweetener with her coffee, and she used a coffee cup with a lid and straw. On 03/19/26 at 12:58 PM, LN H stated only dietary staff passed hot liquids at meals but if it was outside of mealtime, the staff would obtain coffee from the machine then obtain the temperature to make sure it was below 135 degrees F. On 03/19/26 at 01:09 PM, Administrative Nurse D stated on 02/15/26, she received a call from LN G between 09:00 AM and 10:00 AM reporting R1 dropped coffee on herself, and it burned her. She stated LN G reported R1's blood pressure was low. Administrative Nurse D stated LN G called the on-call provider and received orders to send R1 to the ER. She stated the facility received report back that R1 had a new onset of atrial flutter with bradycardia which she thought had something to do with R1 dropping the coffee. Administrative Nurse D stated the hot coffee caused the burn and usually Dietary CC obtained the temperature of the coffee, but he could not remember if he obtained the temperature of the second cup. She stated the facility immediately educated staff on hot liquid safety and ordered a new coffee machine. Administrative Nurse D stated she expected staff to not give hot liquids until it was under 135 degrees F. On 03/19/26 at 01:38 PM, Administrative Staff A stated she received a call from Administrative Nurse D that R1 spilled her coffee on herself, and the facility sent her to the hospital. She stated she interviewed R1 when she returned to the facility and R1 stated she remembered the incident and stated she did not feel well that day. She stated the kitchen served her the coffee hot with a lid on it, but it was obviously hot enough to burn her. Administrative Staff A stated the facility ordered a low-temperature machine set at 145 degrees F and the staff obtained the temperature of every cup to make sure no cups were served above 135 degrees F. She stated dietary staff served the beverages at mealtimes and if a resident needed a hot liquid outside of mealtimes, the staff received directions to get a cup of coffee from the kitchen and obtain the temperature. On 03/19/26 at 02:10 PM, Dietary Staff CC stated R1 requested a second cup of coffee. He stated he refilled her metal coffee cup then put sweetener in it before putting the lid back on and giving it to her. He did not remember if he obtained the temperature prior to giving the cup to R1. He stated he typically obtained the temperature of the coffee and made sure it was below 135 degrees F. Dietary Staff CC stated he received education after the incident. The facility's Hot Liquid Safety policy, revised 02/16/26, directed the dietary department checked hot liquid temperatures prior to the distribution to the nursing units and if the temperature was greater than 140 degrees F, dietary held the liquid until it reached the appropriate temperature. The policy listed a table of water temperatures and time required for a third-degree burn to occur. The policy listed a temperature of 148 degrees F required two seconds and a temperature of 155 degrees F required one second for a third-degree burn to occur. The facility immediately identified, implemented, and completed the following corrective measures:1. The facility educated staff on hot liquid temperature and reheating safety on 02/15/26.2. The facility did one-on-one coaching with Dietary CC on hot liquid safety, care plan compliance, and temperature monitoring on 02/16/26.3. The facility completed hot liquid safety evaluations on all residents on 02/19/26 and updated the Hot Liquid Safety Measures list for residents with their hot liquid interventions.4. The facility updated R1's care plan on 02/23/26.5. The facility ordered a new coffee machine on 02/24/26.6. The facility held a Quality Assurance and Performance Improvement (QAPI) meeting on 02/24/26. Due to the facility completion of all corrective actions prior to the onsite visit, the deficient practice was deemed past noncompliance at a scope and severity of a G (isolated, actual harm not immediate jeopardy).

The facility had a census of 44 residents. The facility had one kitchen. Based on observation, interview, and record review the facility failed to prepare, store, distribute, and serve food under sanitary conditions for the 44 residents in the facility, who receive their meals from the kitchen. This deficient practice placed the residents of the facility at risk for food borne illness. Findings included: - On 03/24/25 at 8:20 AM, during initial kitchen tour, observation revealed the following: Two 24 inch by 24 inch, air vent located above the cooking stove area covered with brownish grease/sticky substance and gray fuzzy substance blowing directly on the food preparation and stove cooking area. Four overhead florescent light fixtures had the covers missing and located over the food preperation area. One 36 inch by 24 inch return air grill covered with brownish gray fuzzy substance that covered the metal grill. Six round light bulbs with wire cages around the bulbs, located in the exhaust hood above the stove top with brownish gray fuzzy substance affixed to the wire cages. Continued observation revealed two fire suppression spigots with brownish gray fuzzy substance that covered the hose and spigot area. On 03/24/25 at 9:00 AM, Dietary staff BB verified the dirty register grill, the dirty light bulbs and fire suppression spigots in the exhaust hood, and the overhead florescent light -the bulbs were not encapsulated with a plastic covering and lacked a cover for the light fixtures. Dietary Staff BB stated maintenance staff cleaned the grills and replaced the light bulbs and fixtures On 03/24/24 at 11:00 AM, Maintenance Staff U verified the dirty register grill, the dirty light bulbs and fire suppression spigots in the exhaust hood, and the overhead florescent light - and verified the bulbs were not encapsulated with a plastic covering and lacked a cover for the light fixtures. Maintenance Staff U stated the light fixtures had been missing the covers since he started at the facility about one year ago and stated the air grill and registers were cleaned about one month ago. The facility's Cleaning and Disinfection of Environment policy, dated October 2018, documented environmental surfaces would be cleaned and disinfected according to current Center for Disease Control (CDC) recommendations for disinfection of healthcare facilities. Housekeeping surfaces would be cleaned on a regular basis, when spills occur, and when the surfaces become visibly soiled.

The facility had a census of 44 residents. The sample included 15 residents. Based on observation, interview, and record review, the facility failed to notify the State Long Term Care Ombudsman (LTCO), Resident (R)9's and R15's facility-initiated discharge to the hospital. This placed the residents at risk for impaired rights. Findings included: -R9's Electronic Health Record (EHR) revealed diagnoses of included healing fracture neck of the left femur (thigh bone,) dementia (a progressive mental disorder characterized by failing memory and confusion) osteoporosis (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk,) and muscle weakness. R9's Quarterly Minimum Data Set (MDS), dated [DATE], recorded the resident had a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The MDS documented R9 required extensive assistance of two staff with bed mobility and transfers. The MDS further documented the resident had no falls since reentry on 01/09/25. The Activities of Daily Living Care Area Assessment (CAA), dated 01/16/25, documented the resident required one on one assistance with transfers due to recent left hip fracture repair. The CAA documented the resident was dependent on staff for all weight bearing Activities of Daily Living (ADLs) and for dressing and personal cares. The Care Plan, dated 01/29/25, documented the resident was a high fall risk due to history of a fall with a fracture, confined to her chair, required assistance with incontinence, and was not able to stand without physical help. The care plan documented staff placed a sign on the wall in her room to remind her to call for assistance and staff would constantly remind her to call for help. The care plan documented staff would assist the resident with ambulation and transfers and would keep her environment free of clutter. A Nurse's Note on 01/02/25 at 02:52 PM, documented the resident hollered for help and upon entering the room the nurse observed R9 on her left side, in a semi sitting position,-up against the end table and in between the recliner and the bathroom entry. Nurse Aide N placed a pillow behind the resident's head and removed her shoes at the resident's request. The resident complained of pain in the position she was in. The nurse and aide repositioned the resident so her back was resting against the recliner. Observation revealed her walker and wheelchair were not in reach or in use at the time of the fall. The resident stated she was trying to get a calendar that had fallen on the floor, and she fell. The resident stated she hit her head and her leg hurt. The resident stated she wanted to go to the hospital to have her leg checked out. Administrative Nurse D. documented the resident had slight shortening of the left leg with rotation observed. The resident was transferred to the hospital at 02:15 PM. On 01/09/25 at 05:07 PM, Nurse's Notes documented the resident returned from the hospital at 04:30 PM per facility van and accompanied by staff. The notes documented the resident had been hospitalized for closed left hip fracture with multiple left rib fractures. The resident had a surgery Open Reduction and Internal Fixation (ORIF) nailing of the left hip while hospitalized . R9's clinical record lacked documentation staff notified the LTCO of the resident's discharge from the facility. On 03/25/25 at 02:45 PM, Administrative Staff A stated she would send the discharges to the Ombudsman at the first of the month from the prior month discharges. Administrative Staff A reviewed the list of residents she had provided to the Ombudsman's office on 02/03/25 and verified R9. Administrative Staff A verifed R9 went to the hospital on [DATE] and she would ensure the notifed the LTCO. The facility's, undated, Transfer or Discharge, Facility -Initiated, stated the under the following circumstances, the notice is given as soon as it is practicable but before the transfer or discharge: a. The health and/or safety of the individuals in the facility would be endangered due to the clinical or behavioral status of the resident. b. The resident's health improves sufficiently to allow a more immediate transfer or discharge. c. An immediate transfer or discharge is required by the resident's urgent medical needs, or d. A resident has not resided in the facility for 30 days. A notice of transfer is provided to the resident and representative as soon as practicable before the transfer and to the long-term care (LTC) Ombudsman when practicable (in a monthly list of residents that include all notice content requirements.) - R15's Electronic Medical Record (EMR) documented R15 had a diagnoses of chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing) and heart failure. R15's Modification of Quarterly Minimum Data Set (MDS), 03/12/25, documented R15 had a Brief Interview of Mental Status (BIMS) score of 12, which indicated moderate cognitive impairment. R15's Care Plan, revised 03/12/25, documented R15 had shortness of breath (SOB) retaining to hypoxia, and instructed staff to elevate the head of R15's bed 45 degrees as R15 would allow. The plan instructed staff to encourage R15 to clear own secretions with effective coughing, if R15 unable to do suction as needed (PRN). The Progress Note, dated 12/1/2024 at 09:32 PM, documented R15 was admitted to the hospital. The Progress note, dated 02/5/2025 at 06:59 PM, documented R15 was admitted to the hospital. Review of R15's clinical record lacked evidence the Office of the Long-Term Care Ombudsman (LTCO-a public official who works to resolve resident issues in nursing facilities) was notified of R15's discharge on the above dates. 03/25/25 at 03:03 PM, R15 sat in a chair in the dining room at an activity, no signs or symptoms of shortness of air. 03/27/25 at 10:00 AM, Administrative Staff A stated she was responsible for notifying the LTCO when residents were transferred to the hospital. Administrative Staff A verified the ombudsman had not been notified when the resident went to hospital on [DATE] and 02/05/25 and stated she must have printed the wrong form. The facility's Transfer or Discharge, Facility Imitated Policy, undated, documented when residents who are sent emergently to an acute care setting, these scenarios are considered facility initiated transfers. notice of transfer are provided to the resident or representative and LTCO when practicable(in a monthly list of residents that included all notice content requirements.

The facility had a census of 44 residents. The sample included 15 residents, of which five were reviewed for medication use. Based on observation, record review, and interview, the facility failed to ensure the Consultant Pharmacist (CP) identify and report Resident (R) 39's antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medication had an approved indication for use. This placed the residents at risk for inappropriate use of medication. Findings included: - The Electronic Medical Record (EMR) for R39 documented diagnoses of dementia (a progressive mental deterioration characterized by confusion and memory failure) without behavioral disturbance, vitamin D deficiency, and hypothyroidism (a condition characterized by decreased activity of the thyroid gland). The Admission Minimum Data Set (MDS), dated [DATE], documented severely impaired cognition. R39 required set-up assistance from staff for eating, oral hygiene, and partial assistance with dressing. R39 had physical and verbal behaviors toward others, wandered four to six days, and rejected care one to three days. R39 received antipsychotic medication (a class of medications used to treat major mental conditions that cause a break from reality) daily. The Psychotropic Drug Use Care Area Assessment (CAA), dated 12/26/24, documented R39 received risperidone (antipsychotic medication) on schedule for her anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) and agitation (feeling of aggravation or restlessness brought on by a provocation or a medical condition). The Care Plan, dated 01/13/25, directed staff to administer medications as directed, document any side effects, and monitor her behaviors. The care plan directed staff to complete the Abnormal Involuntary Movement Scale (AIMS rating scale that was designed to measure involuntary movements know as tardive dyskinesia). The Physician's Order, dated 12/21/24, directed staff to administer risperidone, 0.25 milligrams (mg), by mouth, in the afternoon, for anxiousness (experiencing worry, unease, or nervousness), until 12/27/24. This medication was discontinued on 12/23/24. The Physician's Order, dated 12/23/24, directed staff to administer risperidone, 0.5 mg, by mouth, twice a day, for agitation. This medication was discontinued on 01/16/25. The Physician's Order, dated 01/16/25, directed staff to administer risperidone, 0.25mg, by mouth, twice a day, for psychosis (any major mental disorder characterized by a gross impairment perception). This medication was discontinued on 01/29/25. The Physician's Order, dated 01/29/25, directed staff to administer risperidone, 0.5 mg, by mouth, twice a day, for dementia without behavioral disturbance. In the review of the EMR and Consultant Pharmacist monthly review from 12/2024 to 03/2025, lacked documentation regarding the approved indication or risk versus benefit for the continued use of the risperidone medication for dementia. On 03/25/25 at 09:23 AM, R39 ambulated down to the doors to leave the Memory Care Unit, and knocked on the door over and over, stating hey lady, hey lady! On 03/25/25 at 09:40 AM, Certified Medication Aide (CMA) R stated R39 spent a lot of time at the doors going out of the Memory Care Unit, exit seeking. Staff redirect her by offering food or conversation. On 03/25/25 at 02:31 PM, Licensed Nurse (LN) G stated R39 was often more active and exit-seeking during the evening and not during the day. When R39 was anxious. staff take her to her room and show her the paintings she painted that hung in her room or show her the book she had with her paintings in it. LN G stated R39's husband visited daily and often took her out for coffee or ice cream and spent a lot of time with her. LNG stated R39's behaviors have been more under control with the risperidone medication. On 03/25/25 at 03:31 PM, Administrative Nurse D stated she was unaware of the diagnosis of dementia for risperidone and stated she did not have a risk versus benefit or any type of indication for the use of the medication. Administrative Nurse D stated, the Consultant Pharmacist had not reported any irregularities related to the medication to her. The facility's Pharmacy Services policy, undated, documented the facility ensures that pharmaceutical services, are provided to meet the needs of each resident, are consistent with state and federal requirements, and reflect current standards of practice. The facility failed to ensure that the CP identified and reported R39's antipsychotic medication had an approved indication for use. This placed the resident at risk for receiving inappropriate psychotropic medication.

The facility had a census of 44 residents. The sample included 15 residents, of which five were reviewed for medication use. Based on observation, record review, and interview, the facility failed to ensure the Consultant Pharmacist (CP) identify and report Resident (R) 39's antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medication had an approved indication for This placed the residents at risk for inappropriate use of medication. Findings included: - The Electronic Medical Record (EMR) for R39 documented diagnoses of dementia (a progressive mental deterioration characterized by confusion and memory failure) without behavioral disturbance, vitamin D deficiency, and hypothyroidism (a condition characterized by decreased activity of the thyroid gland). The admission Minimum Data Set (MDS), dated [DATE], documented severely impaired cognition. R39 required set-up assistance from staff for eating, oral hygiene, and partial assistance with dressing. R39 had physical and verbal behaviors toward others, wandered four to six days, and rejected care one to three days. R39 received antipsychotic medication (a class of medications used to treat major mental conditions that cause a break from reality) daily. The Psychotropic Drug Use Care Area Assessment (CAA), dated 12/26/24, documented R39 received risperidone (antipsychotic medication) on schedule for her anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) and agitation (feeling of aggravation or restlessness brought on by a provocation or a medical condition). The Care Plan, dated 01/13/25, directed staff to administer medications as directed, document any side effects, and monitor her behaviors. The care plan directed staff to complete the Abnormal Involuntary Movement Scale (AIMS rating scale that was designed to measure involuntary movements know as tardive dyskinesia). The Physician's Order, dated 12/21/24, directed staff to administer risperidone, 0.25 milligrams (mg), by mouth, in the afternoon, for anxiousness (experiencing worry, unease, or nervousness), until 12/27/24. This medication was discontinued on 12/23/24. The Physician's Order, dated 12/23/24, directed staff to administer risperidone, 0.5 mg, by mouth, twice a day, for agitation. This medication was discontinued on 01/16/25. The Physician's Order, dated 01/16/25, directed staff to administer risperidone, 0.25mg, by mouth, twice a day, for psychosis (any major mental disorder characterized by a gross impairment perception). This medication was discontinued on 01/29/25. The Physician's Order, dated 01/29/25, directed staff to administer risperidone, 0.5 mg, by mouth, twice a day, for dementia without behavioral disturbance. In the review of the EMR and Consultant Pharmacist monthly review from 12/2024 to 03/2025, lacked documentation regarding the approved indication or risk versus benefit for the continued use of the risperidone medication for dementia. On 03/25/25 at 09:23 AM, R39 ambulated down to the doors to leave the Memory Care Unit and knocked on the door over and over, stating, hey lady! hey lady! On 03/25/25 at 09:40 AM, Certified Medication Aide (CMA) R stated R39 spent a lot of time at the doors going out of the Memory Care Unit, exit seeking. The staff redirect her by offering food or conversation. On 03/25/25 at 02:31 PM, Licensed Nurse (LN) G stated R39 was often more active and exit-seeking during the evening and not during the day. Wen R39 was anxious. staff take her to her room and shows her the paintings she painted that hung in her room or show her the book she had with her paintings in it. LN G stated R39's husband visited daily and often took her out for coffee or ice cream and spent a lot of time with her. LNG stated R39's behaviors have been more under control with the risperidone medication. On 03/25/25 at 03:31 PM, Administrative Nurse D stated she was unaware of the diagnosis of dementia for risperidone and stated she did not have a risk versus benefit or any type of indication for the use of the medication. Administrative Nurse D stated, the Consultant Pharmacist had not reported any irregularities related to the medication to her. The facility's Psychotropic Medication Use policy, dated 07/22, documented that residents would not receive medications that are not clinically indicated to treat a specific condition. Consideration of the use of any psychotropic medication is based on a comprehensive review of the resident. This includes evaluation of the resident's signs and symptoms to identifying causes. The facility failed to ensure that the CP identified and reported R39's antipsychotic medication had an approved indication for use. This placed the resident at risk for receiving inappropriate psychotropic medication.

The facility had a census of 31 residents. Based on observation, interview, and record review, the facility failed to label Resident (R) 12 and R31s' insulin (a hormone that lowers the level of glucose in the blood) flex pens when started in use and when expired. This deficient practice placed the affected residents at risk for ineffective medications. Findings included: - On 03/24/25 at 09:10 AM, observation of the facility's 100 and 200 hall treatment cart revealed the following: R12's Lantus (long-acting insulin) two flex pens were not labeled with an open or expired date. R31's Humalog (fast-acting insulin) flex pen was labeled with an open date of 02/26/25 and expired date of 03/19/25. (Date of observation 03/24/25 - 5 days past expiration) On 03/24/25 at 09:15 AM, Administrative Nurse D verified the nurses should label and date the insulin flex pens with the date opened and the expiration date and should discard the expired insulin pens. Medlineplus.gov directs open, unrefrigerated Lantus and Humalog can be used within 28 days; after that time, they must be discarded. The facility's Storage of Medication policy, undated, documented the facility would assure proper storage and safe storage of medications requiring refrigeration and to prevent the potential alteration of medication by exposure to improper temperatures. The facility would provide safe and effective storage of all drugs and biologicals in a locked storage area with limited access by authorized personnel. The facility would ensure that all drugs and biologicals used would be labeled in accordance with professional standards, including expiration dates (when applicable) and with appropriate accessary and precautionary instructions (such as shake well, take with meals, do not crush, special storage instructions.) Staff should observe proper storage and labeling requirements for all medications and vaccines during the performance of their daily tasks and should demonstrate safety in regard to the medication's integrity, such duties should include but not limited to: Remove any expired medications from active stock and discard medications according to facility policy. The facility failed to date the insulin flex pens when opened and the expiration date placing the residents at risk for ineffective medication

The facility had a census of 44 residents. Based on observation, record review and interview the facility failed to provide a safe, sanitary environment for Resident (R) 15 when staff failed to clean his carpet and recliner. Findings included: 03/24/25 at 10:00 AM, R15's room had a black stain in the carpet in front of a recliner, approximately 18 inches (in) long by eight in wide. The recliner had a red stain on the left arm , approximately six in. by three in wide. The left arm cover had a yellow stain , approximately two in by two in. The room and the recliner had a urine odor. 03/25/25 at 11:47 AM Housekeeping Supervisor (HS) V verified there was a urine odor in R15 room. HS V stated the urine smell was in the carpet and the recliner. HS v verified the stains in the carpet and on the recliner and stated she had cleaned the carpet several times and could not get the urine odor out, it was probably in the carpet pad also. 03/25/25 11:59 AM Administrative Staff A stated she was aware of the urine smell in the resident's room and recliner. The stain in front of the recliner is from when the resident was able to do crafts, he spilled paint. Administrative Staff A stated the faciity had a plan to start replacing carpeted rooms with vinyl flooring. Administrative Staff A stated she knew the recliner had an urine odor. The facility's Cleaning and Disinfection of Environmental Surfaces Policy, revised August 2019, documented environmental surfaces would be cleaned and disinfected according to current Centers for Disease Control and Prevention (CDC) recommendations for disinfection of healthcare facilities and the Occupational Safety and Health Administration (OSHA) bloodborne pathogen standard.

The facility had a census of 44 residents. The sample included 15 residents with one reviewed for pressure ulcers. Based on observation, record review, and interview, the facility failed to initiate effective interventions to prevent the development of a left heel, facility acquired, unstageable pressure ulcer (depth of the wound is unknown due to the wound bed being covered by a thick layer of other tissue and pus,) for Resident (R) 9. Findings included: - R9 's diagnoses included healing fracture neck of the left femur (thigh bone,) dementia (a progressive mental disorder characterized by failing memory and confusion) osteoporosis (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk,) and muscle weakness. R9's Quarterly Minimum Data Set (MDS), dated [DATE], recorded the resident had a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The MDS documented required extensive assistance of two staff with bed mobility and transfers. The MDS further documented the resident had one unstageable pressure ulcer that was not present on admission. The Pressure Ulcer Care Area Assessment (CAA), dated 01/16/25, documented the resident was a moderate risk for pressure ulcers due to her skin is often moist, being chairfast, mobility limitations and problem with friction and shearing due to moderate to maximum assistance. The CAA documented the resident required one on one assistance with transfers due to recent left hip fracture repair. The CAA documented the resident was dependent on staff for all weight bearing Activities of Daily Living (ADLs) and for dressing and personal cares. The Braden Scale Assessment for predicting pressure ulcer risk, dated 12/26/24 documented a score of 16.0 indicating the resident was at risk. The Pressure Ulcer Care Plan, dated 01/09/25, documented the resident was at moderate risk for pressure ulcers due to skin is often moist, being chair fast, mobility limitations and problems with frictions and shearing due to moderate to maximum assistance with movement. The care plan directed the staff to complete a weekly skin assessment and report any skin concerns to the wound nurse and physician. The care plan directed the staff to provide a pressure redistribution mattress in the bed and a pressure relief cushion in her recliner. Interventions would be adjusted according to R9's needs. The Physician Order, dated 01/09/25 directed the staff to apply a pressure redistribution mattress to bed, and a pressure relieving cushion in her recliner and wheelchair. The 02/15/25 at 06:53 AM, Nurse's Notes, documented the aide reported a new skin impairment on the left heel. The nurse assessment documented the area measured 8.0 centimeter (cm) by 5.0 cm across a boney prominence of the heel. The staff were to add heel protector boots while the resident was in bed and recheck history of interventions. The staff are presently off-loading the heels at the time of impairment discovery, and staff would monitor the left heel area daily for eschar changes and notify the nurse and primary care physician if any changes were noted. The Physician Order, dated 02/16/25, documented to monitor the left heel area daily, do not apply a dressing to the area. The staff would notify the wound nurse and the primary care physician if any changes occur, or sign and symptoms of infection are present. The Weekly Pressure Injury Skin Report, dated 02/16/25, documented R9 had an area on her left heel, measuring 5.0 centimeter (cm) by 8.0 cm, no tunneling, with thick eschar (dead tissue), hard leathery black exudate (a fluid that leaks out of body vessels and tissues.) The report documented the suspected cause was from R9's recliner. The staff have added task of placing a heel protection on the left heel while in recliner. The 02/19/25 at 12:58 PM, nurse's notes, documented the resident had one wound, a patch of eschar that covered the entire heel and pressure interventions started for management include wearing protective heel and foot cushions while the resident was in the recliner. Heel protectors have been added to the care plan off-loading heels were in place at the time of the wound occurrence, and heel protectors have been added to the care plan, to be on the left heel while in the recliner as this is the suspected cause of the pressure location. R9 has been noted to draw up her left leg and place her heel in the diversion of the footrest of the chair matching roughly to the eschar location. The Weekly Pressure Injury Skin Report, dated 03/08/25, documented R9's area on left heel, measured 5.0 cm by 8.0 cm, no tunneling, unstageable, with eschar of the left heel. The Weekly Pressure Injury Report, dated 03/12/25, documented R9 had a left heel pressure ulcer, measuring 4.1 cm by 4.1 cm, no tunneling, eschar was noted to have slight peeling at the distal edges, and a ring of it came off during the week and the remainder is well adhered. The surrounding tissue is pink with some scar tissue from the healing area. The Weekly Pressure Injury Report, dated 03/22/25, documented R22 had a left heel pressure ulcer, measuring 3.5 cm by 3.7 cm, no tunneling, unstageable, with eschar, and hard leathery black exudate. The report documented more eschar flaked off during assessment and the eschar remained firmly adhered. The evaluation documented the area was improving. On 03/24/25 at 12:00 PM, observation revealed R9 sat in her wheelchair at the dining room table, awaiting staff to deliver her lunch. Continued observation revealed the resident had a pressure relieving boot on her left foot/heel and the foot has slipped between the two metal footrest pedals. On 03/25/25 at 07:45AM, observation revealed R9 sat in recliner in her room with pressure relieving boot on her left foot/heel. Continued observation revealed LN H removed the resident pressure relieving boot and sock and revealed the resident's left heel with black eschar covering the heel no drainage and the eschar had separated from the skin. LN H placed the resident's sock and pressure relieving boot on her left heel/foot. On 03/25/25 at 08:30 AM, Administrative Nurse D verified the resident developed the unstageable pressure ulcer on her left heel 02/15/25. Administrative Nurse D verified the resident did not have pressure relieving boot upon admission to the facility post left hip fracture 01/02/25. Administrative Nurse D verified the resident was at risk for skin impairment and the staff off loaded her feet when in bed but stated LN I felt the resident rested her left heel on the footrest of the recliner and this is how the area developed. The The Wound Assessment, Prevention and Treatment, policy undated, documented a resident who enters the facility without pressure ulcers would not develop them unless the individual's clinical condition demonstrates that they were unavoidable. In addition, if a resident has a wound, he/she would receive necessary treatment and services to promote healing, prevent infection, and prevent new wounds from developing. On admission a comprehensive assessment that includes skin condition and other casual factors that place a resident at risk for developing pressure ulcers and/or delayed healing and the nature of the pressure to which the resident is subject to. The assessment should identify which risk factors can be removed or modified. The assessment also helps in identifying the resident with multi-system failures or an end-of-life condition or who is refusing and treatment and the basis for the refusal and the identification and evaluation of potential alternatives. All residents with a pressure ulcer and all residents identified at risk for skin breakdown would have the problem identified on the Plan of Care with appropriate preventative approaches identified.

The facility identified a census of 36 residents with one kitchen. Based on observation, record review, and interviews, the facility failed to maintain sanitary dietary standards related to storage of food. This deficient practice placed the residents at risk related to food borne illnesses and food safety concerns. Findings included: - On 06/13/23 at 07:15 AM in the kitchen's small refrigerator an observation revealed a bag of mozzarella cheese open with no date. On 06/13/23 at 07:16 AM in the kitchen's small refrigerator an observation revealed bacon, cut into small pieces, in a resealable bag that had no label or date. On 06/13/23 at 07:17 AM in the kitchen's small refrigerator an observation revealed three, unlabeled bottles of salad dressing that were open with no date. On 06/13/23 at 07:26 AM on a small storage shelf in the main kitchen area, an observation revealed a bag of raisin bran cereal that was opened with no date. On 06/13/23 at 07:34 AM in the kitchen's large refrigerator an observation revealed one resealable bag of various lunch meat. The bag did not have a label and was undated. On 06/13/23 at 07:35 AM in the kitchen's large refrigerator an observation revealed one, resealable bag of small sub sandwiches. The bag did not have a label and was undated. On 06/13/23 at 07:36 AM in the kitchen's large refrigerator an observation revealed one, resealable bag of cheese cubes. The bag did not have a label and was undated. On 06/13/23 at 07:40 AM in the kitchen's freezer an observation revealed a resealable bag of chicken strips. The bag did not have a label and was undated. On 06/13/23 at 07:44 AM in the kitchen's dry storage area an observation revealed one, opened bag of breadcrumbs. The bag did not have a label and was undated. On 06/13/23 at 07:47 AM in the kitchen's dry storage area an observation revealed one box of cocoa powder on the top shelf. The box contents were open to air and undated. On 06/13/23 at 07:50 AM in the kitchen's dry storage area an observation revealed three bags of noodles. Two bags remained in the manufactures packaging and were opened with no date. One bag was resealable with no label and was undated. On 06/15/23 at 11:28 AM Dietary BB stated opened food items should be sealed, labeled, and dated. She further stated that some food items would be placed back into their original boxes if they were in an unlabeled bag. She stated that food items should not have been left open to air and should have been sealed. The Facility's Food Receiving and Storage policy revised on October 2017, documented all foods stored in the refrigerator or freezer will be covered, labeled, and dated (use by date). The facility failed to maintain sanitary dietary standards related to storage of food. This deficient practice placed the residents at risk related to food borne illnesses and food safety concerns.

The facility had a census of 36 residents. The sample included 12 residents. Based on observation, record review, and interview the facility failed to secure chemicals in a safe, locked area, and out of reach of the nine cognitively impaired, independently mobile residents. The facility additionally failed to identify and implement resident centered fall intervention for Resident (R)20's repeated falls and failed to ensure implemented interventions identified during some investigations were added to the R20's plan of care. The facility further failed to prevent an avoidable accident when staff failed to ensure the floor was dry prior to a transfer, resulting in a fall for R18. This placed the affected residents at risk for preventable accidents and related injuries. Findings Included: - On 06/13/23 at 07:03AM an inspection of the facility's 100 and 200 hallway shower rooms revealed unsecured disinfectant cleaning products accessible inside both unlocked rooms. An inspection of the 100 hallway revealed an unlocked soiled linen room with disinfectant cleaner and furniture polish in an accessible cabinet. An inspection of the Assisted Living hallway, accessible to all facility residents, revealed a laundry room with two disinfectant cleaning bottles in an unsecured cabinet. All products identified contained the warning, Keep out of reach of children, hazardous to humans can cause eye irritation, harmful if swallowed. On 06/15/23 at 12:17PM Certified Nurse's Aide (CNA) M stated residents should not have access to cleaning chemicals. He stated staff should lock up cleaners and spray to prevent accidental poisoning. On 06/15/23 at 01:02PM Administrative Nurse D stated the cleaning chemicals should be stored in a locked cabinets or supervised when in use. A review of the facility's Hazardous Area, Device, and Equipment policy revised 07/2017 indicated the facility will protect its residents from potentially hazardous equipment, areas, and toxic chemicals. The facility failed to secure chemicals in a safe, locked area, and out of reach of the nine cognitively impaired, independently mobile residents. This placed the affected residents at risk for preventable accidents. - The Medical Diagnosis section within R20's Electronic Medical Records (EMR) included diagnoses of hemiparesis (muscular weakness of one half of the body), hemiplegia (paralysis of one side of the body), retention of urine, type two diabetes (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), weakness, depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness) and cerebral infarction (sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain). A review of R20's Quarterly Minimum Data Set (MDS) dated [DATE] noted a Brief Interview for Mental Status (BIMS) score of five indicating severe cognitive impairment. The MDS indicated he required limited assistance from one staff for transfers, personal hygiene, dressing, toileting, and bathing. The MDS indicated he was frequently incontinent of urine and occasionally incontinent of bowel with no toileting program. A review of R20's Activities of Daily Living (ADLs) Care Area Assessment (CAA) completed 11/22/22 indicated he required limited to extensive assistance from staff for transfers, dressing, toileting, and personal hygiene. The CAA indicated he had an unsteady gait and required assistance from staff for safety and reduction of failing. The CAA indicated he was a high fall risk and overestimated his limits. R20's Urinary Incontinence CAA completed 11/22/22 indicated he was occasionally incontinent of urine and bowel. The CAA indicated he required staff him for ADLs. The CAA indicated he required a one-to-one staff assist for transfer, dressing, and toileting. R20's Fall CAA completed 11/22/22 indicated he was a fall risk related to his medical diagnoses, bowel/bladder incontinence, needs for assistance with ADLs, and unsteady gait/balance. The CAA instructed staff to assist him with transfers and ADLs. A review of R20's Care Plan initiated 11/22/22 indicated he required limited to extensive assistance with transfers, dressing, and bathing. The plan noted he required limited assistance from one staff for bed mobility and toileting (11/22/22). The plan indicated nursing staff will provide incontinence cares after each toileting and as needed (11/22/22). The plan indicated staff will check R20 every two hours for incontinence and complete skin assessment. The plan indicated he was a high fall risk. The plan indicated staff will provide one to one assistance for all ambulation and transfers (11/22/22). The plan noted R20 was intermittently confused and required constant reminders to call staff for assistance (11/22/22). A review of R20's EMR revealed a Fall Investigation dated 11/11/22. The report indicated he was found on the floor of his bathroom after attempting to use the restroom. The report indicated he was provided a portable urinal and staff completed hourly checks for the night to reinforce waiting for staff assistance. A review of R20's EMR revealed a Fall Investigation dated 03/08/23. The report indicated he was found on the floor next to his bed. The report indicated he did not activate his call light before attempting to transfer himself. The intervention indicated staff would reinforce the needed use for his call light. The report indicated he had a personal safety alarm (pad alarm). A review of R20's EMR revealed a Fall Investigation dated 04/01/23. The report revealed R20 was found by staff laying on his restroom floor. The reported noted R20 reported he lost his balance and slid down the bathroom door. The reported noted he was incontinent of bladder. The report's intervention was for R20 not to leave his bathroom unattended by staff. The report indicated staff would help toileting before and after meals. A review of R20's Progress Notes indicated he had a fall on 05/24/23 at 10:22pm. The note indicated he suffered a bruise in his coccyx. The note indicated he was found on the bathroom floor by staff after attempting to self-toilet himself. The note indicated he was reminded to use his call light for staff assistance. The note indicated R20 reported he was in a hurry to use the restroom and fell due to weakness. The facility did not provide a fall investigation for this incident. On 06/13/22 at 09:02AM R20 sat on his bed. A urinal sat on the floor next to his bed. R20 reported he had multiple falls. He stated his falls had been related to going to his bathroom. He stated he would lose his balance or fall due to being weak. He reported he sometimes forget to call for staff before going to the restroom. R20's restroom had non-skid floor strip and a grab bar installed by the toilet. On 06/15/23 at 12:05PM Certified Nurse's Aide (CNA) M stated R20 often forgets to call for help and will take himself to the bathroom without assistance. He stated staff offered frequent reminders, but R20's memory was too bad to remember. He stated staff will check on R20 frequently and offer help. He stated R20 often turned off his alarm and staff would not know when he took himself to the restroom. On 06/15/23 at 12:34PM Licensed Nurse (LN) G stated R20 did not have issues during the day but often got up in the middle of the night to use the restroom. He stated most of R20's falls occurred during the night. On 06/15/23 at 01:02PM Administrative Nurse D stated staff were expected provide toileting for R20 per his care planned interventions. She stated R20 had poor memory recall and needed multiple reminders to use his call light. She stated R20 fell because his muscles were weak, and he attempted to self-transfer to the restroom. She stated it depended on what kind of day R20 was having and how alert he was. A review of the facility's Accident/Falls policy revised 03/2018 indicated the facility will identify risk related to falls/accidents to allow interventions to be implemented. The policy noted a plan of care will address the individualized focus, goal, and interventions directed towards reducing the resident's risk of injury and potential reoccurrences of falls. The facility failed to identify and implement resident centered fall interventions for R20's repeated falls and failed to ensure implemented interventions identified during some investigations were added to the resident's plan of care. This placed him at risk for preventable accidents and injuries. 47834 - R18's Electronic Medical Record (EMR) documented diagnoses of repeated falls, dementia (progressive mental disorder characterized by failing memory, confusion), and age-related osteoporosis (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk). The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 15 which suggested R18 was cognitively intact. The MDS documented R18 required extensive assistance of one staff member for many of her activities of daily living (ADL). The ADLs Functional Status/Rehabilitation Potential Care Area Assessment (CAA), dated 12/28/22, documented R18 was limited to extensive assist on one staff member for ADLs. The MDS documented that R18 was unsteady and required stand by assist for safety. The Falls CAA dated 12/28/22, documented R18 was a high risk for falls due to history of falls, secondary diagnosis, and that she required an ambulatory aide and staff assistance. The Care Plan dated 01/16/23, documented R18 was a high risk for falls due to history of falls, secondary diagnosis, weakness and need for ambulatory aide. An approach dated 01/16/23 documented R18 slipped to the floor in the shower room with staff present and directed staff to make sure the floor was dry or use a towel/bathmat to stand on and offer shoes or slippers. An undated Complaint Investigation Witness Statement documented that Certified Nurse's Aide (CNA) O was transferring R18 from the shower chair to her walker. R18 slipped and fell on her bottom. CNA O documented that the floor was still a little wet during the transfer. A Fall Scene Investigation Report dated 04/22/22 documented the root cause of the fall appeared to be the floor not being dried while R18 transferred from a seated to standing position. The report further documented an intervention to prevent future falls that staff were to dry the floor or have a mat or towel down away from water on the floor. A Progress Note dated 04/26/22, documented R18 slid in the shower on 04/22/22 while staff were present. It documented that staff were to make sure that the floor is not slick in the future by using a towel or floor mat for R18 to stand on and to offer the option of wearing slipper or shows prior to standing in the shower. An observation on 06/14/23 at 12:12 PM revealed R18 sat in her recliner in her room and watched TV. Staff assisted and setup her meal try. On 06/15/23 12:17 PM Certified Nurse Aide (CNA) M stated before attempting to transfer residents in the shower room, staff should wipe up any water on the floor. On 06/15/23 at 12:34 Licensed Nurse (LN) G stated before transferring a resident in the shower room, staff should do as much as they can to dry the resident as much as possible and get them dressed in the shower chair. LN G then stated staff should use a gait belt and clean up any water that is noted to be on the floor prior to transferring the resident. On 06/15/23 at 01:02 PM Administrative Nurse D stated staff were expected to dry the floor prior to transferring residents in the shower room. The facility's Falls policy revised on March 2018, documented that frail and elderly individuals are often at greater risk for serious adverse consequences of falls. The facility failed to prevent an avoidable accident when staff failed to ensure the shower room floor was dried/cleared of water before attempting to transfer R18 causing her to slip and fall. This deficient practice placed R18 at risk for injury.

The facility reported a census of 36 residents. Based of observations, record review, and interviews, the facility failed to ensure safe storage and handling of the resident's medications. This deficient practice placed the residents at risk for unnecessary medication and administration errors. Findings Included: - On 06/13/23 at 07:02AM a medication treatment cart outside Resident (R)10's room contained a Novolog Flexpen (injectable short-acting hormone which regulates blood sugar) left unsecured on top of the cart from 07:02AM to 07:10AM. The insulin belonged to R10. At 07:10AM Licensed Nurse (LN) G returned to the cart and secured the pen. On 06/15/23 at 12:34PM Licensed Nurse (LN) G stated medication should be secured when not being immediately administered or supervised. He stated staff should locked up medication in the cart when stepping away from the cart. On 06/15/23 at 01:02PM Administrative Nurse D stated staff were expected to lock up medication when not in use or keep constant supervision on medication being prepared for the residents. A review of the facility's Medication Storage policy revised indicated that all medications will be stored in a manner that is sanitary, temperature/moisture controlled, and secured. The policy indicated medication supply will be monitored and reordered before expiration or low supply. The facility failed to ensure safe storage and handling of the resident's medications. This deficient practice placed the residents at risk for unnecessary medication and administration errors.

The facility identified a census of 35 residents. Based on observations, record review, and interviews, the facility failed to ensure proper infection control standards were followed related to clean supply storage, respiratory equipment, shared care equipment, hand hygiene during medication administration, and providing cares. This deficient practice placed the residents at risk for complications related to infectious diseases. Findings Included: - On 06/13/23 at 07:10AM an inspection of the 100-hallway shower room revealed three opened packages of incontinence briefs stored on a shelf above the toilet. The content of packages (incontinence briefs) was pulled out of the plastic wrapper and stored directly on the shelf. On 06/13/23 at 08:01 AM Laundry Staff V stated she obtained water temperature daily but only recorded the temperature weekly. The facility was unable to provide evidence staff routinely assessed laundry water temperature. On 06/13/23 at 08:01AM Resident (R)35's nebulizer face mask and tubing were on his bed, unbagged. His tubing was not labeled/dated indicating what day the tubing was placed. R35's humidifier bottle on his supplemental oxygen machine was not labeled/dated to show when it was filled. On 06/14/23 at 07:08 AM Certified Medication Aide (CMA) S prepared medication for R 33, entered R33's room, administered the medication to R33 from the plastic medication cup. CMA S filled R33's water pitcher. CMA S exited the room, pushed the medication cart to R4's room. Without performing any hand hygiene, CMA S prepared medication from the medication cards into a plastic cup. CMA S entered R4's room and handed the medication cup to R4. CMA S exited the room, pushed the medication cart to R10's room. Without performing any hand hygiene still, CMA S prepared medication from medication cards into a plastic medication cup, entered R10's room, and administered medication to R10 with a spoon. CMA S exited R10's room without performing hand hygiene. On 06/14/23 at 09:14 AM Certified Nurse Aide (CNA) N completed a Hoyer lift (total body mechanical lift used to transfer residents) transfer for R10. CNA N then rolled the Hoyer lift into the beauty shop to store without disinfecting the lift after use. On 06/14/23 at 11:42 AM CNA N and CNA P explained to R10 they were going to perform catheter care. CNA N donned gloves, CNA P had gloves on. CNA N removed the tape from the incontinent brief and pulled the brief downward between R10's legs. CNA N removed a disposable wipe from the package; she wiped in downward motion around R10's labia, CNA N disposed of the soiled wipe and repeated this for three more wipes. CNA P helped R10 to turn onto her left side. CNA N wiped R10's coccyx and rectal area. CNA N removed soiled brief from under R10's bottom. Without changing soiled gloves, CNA N placed a clean brief under R10, and CNA P helped apply incontinent brief onto R10. CNA N and CNA P both doffed gloves but did not perform hand hygiene. The CNAs then and assisted R10 with pulling up slacks and putting her sock back onto her foot. On 06/14/23 at 01:34PM R35's nebulizer face mask and tubing sat unbagged on his bedside dresser. His nebulizer tubing was dated with a tape label. R35's nasal cannula and oxygen tubing sat over his bedside table. His oxygen tubing and humidifier had no date/label. On 06/14/23 at 09:14 AM CNA N stated the Hoyer lift should be disinfected between each use. CNA N stated the staff usually used wet wipes and wiped it down, because they did not have any disinfect wipes. On 06/15/23 at 12:17PM CNA M stated hand hygiene should be completed in before and after cares were provided. He stated medical equipment shared by more than one resident should be thoroughly disinfected before using on other residents. He stated urinary catheter collection bags should be held and placed below the resident's bladder. He stated clean hygiene products and linen should be stored separately from soiled or dirty items. CNA M stated oxygen therapy equipment should have been stored in clean plastic bag to prevent contamination. On 06/15/23 at 12:34PM Licensed Nurse (LN) G stated hand hygiene should be completed before prepping medications, performing blood glucose (blood sugar) checks, providing cares, and transferring residents. He stated hand hygiene should be completed directly after doffing gloves. He stated oxygen tubing and masks should be stored in a plastic bag and never meet contaminated surfaces. He stated shared equipment was always disinfected in between uses. LN G stated hand hygiene should be preformed between each resident when administering medication. On 06/15/23 at 01:02PM Administrative Nurse D stated the facility currently was holding in-services related to infection control practices. She stated shared equipment should be wiped down with alcohol-based wipes in between uses Administrative Nurse D stated she would expect hand hygiene to be completed between each resident during medication administration. A review of the facility's Oxygen Therapy policy revised 10/2010 indicated the facility will follow safe oxygen administration practices that included sanitary administration and equipment storage, tracking of treatments, and continual assessment of the residents and equipment. A review of the facility's Cleaning and Disinfection of Resident-Care Equipment policy revised 07/2014 indicated all care equipment will be disinfected before and after use. The policy indicate hand hygiene will be completed in between cares provided and using equipment. A review of the facility's Handwashing /Hand Hygiene revised 08/2015 indicated hand hygiene will be completed to prevent the spread of infection. The policy no01/2014 [NAME] hand hygiene should be completed before, during, and after providing cares. The policy noted hand hygiene should be completed directly after removing personal protective equipment (PPE). A review of the facility's Laundry Policy revised 01/2014 indicated laundry temperature must be monitored for sanitary cycling. The policy indicated the facility must ensure high temperatures washes remained at least 160 degrees Fahrenheit. The facility failed to ensure proper infection control standards were followed related to clean supply storage, respiratory equipment, shared care equipment, and delivery of cares. This deficient practice placed the residents at risk for complications related to infectious diseases.

The facility identified a census of 36 residents. The sample included 12 residents with one resident reviewed for hospitalization . Based on observation, record review, and interviews, the facility failed provide written notice of transfer with the required information to Resident (R) 90 and/or to their legal representative in a practicable amount of time. The facility also failed to send notification to the office of the state Long-Term Care Ombudsman of the facility's transfers and discharges. This deficient practice had the risk of miscommunication between facility and resident/family and possible missed opportunity for healthcare service for these residents. Findings included: - R90's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of history of a traumatic brain injury (usually results from a violent blow or jolt to the head or body) and chronic obstructive pulmonary disease (COPD- progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 14 which indicated intact cognition. The MDS documented that R90 required extensive assistance of two staff members for activities of daily living (ADLs). The Quarterly MDS dated [DATE] documented a BIMS score of 15 which indicated intact cognition. The MDS documented that R90 required extensive assistance of two staff members for ADLs. R90's ADL Functional/Rehabilitation Potential Care Area Assessment (CAA) dated 11/14/22 documented R90 required extensive assistance of two staff for ADLs. R90's Care Plan dated 11/16/22 documented R90 planned to remain at the facility. Review of the EMR under Progress Notes tab revealed documentation: A Nurses Note dated 06/07/2023 at 04:13 AM documented R90 had change in condition and was sent to the hospital for evaluation and treatment. A Nurses Note dated 06/07/2023 at 09:13 AM documented R90 was admitted to the hospital. R90's clinical record lacked evidence the facility provided a written notification of discharge which contained the required information to R90 and/or legal representative. On 06/15/23 at 11:00 AM the facility provided documentation the Long-Term Care Ombudsman's office was notified of transfers and discharges from 01/23/23 to 05/23/23. On 06/14/23 at 07:09 AM R90 wheeled his wheelchair down the hallway without assistance to the dining room. On 06/14/23 at 10:00 AM Administrative Staff A stated the facility did not provide the resident or their legal representative written notification. Administrative Staff A stated the facility would always call the legal representative to notify them of the transfer or discharge. On 06/15/23 at 09:30 AM Administrative Staff B stated the facility had not notified the Long-Term Care Ombudsman's office of any transfers or discharges since January 2023. The facility's Transfer or Discharge policy last revised 03/2017 documented the residents and/or representatives would be notified in writing, and in a language and format they understood. A copy of the notice would be sent to the Office of the State Long-Term Care Ombudsman at the same time the notice of transfer or discharge is provided to the resident and representative. The facility failed to provide written notice of transfer with the required information to R90 and/or to their legal representative and notify the Long-Term Care Ombudsman's office of any transfers or discharges since January 2023. This deficient practice had the risk of miscommunication between facility and resident/family and possible missed opportunity for healthcare service for these residents.

The facility identified a census of 36 residents. The sample included 12 residents. Based on observation, record review and interview, the facility failed to ensure a care plan area was initiated to address Resident (R) 2's limited range of motion (ROM) due to contracture (an abnormal permanent fixation of a joint) of her joints, bilateral upper and lower extremities, and neck to maintain her current level of ROM and promote comfort. This deficient practice placed R2 at risk for decreased ROM and impaired comfort. Findings included: - The electronic medical record for (EMR) for R2 documented diagnoses of osteoporosis (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk), and rheumatoid arthritis (RA-a chronic inflammatory disease that affected joints and other organ systems). The Annual Minimum Data Set (MDS) dated [DATE] for R2 documented a Brief Interview for Mental Status (BIMS) score of 13 which indicated intact cognition. R2 required limited assistance with eating but was total dependent on two staff for all other activities of daily living (ADLs). R2 had limited functional ROM of both upper and lower extremities on both sides. R2 was not receiving restorative services. R2 was on hospice services. The Quarterly MDS dated [DATE] documented R2 had a BIMS of 13 which indicated intact cognition. R2 required limited assistance with eating but was total dependent on two staff for all other ADLs. R2 had limited functional ROM of both upper and lower extremities on both sides. R2 was on hospice services. R2 was not receiving restorative services. The ADL Care Area Assessment (CAA) dated 02/17/23 documented R2 was non-ambulatory (not able to walk about) and required two staff with a mechanical lift (a device used to assist with transferring a resident) for transfers due to pain and weakness. R2 would occasionally sit on the side of her bed with assistance. R2's hands were twisted with moderate contracture of the right upper extremity noted. R2 had RA. R2's bilateral lower extremities had moderate contractures as well as moderate foot drop noted. R2 was totally dependent on two staff for bed mobility. The ADLs Functional Status/Rehabilitation Potential Care Plan dated 02/17/23 for R2 directed staff that R2 was extensive to total assist of two. R2 required assistive devices of protective booties, air mattress, wheelchair, oxygen, and mechanical lift for transfers. The care plan lacked direction to staff regarding restorative services or interventions to address her contracture and/or interventions/exercises to prevent further decline of joint ROM. The Pain Care Plan dated 02/17/23 directed staff to administer pan medications as prescribed by physician. Staff would allow R2 to voice her pain and talk and ventilate about issues she may wish to discuss. Staff would attempt non-pharmacological pain relief measures, such as, removing from increased stimuli environment, calm approach, offering beverages or snacks, repositioning and massage. The Care Plan lacked a care area to address R2's contractures of hands, lower extremities, and neck; it lacked interventions to direct staff on cares for the contractures. The Orders tab in the EMR for R2 lacked any order for a restorative program or ROM exercises/devices or any type of restorative program direction for R2's contractures. On 06/15/23 at 08:30 AM R2 laid in bed wearing a hospital gown. R2 had colored pencils and a coloring page on the bed. R2 stated her neck was painful and contracted to the right. R2 stated she rested her head on her right shoulder a lot. R2 stated her hands were hideous and very painful due to her arthritis. R2 stated she wished she had a pillow or something to support her neck more; she had one at one time but does not know what happened to it. On 06/15/23 at 12:15 PM Certified Nurse Aide (CNA) M stated that R2 used to have a neck pillow, but she did not like it and would not use it most of the time. CNA M stated R2 did experience a lot of pain in her hands and neck and was not aware of any type of restorative or exercise interventions for R2. CNA M stated R2 was on hospice services and could not say what hospice might provide for R2 for her contractures. On 06/15/23 at 12:15 PM Licensed Nurse (LN) G stated he had tried to do some ROM exercises and things with R2 but would have to stop due to her severe pain she would experience. LN G was not aware of R2 being on any type of restorative program currently. LN G stated he was not positive what interventions were in place for R2's contractures without looking at her care plan. On 06/15/23 at 01:01 PM Administrative Nurse D stated R2 should have a care area and interventions in place to address her contractures and to maintain her ROM. The facility did not have a restorative program currently. Administrative Nurse D stated that therapy did not work with residents that were on hospice. Administrative Nurse D stated that some of the staff did try to do some ROM exercises with R2 but that was not charted anywhere that she was aware of. Administrative Nurse D stated the facility tried several different things to try to help with R2's contractures but due to her pain those did not work for long or R2 would refuse them. The facility did not provide a policy for care plans. The facility failed to ensure a care plan was initiated for R2 to address her limited ROM due to contractures of her joints, both upper and lower extremities and neck. The facility failed to have interventions in place to maintain R2's her current level of ROM and promote comfort. This deficient practice placed R2 at risk for decreased ROM and impaired comfort.

The facility identified a census of 36 residents. The sample included 12 residents with four reviewed for bowel and bladder management. Based on observation, record review, and interviews, the facility failed to implement individualized toileting interventions related to bowel and bladder incontinence for Residents (R)17 and provide sanitary Foley catheter (tube inserted into the bladder to drain urine into a collection bag )care for R10. This deficient practice placed the residents at risk for complications related to infection and incontinence. Findings Included: - The Medical Diagnosis section within R17's Electronic Medical Records (EMR) included diagnoses of amputation of right foot great toe, diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), chronic obstructive pulmonary disease (COPD- progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), hypertension (high blood pressure), gout (inflammation of the joints), and cellulitis (skin infection caused by bacteria characterized by heat, redness and swelling). A review of R17's Significant Change Minimum Data Set (MDS) dated [DATE] noted a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment. The MDS indicated he required limited assistance from one staff for bed mobility, transfers, dressing, personal hygiene, toileting, and bathing. The MDS indicated he was occasionally incontinent of urine and always continent of bowel. The MDS indicated he had no toileting program in place. A review of R17's Activities of Daily Living (ADLS) Care Area Assessment (CAA) completed 02/20/23 indicated he required supervised to limited assistance with his ADLs due to his recent toe amputations. The CAA indicated he could call for assistance when needed. R17's Urinary Incontinence CAA completed 02/20/23 indicated a plan will be created to address his urinary incontinence. The CAA indicated he was occasionally incontinent of urine and will use a portable urinal to void. The CAA indicated he used a bedside commode (portable toilet) for bowel movements. A review of R17's Care Plan initiated 03/07/23 indicated he required supervision to limited assistance from one staff for his ADLs. The plan indicated he had occasional urinary incontinence. The plan indicated he required assistance dressing and using incontinence products after incontinent episodes. The care plan lacked individualized interventions to prevent, maintain and promote R17's highest level of functioning related to incontinence. A review of R17's EMR revealed a Bladder Observation form completed on 02/08/23. The form indicated he was incontinent of bladder. The form indicated he had occasional nocturia (nighttime urinary incontinence) and bed wetting. The form indicated he was at risk for stress incontinence. A review of R17's EMR revealed a Bladder Observation form completed on 02/23/23. The form indicated he was incontinent of bladder. The form indicated he had impaired mobility, diabetes, and urge incontinence. A review of R17's EMR revealed a Bladder Observation form completed on 05/15/23. The form indicated he was incontinent of bladder. The form indicated he had impaired mobility, diabetes, and urge incontinence. On 06/13/23 at 07:08AM R17's room smelled heavily of urine. Three portable urinals sat on the floor next to his bed. One of the urinals was one-third full of urine. The portable commode was positioned across the room next to his roommate's bed. R17 reported that since his toe amputation his ability to go to the bathroom has decreased. He stated he used to be able to take himself but now required more staff assistance. He stated his incontinence episodes have increased. On 06/15/23 at 12:34PM Licensed Nurse (LN) G stated R17 often had urinals next to his bed in case he needed to urinate at nighttime. He stated R17 was not on a toileting program but was incontinent of bowel and bladder. He stated R17 was independent but recently required more assistance due to his toe amputation. On 06/15/23 at 01:02PM Administrative Nurse D stated staff were expected check on each resident every two hours to offer restroom breaks. She stated staff should ensure each resident's call light is in place and check on them frequently. She stated R17 can use his portable urinal, but staff should offer assistance for the commode due to him being a fall risk due to his toe. A review of the facility's Urinary Incontinence policy revised 09/2010 indicated each resident will be continually assessed and provided interventions to maintain and promote each resident's care and prevent a decline. The policy noted each resident's medication, diagnosis, and environmental factors will be assessed to provide personalized care plans to address to care needs. The facility failed to implement individualized toileting plans or attempt a toileting program related to bowel and bladder incontinence for R17. This deficient practice placed R17 at risk for complications related to incontinence. 41037 - R10's electronic medical record (EMR) from the Diagnoses tab documented diagnoses of urinary tract infection (UTI-an infection in any part of the urinary system), unspecified bladder disorder, retention of urine (lack of ability to urinate and empty the bladder), and depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness). The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 12 which indicated moderately impaired cognition. The MDS documented that R10 was dependent on two staff members assistance for activities of daily living (ADLs). The MDS documented R10 had an indwelling catheter (tube inserted into the bladder to drain urine) during the look back period. The Quarterly MDS dated [DATE] documented a BIMS score of 11 which indicated moderately impaired cognition. The MDS documented that R10 was dependent on two staff members assistance for ADLs. The MDS documented R10 had an indwelling catheter (tube placed in the bladder to drain urine into a collection bag) during the look back period. R10's ADL Functional/Rehabilitation Potential Care Area Assessment (CAA) dated 02/13/23 documented R10 was dependent on staff for ADLs. R10's Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA) dated 02/13/23 documented R10 had an indwelling catheter related to her diagnosis of urinary retention. R10's Care Plan dated 02/13/23 documented R10 would be provided catheter care every shift. Review of the EMR under Orders tab revealed physician orders: Obtain urine output every shift dated 10/30/20. Indwelling catheter care every shift dated 1/07/20. May Irrigate foley catheter daily with 30 milliliters (ml) of sterile saline for catheter occlusion, if not effective, may change catheter as needed dated 01/04/23. Foley catheter size 18 French, or 20 French (nurse may choose size), change monthly and as needed. Change every third day of the month (special instructions: indicate the Size of catheter used) dated 06/02/23. Review of R10's EMR revealed from 01/01/23 to 05/30.23 R10 had received antibiotic treatment for UTIs: Cephalexin capsule (antibiotic used to treat bacterial infections) 500 milligrams (mg) one capsule by mouth twice a day for seven days for UTI dated 01/13/23. Cipro tablet (antibiotic used to treat bacterial infections) 500 mg one tablet by mouth twice a day for seven days for UTI dated 03/19/23. Cephalexin capsule 500 mg give one capsule twice a day for seven days for UTI dated 05/07/23. On 06/14/23 at 09:06 AM Certified Nurse Aide (CNA) N and CNA P transferred R10 with a Hoyer lift from a recliner into the bed. R10's urine collection bag, covered by a dignity bag, was attached to the arm of Hoyer lift next to R10's head. CNA N and CNA P removed the resident from the Hoyer lift, and then CNA N and CNA P removed R10's slacks, sock and checked R10's incontinence product while the window blinds were open out to the front of facility and the parking area in front of the building. On 06/14/23 at 11:42 AM CNA N and CNA P explained to R10 they were going to perform catheter care. CNA N donned gloves, CNA P had gloves on. CNA N removed the tape from the incontinent brief and pulled the brief downward between R10's legs. CNA N removed a disposable wipe from the package; she wiped in downward motion around R10's labia, CNA N disposed of the soiled wipe and repeated this for three more wipes. CNA P helped R10 to turn onto her left side. CNA N wiped R10's coccyx and rectal area. CNA N removed soiled brief from under R10's bottom. Without changing soiled gloves, CNA N placed a clean brief under R10, and CNA P helped apply incontinent brief onto R10. CNA N and CNA P both doffed gloves but did not perform hand hygiene. The CNAs then and assisted R10 with pulling up slacks and putting her sock back onto her foot. On 06/15/23 at 12:19 PM Certified Nurse Aide (CNA) M stated staff should always hand sanitize between doffing and donning a new pair of gloves after providing peri-care or catheter care before clean items are touched or applied. CNA M stated a resident's catheter bag should always be placed below the bladder. On 06/15/23 at 12:34 PM Licensed Nurse (LN) G stated hand hygiene should always be preformed before donning gloves and between each glove change. LN G stated a resident's catheter bag should never be placed above a resident's bladder at any time. On 06/15/23 at 01:02 PM Administrative Nurse D stated the facility had begun to work on hand hygiene and catheter care competencies in April 2023 with nursing staff. Administrative Nurse D stated her expectation was for the staff to complete hand hygiene between glove changes, between dirty and clean and any time their hands where visibly soiled. Administrative Nurse D stated she would except the staff to keep any resident's catheter bag below their bladder to prevent urinary tract infections. The facility's Catheter Care, Urinary policy last revised 09/2014 documented the purpose of this procedure is to prevent catheter-associated urinary tract infections. The urinary drainage bag must be always held or positioned lower than the bladder to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder. The facility failed to ensure the standard of care was provided during catheter care and failed to maintain the catheter drainage bag below the bladder for R10, who had a history of frequent UTIs. This deficient practice placed R10 at risk of catheter related complications and further UTIs.

The facility identified a census of 36 residents. The sample included 12 residents with two reviewed for respiratory care. Based on observation, record review, and interviews, the facility additionally failed to date and store Resident (R)35's supplemental oxygen equipment (masks and tubing) in a sanitary manner. This deficient practice placed R35 at risk for complications related to respiratory care and infections. Findings Included: - The Medical Diagnosis section within R35's Electronic Medical Records (EMR) included diagnoses of congestive heart failure (CHF), anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness), chronic obstructive pulmonary disorder (COPD), shortness of breath, ,and depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness). A review of R35's Significant Change Minimum Data Set (MDS) dated [DATE] noted a Brief Interview for Mental Status (BIMS) score of 11 indicating mild cognitive impairment. The MDS indicated he required limited assistance from one staff for all his Activities of Daily Living (ADLs). The MDS indicated he received hospice and respiratory services. A review of R35's ADLs Care Area Assessment (CAA) completed 05/02/23 indicated he required one-to-one assistance for transfers, bed mobility, dressing, toileting, bathing, and personal hygiene. R35's Fall CAA completed 05/02/23 indicated he recently admitted to hospice services and was a high fall risk. The CAA indicated he had high fall risk related to dressing, toileting, and transfers to his wheelchair. A review of R35's Care Plan initiated 05/02/23 indicated he received hospice services due to his diagnoses. The plan indicated hospice provided oxygen therapy and supplies. The plan indicated staff would provide oxygen per the medical provider's order. A review of R35's EMR under Physician's Order revealed an order dated 02/28/23 for staff to administer three liters of oxygen continuously. A review of R35's EMR revealed no documentation tracking his oxygen equipment changes or maintenance. On 06/13/23 at 08:01AM R35's nebulizer face mask and tubing were on his bed, unbagged. His tubing was not labeled/dated indicating what day the tubing was placed. R35's humidifier bottle on his supplemental oxygen machine was not labeled/dated to show when it was filled. On 06/14/23 at 01:34PM R35's unbagged nebulizer face mask and tubing sat on his bedside dresser. His nebulizer tubing was dated with a tape label. R35's nasal cannula and oxygen tubing sat over his bedside table. His oxygen tubing and humidifier had no date/label. On 06/15/23 at 12:34PM Licensed Nurse (LN) G stated indicated tubing should be changed weekly. He stated oxygen equipment should be stored in a provided storage bag when not in use. He stated the equipment should be dated to should when the equipment was changed. He stated the oxygen equipment should never touch contaminated equipment. On 06/15/23 at 01:02PM Administrative Nurse D stated staff were expected check to oxygen equipment each time they entered a resident's room to ensure sanitary storage. She stated the tubing and equipment should be changed out weekly and dated upon placement. A review of the facility's Oxygen Therapy policy revised 10/2010 indicated the facility will follow safe oxygen administration practices that included sanitary administration and equipment storage, tracking of treatments, and continual assessment of the residents and equipment. The facility failed to ensure R35's supplemental oxygen therapy equipment was dated and stored in a sanitary manner when not in use. This deficient practice placed R35 at risk for complications related to respiratory care and infections.

The facility identified a census of 36 residents. The sample included 12 residents. Based on observation, record review and interview, the facility failed to ensure nurse aid staff possessed the competency and skills necessary to care for residents' catheters (a tube placed into the bladder to drain urine into a collection bag). This deficient practice placed the affected residents at risk for catheter related urinary tract infection (UTI-an infection of the organs of the urinary tract) or other urinary system complications. Findings included: - On 06/14/23 at 09:06 AM Certified Nurse Aide (CNA) N and CNA P transferred R10 with a Hoyer lift (a mechanical lift used to aid in the safe transfer of a resident from one surface to another) from a recliner into the bed. R10's urine collection bag, covered by a dignity bag, was attached to the arm of Hoyer lift next to R10's head. On 06/14/23 at 11:42 AM CNA N and CNA P explained to R10 they were going to perform catheter care. CNA N donned gloves, CNA P had gloves on. CNA N removed the tape from the incontinent brief and pulled the brief downward between R10's legs. CNA N removed a disposable wipe from the package; she wiped in downward motion around R10's labia, CNA N disposed of the soiled wipe and repeated this for three more wipes. CNA P helped R10 to turn onto her left side. CNA N wiped R10's buttocks and rectal area. CNA N removed the soiled brief from under R10's bottom. Without changing the soiled gloves, CNA N placed a clean brief under R10, and CNA P helped apply incontinent brief onto R10. CNA N and CNA P both doffed gloves but did not perform hand hygiene. The CNAs then and assisted R10 with pulling up slacks and putting her sock back onto her foot. Review of facility training materials revealed the facility held a Skills Competency Check for staff members on 03/13/23, 03/14/23, and 03/15/23. The nurse aide staff were checked off for competency skills that included glove use; hand hygiene/alcohol based-rub use; infection control and precautions; personal protective equipment (PPE); Hoyer lift, and sit to stand lift. The facility was unable to provide evidence of training and competency assessment for catheter care. On 06/15/23 at 12:15 PM CNA M stated that the catheter bag should always be below the level of the bladder. CNA M stated privacy should be provided when giving a resident care and the curtain pulled and blinds should be shut in the room. CNA M stated the aides did a competency check about three months ago and went over hand washing, and catheter care. On 06/15/23 at 12:34 PM Licensed Nurse (LN) G stated staff had competency checks were done a few months ago that included hand hygiene. LN G stated that catheter care checkoff was done annually. LN G stated when a resident was being transferred using a lift, the catheter bag should always be kept below the level of the bladder, so the urine did not flow back into the bladder. LN G stated the blinds and curtains should be closed when care was provided to a resident. LN G stated hand hygiene should be done any time you take off dirty gloves and put on clean gloves. On 06/15/23 at 01:01 PM Administrative Nurse D stated the facility held competency checkoffs back in March for all staff and new hires were checked off at the time of hire. Administrative Nurse D stated the competency check included hand hygiene, gloves, catheter care, PPE use. Administrative Nurse D stated the catheter bag should never be hung or transported above the level of the bladder as the urine could backflow into the bladder. Administrative Nurse D would expect staff to perform hand hygiene anytime they took gloves off and put clean gloves on. The facility lacked a policy regarding staff skills competency. The facility failed to ensure nurse aid staff possessed the competency and skills necessary to care for residents' catheters. This deficient practice placed the affected residents at risk for possible catheter related urinary tract infection

The facility identified a census of 36 residents. The sample included 12 residents with six residents sampled for unnecessary medications. Based on observation, record review and interview the facility failed to ensure the Consultant Pharmacist (CP) identified and reported the lack of staff monitoring Resident (R) 36 for side effects and behaviors associated with the use/administration of the antidepressant (class of medications used to treat mood disorders and relieve symptoms of depression) medication mirtazapine. These deficient practices placed R38 at risk of unnecessary mediation administration and potential adverse side effects. Findings included: - The electronic medical record (EMR) for R36 documented diagnoses of major depressive disorder (major mood disorder), and Alzheimer's disease (a progressive mental deterioration characterized by confusion and memory failure). The Admission Minimum Data Set (MDS) for R36 documented she had a Brief Interview for Mental Status (BIMS) score of three which indicated severely impaired cognition. R36 required supervision with her activities of daily living (ADLs). R36 required the use of an anti-depressant. The Psychotropic Care Area Assessment (CAA) documented R36 received the antidepressant mirtazapine. The Psychotropic Drug Use Care Plan dated 04/26/23 for R36 directed nursing staff would assess for increased signs and symptoms of depression as evidenced by withdrawal, sad affect, and crying. The nursing staff would monitor for evidence of worsening behavior. If noted, staff would notify the responsible party and physician and document findings. Nursing staff would monitor for side effects of mirtazapine. The Orders tab for R36 documented an order dated 04/18/23 for mirtazapine 7.5 milligrams (mg) daily at bedtime for Alzheimer's disease. This order was discontinued on 05/02/23. The Orders tab for R36 documented an order dated 05/02/23 for mirtazapine 15 milligrams (mg) daily at bedtime for major depressive disorder. R36's clinical record including the Medication Administration Record/Treatment Administration Record (MAR/TAR) and Tasks for April 2023, May 2023 and June 2023 lacked evidence that R36 was monitored for target behaviors and side effects associated with the administration of mirtazapine. The April 2023 Pharmacist Monthly Medication Regimen Review (MRR) for R36 recommended the diagnosis of major depressive disorder for R36's mirtazapine. The May 2023 MRR lacked any recommendations for R36. On 06/13/23 at 08:03 AM R36 wandered about the memory unit, and stated she was waiting for her husband to come visit her. On 06/15/23 at 09:00 AM R36 walked about her room talking to herself. On 06/15/23 at 12:34 PM Licensed Nurse (LN) G stated that a resident should be monitored for side effects and behaviors when on an antidepressant. LN G stated R36 was on an antidepressant medication and there should be monitoring of that medication on the TAR but could not say positively that R36 was being monitored for side effects or behaviors. LN G stated he had entered nursing recommendations and/or physician responses to the CP's MRR when received. On 06/15/23 at 01:01 PM Administrative Nurse D stated that the Pharmacist would email her recommendations to the facility and management nursing would review the recommendations and then would forward them to the physician(s). Administrative Nurse D stated when the physician signed responses was received, they would be given to the charge nurse or nurse on duty for them to make the changes and notify family as needed. R36 should be monitored for side effects and behaviors. On 06/19/23 at 01:34 PM Consultant GG was unavailable to answer questions. The facility did not provide a policy regarding MRR/Pharmacy Review. The facility failed to ensure the CP identified and reported the lack of staff monitoring and documenting R36 for side effects and increased behaviors associated with the administration of the antidepressant mirtazapine. This deficient practice placed R36 at risk for unnecessary medication administration and adverse side effects.

The facility identified a census of 36 residents. The sample included 12 residents. Based on observation, record review and interview, the failed to ensure a restorative program was provided to Resident (R) 2, who had limited range of motion (ROM) due to contracture (an abnormal permanent fixation of a joint) of her joints, to maintain her current level of ROM and promote comfort. This deficient practice placed R2 at risk for decreased ROM and impaired comfort. Findings included: - The electronic medical record for (EMR) for R2 documented diagnoses of osteoporosis (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk), and rheumatoid arthritis (RA-a chronic inflammatory disease that affected joints and other organ systems). The Annual Minimum Data Set (MDS) dated [DATE] for R2 documented a Brief Interview for Mental Status (BIMS) score of 13 which indicated intact cognition. R2 required limited assistance with eating but was total dependent on two staff for all other activities of daily living (ADLs). R2 had limited functional ROM of both upper and lower extremities on both sides. R2 was not receiving restorative services. R2 was on hospice services. The Quarterly MDS dated [DATE] documented R2 had a BIMS of 13 which indicated intact cognition. R2 required limited assistance with eating but was total dependent on two staff for all other ADLs. R2 had limited functional ROM of both upper and lower extremities on both sides. R2 was on hospice services. R2 was not receiving restorative services. The ADL Care Area Assessment (CAA) dated 02/17/23 documented R2 was non-ambulatory (not able to walk about) and required two staff with a mechanical lift (a device used to assist with transferring a resident) for transfers due to pain and weakness. R2 would occasionally sit on the side of her bed with assistance. R2's hands were twisted with moderate contracture of the right upper extremity noted. R2 had RA. R2's bilateral lower extremities had moderate contractures as well as moderate foot drop noted. R2 was totally dependent on two staff for bed mobility. The ADLs Functional Status/Rehabilitation Potential Care Plan dated 02/17/23 for R2 directed staff that R2 was extensive to total assist of two. R2 required assistive devices of protective booties, air mattress, wheelchair, oxygen, and mechanical lift for transfers. The care plan lacked direction to staff regarding restorative services or interventions to address her contracture and/or interventions/exercises to prevent further decline of joint ROM. The Orders tab in the EMR for R2 lacked any order for a restorative program or ROM exercises or any type of restorative program direction. On 06/15/23 at 08:30 AM R2 laid in bed wearing a hospital gown. R2 had colored pencils and a coloring page on the bed. R2 stated her neck was painful and contracted to the right. R2 stated she rested her head on her right shoulder a lot. R2 stated her hands were hideous and very painful due to her arthritis. R2 stated she wished she had a pillow or something to support her neck more; she had one at one time but does not know what happened to it. On 06/15/23 at 12:15 PM Certified Nurse Aide (CNA) M stated that R2 used to have a neck pillow but she did not like it and would not use it most of the time. CNA M stated R2 did experience a lot of pain in her hands and neck and was not aware of any type of restorative or exercise interventions for R2. CNA M stated R2 was on hospice services and could not say what they might provide for R2. On 06/15/23 at 12:15 PM Licensed Nurse (LN) G stated he had tried to do some ROM exercises and things with R2 but would have to stop due to her severe pain she would experience. LN G was not aware of R2 being on any type of restorative program currently. On 06/15/23 at 01:01 PM Administrative Nurse D stated the facility did not have a restorative program currently. Administrative Nurse D stated that therapy did not work with residents that were on hospice. Administrative Nurse D stated that some of the staff did try to do some ROM exercises with R2 but that was not charted anywhere that she was aware of. Administrative Nurse D stated the facility tried several different things to try to help with R2's contractures but due to her pain those did not work for long or R2 would refuse them. The ADLs, Supporting facility policy revised March 2018 documented: Appropriate care and services would be provided for residents who were unable to carry out ADLs independently. A resident's ability to perform ADLs would be measured using clinical tools, including the MDS. Functional decline or improvement would be evaluated in reference to the assessment reference date (ARD). Interventions to improve or minimize a resident's functional abilities would be in accordance with the resident's assessed needs, preferences, stated goals and recognized standards of practice. The resident's response to interventions would be monitored, evaluated and revised as appropriate. The facility failed to ensure a restorative program was provided to R2, who had limited ROM due to contractures of her joints, in order to maintain her current level of ROM and promote comfort. This deficient practice placed R2 at risk for decreased ROM and impaired comfort.

The facility identified a census of 36 residents. The sample included 12 residents. Based on observation, record review and interview, the facility failed to ensure Resident (R) 28 had interventions in place to promote healing of a pressure ulcer (a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). This deficient practice placed R28 at risk for delayed healing and additional skin breakdown. Findings included: - The electronic medical record (EMR) for R28 documented diagnoses of unstageable pressure ulcer of the heel, infection of skin (occur when bacteria infect the skin and sometimes the deep tissue beneath the skin), and fracture (broken bone) of left femur (thigh bone). The Significant Change Minimum Data Set (MDS) dated [DATE] documented R28 had a Brief Interview for Mental Status (BIMS) score of three which indicated severely impaired cognition. R28 required extensive assistance to total dependence on two staff for her activities of daily living (ADLs). R28 was at risk for pressure ulcers. R28 had surgical wounds. R28 used a pressure reducing device for the chair and bed. R28 was on a turning/repositioning program. R28 received surgical wound care. The Quarterly MDS dated [DATE] documented R28 had both long and short-term memory problems. R28 displayed inattention and disorganized thinking continuously. R28 required extensive assistance of one staff for her ADLs. R28 had functional limitation in range of motion to her lower extremities. R28 utilized a wheelchair for mobility. R28 was at risk for pressure ulcers and currently had one unstageable pressure ulcer due to the coverage of wound bed by slough (dead tissue, usually cream or yellow in color) and/or eschar (dead tissue). R28 used a pressure reducing device for the chair and bed. R28 had nutrition or hydration interventions to manage skin problems in place. R28 received pressure ulcer care and application of non-surgical dressing to feet. The ADL Care Area Assessment (CAA) dated 07/05/22 documented R28 was extensive to total assist with ADLs at that time. R28 needed two staff assist except with eating. R28 would feed herself at most times with set up assist after meal was served. R28 had a catheter (tube placed in the bladder to drain urine into a collection bag) in place, related to surgical wound and retention after trial removal. R28 was incontinent of her bowel. Staff anticipated her needs. The Nutritional Status Care Plan initiated 07/14/22 directed staff to provide weekly skin assessments. Nursing staff would use the Braden Scale (an assessment tool used to measure the risk for developing pressure ulcer). The Care Plan initiated 07/14/22 lacked a care area for skin and or pressure related skin concerns. The Pressure Ulcer Care Plan initiated on 10/10/22 (almost three months after the wound developed) directed staff to apply barrier cream with each incontinent episode. Staff was to complete a Braden Scale quarterly and with any readmission or significant change in status to assess any changes related to pressure risk score. Staff was to ensure a low air loss mattress was in place. Nursing was to complete weekly skin assessments and report any skin concerns to the wound nurse and physician. Staff was directed to offload hells and bony prominences while in bed R28's allowance. Staff was always to ensure R28 had protective heel boots on. Staff was to do treatment to left heel as ordered. A Braden Scale assessment dated [DATE] documented R28 was at moderate risk for pressure ulcer development. The Wound Care assessment dated [DATE] documented a wound to R28's left heel that measured five centimeters (cm) by 4.8 cm. The Orders tab listed an order dated 09/23/22 for wound care to left heel. Monitor daily for signs of weakening eschar adherence. The signs included drainage, peeling edges, or eschar moving when contacting it. Do not make any attempt to remove the eschar. Notify wound nurse if any changes occur. This order was discontinued 02/02/23. A Progress Note dated 06/13/23 at 06:49 PM documented R28 continues to have an unstageable pressure ulcer to the left heel. This area has been slowly positively progressing since the addition of calcium alginate (a type of wound dressing) last week. There was less moisture and exudate (drainage) was present in the wound on this visual. No pain or signs/symptoms of infection observed. Wound measured 0.9 by two (cm) currently. Significant margin improvement noted. On 06/14/23 at 07:13 AM R28 laid in bed on her right side with no heel protectors on her feet. On 06/15/23 at 08:05 AM R28 sat in her wheelchair at the dining room table, R28 had a bandage around her left heel, and her right foot was bare. On 06/15/23 at 12:15 PM Certified Nurse Aide (CNA) M stated the aides filled out a bath sheet each time a resident showered and would report skin issues to the nurse at that time. CNA M stated R28 did have a wound on her left heel. CNA M stated he thought the wound developed in the facility. On 06/15/23 at 12:34 PM Licensed Nurse (LN) G stated that R28 had been in the hospital due to a fracture in June of 2022 and returned to the facility. R28 developed the wound to her left heel a few weeks after her return. LN G stated he knew that R28's heels were offloaded but could not say about any other interventions that were in place to prevent the heel wound. On 06/15/23 at 01:01 PM Administrative Nurse D stated R28's heels had been offloaded and to float the heels and skin assessments were completed weekly. Administrative Nurse D stated R28 had some other skin issues going on. Administrative Nurse D could not say if any other interventions had been in place before R28 developed the pressure wound to her left heel. The facility policy Prevention of Pressure Injuries revised April 2020 documented: Review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable. Assess the resident on admission (within eight hours) for existing pressure injury risk factors. Repeat risk assessment weekly and upon any changes in skin condition. Select appropriate support surfaces based on resident's risk factors, in accordance with current clinical practice. Review and select medical devices with consideration to the ability to minimize tissue damage, including size, shape, its application and ability to secure the device. Monitor regularly for comfort and signs of pressure-related injury. For prevention measures associated with specific devices, consult current clinical practice guidelines. The facility failed to ensure staff implemented the interventions to promote pressure wound healing for R28. This deficient practice placed R28 at risk for delayed healing and additional skin break down.

The facility identified a census of 51 residents. The sample included one resident reviewed for accidents. Based on record review, interview, and observations, the facility failed to prevent an avoidable accident when staff failed to safely apply and monitor a warmed rice pack. On 01/11/23, Resident (R)1, who required assistance with cares asked for a warm pack for her stomach. Certified Nurse Aide (CNA) M warmed a rice pack in the microwave for one minute and 30 seconds then wrapped the rice pack with two towels and placed on R1's abdomen. After lunch, roughly one hour, R1 still had the rice pack on her abdomen. CNA M removed the rice pack and noted that R1 had a reddened area that was blistering and painful. Findings included: - R1's Electronic Medical Record (EMR) recorded diagnoses of chronic bladder pain, type 2 diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), muscle weakness, anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) disorder, and burn of unspecified degree of abdominal wall. The Annual Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. R1 required extensive assistance of two staff members for bed mobility, dressing, and total dependence of two staff members with transfers. The Quarterly MDS assessment dated [DATE] documented a BIMS score of 14, which indicated intact cognition. R1 required extensive assistance of two staff members for bed mobility, transfers, and dressing. The Visual Function Care Area Assessment (CAA) dated 02/23/22 documented R1 had poor eyesight in bilateral eyes due to diabetes and only saw shapes and light. The Activities of Daily Living (ADL) CAA dated 02/23/22 documented R1 required two-person assistance with a full body lift for transfers and was propelled by staff in her wheelchair. R1 could eat and drink with set up, but was noted to be dependent on staff for all other ADL cares. The Pressure Ulcer Care Plan initiated 03/03/22 directed staff to report any signs of skin breakdown (sore, tender, red, or broken areas). The ADL Functional/Rehabilitation Care Plan initiated 03/03/22 directed staff to report any noted impaired skin integrity to the medical director and responsible party and document findings. The Nursing Note dated 01/11/23 at 02:04 PM documented R1 requested a hot pack from CNA M due to lower abdominal discomfort. CNA M obtained and applied a hot pack without consulting LN G. When the hot pack was removed it was noted that R1 had a reddened skin with blistering five inches by three and a half inches under the hot pack. LN G notified Administrative Nurse D. The Facility Investigation dated 01/12/23 recorded on 01/11/2023 at approximately 01:00 PM CNA M reported to Licensed Nurse (LN) G that she had placed a rice filled hot back on R1 and that when she removed it, R1's skin was red. CNA M had obtained a rice pack from the nursing supply closet, heated it in the microwave, wrapped it in a towel and applied it without the charge nurse's knowledge earlier in CNA M's shift. R1 asked for her to apply another rice pack again at lunch time because the first one helped. CNA M re-heated the rice pack, wrapped it in a towel, and re-applied it to the resident's abdomen area, again without licensed nursing staff knowledge. After lunch, when staff were assisting R1 to bed, CNA M removed the pack and noticed a reddened area. CNA M immediately notified the charge nurse. LN G immediately notified Administrative Nurse D. Staff assessed R1's stomach and noticed a reddened area approximately three inches by five inches that appeared red with some skin breakage. The Nursing Note dated 01/12/23 at 12:06 PM noted R1 had some skin slightly peeled away. The Nursing Note dated 01/13/23 at 03:17 PM documented R1 had an abdominal burn pink in color, the size of a lemon. R1 was missing the top layer of blister not intact to area. The Nursing Note dated 01/14/23 at 12:16 PM documented R1 complained the burn area was painful, and itching. The Nursing Note dated 01/15/23 at 09:33 AM documented R1's abdomen had very mild blistering on the outskirts of the burned area. The burned area measured four centimeters (cm) by five cm, with no depth noted. R1 had very little drainage that appeared serous (thin, clear, watery) in color and viscosity, mild sticking was noted. R1 reported that there was periodic pain associated with rubbing of clothes. The Wound Management assessment dated [DATE] at 09:43 AM documented a wound with partial thickness with redness, blistered, moist, and painful. The area of blistering was present on the outskirts of the wound, peeled skin noted to cover 20% of the wound. The wound had light/scant tissue moisture, enough to stick to clothing/dressing. R1 reported pain occurred with pressure or rubbing. The wound was non-blanching and had scabbing present with serous drainage noted. The Wound Management assessment dated [DATE] at 02:08 PM documented the wound was full thickness, dry, and discolored with no pain. The burn progressed and showed more tissue damage. The wound had more tissue exposed with serosanguineous (thin, blood tinged) drainage noted. The Nursing Note dated 01/20/23 at 02:14 PM documented R1's burn had the presence of blistering and eschar (dead tissue). Eschar covered 60 % of the burn surface with blistering around the edges. R1 denied pain or discomfort but stated that it hurt when pressure or rubbing occurred from clothing, for example. The wound was four cm by five cm, depth in unmeasured, very little moisture or exudate (drainage) present. The Nursing Note dated 01/23/23 at 03:51 PM documented R1 had notable eschar in a slightly deformed X shape. On the left side of the X shape and area appeared to be blistered skin leftover from a ruptured blister. The entire burned area measured 5.5 cm by 8.25 cm, eschar was present in a 5.5 cm by 6.6 cm area. Estimated 70 % of the wound bed was covered in eschar and the remaining 30% was sloughing tissue. On 01/24/23 at 01:25 PM observation of R1's abdominal area revealed the area was a lemon-shaped open area with a donut shape in the center of opened area. The donut shape area was three quarters eschar with one quarter slough (soft dead tissue and exudate). There was scant reddish/pink discharge noted on the island dressing that was removed. R1 stated the day she received the rice pack the second time she noted the area had started to hurt but did not realize it was from the heat. R1 further stated that when her clothing rubs on the dressing or any type of pressure is on the area, the area is painful. On 01/24/23 at 12:50 PM CNA M stated that she gave R1 the rice bag two different times on 01/11/23; the first time was when R1 was in bed. CNA M stated she heated the rice pack up in the microwave for one minute and then wrapped it in a towel for R1 and placed it on her lower abdomen. CNA M revealed that R1 asked CNA M to reheat the rice pack a second time when R1 was getting up for lunch. CNA M stated she heated the rice pack up in the microwave for 1.5 minutes and then wrapped the rice pack in two towels. CNA M further stated she did not think that the rice pack was too hot because she placed it on her chest, over her scrub top, while she walked back to R1. CNA M revealed that she placed the reheated rice pack on R1's lower abdomen and took R1 out to lunch. CNA M further revealed that the approximate time the heated rice pack was on R1's lower abdomen the second time was roughly one hour. When CNA M went to lay R1 down, CNA M removed the rice pack and noted the red mark. CNA M immediately notified LN G. CNA M stated she thought that anyone could get R1 a rice pack and heat it up. CNA M further stated an unidentified CNA told her where to locate a rice pack. On 01/24/23 at 01:45 PM Administrative Nurse D stated CNA M was taught in her training to become a CNA that CNA M had to go to the nurse before applying any type of heating pad to a resident. Administrative Nurse D revealed that she was aware CNA M had been taught that because Administrative Nurse D taught CNA M's class. The facility's Compress, Applying Warm policy revised February 2018 documented the purpose of the procedure was to ease the body of pain caused by inflammation and congestion, to aid in treatment of the resident's condition, to promote drainage in infections, to improve circulations and to apply heat to an area. The general guidelines directed staff to check the resident's skin often for redness or discoloration. It further directed that a heating pad should only be used for the prescribed length of time and should not be used for extended periods. The facility failed to prevent an avoidable accident when staff failed to safely apply and monitor a warmed rice pack. Which resulted in a burn for R1. The facility implemented corrective actions by educating all nursing staff regarding use of heat, CNA M also received instruction on the CNA scope of practice. All rice packs were removed from the facility and the incident reveiewed at the Quality Assurance and Performance Improvement committee. The deficient practice was cited at past non-compliance.

The facility identified a census of 43. The sample included three residents and three residents were reviewed for accidents. Based on observations, record review, and interviews, the facility failed to ensure Resident (R) 1 remained free from accidents when facility staff failed to provide one-to-one assistance during ambulation and transfer for R1. This deficient practice resulted in R1 falling in her room and fracturing her left hip. Findings included: - The Diagnoses tab of R1's Electronic Medical Record (EMR) documented a diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion) without behavioral disturbance. The Admission Minimum Data Set (MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of three, which indicated severe cognitive impairment. R1 required limited physical assistance with two staff for bed mobility and transfers; limited physical assistance with one staff for walking, locomotion, dressing, toileting, and personal hygiene. R1 had two or more non-injury falls, and one injury fall since admission. The Quarterly MDS dated [DATE], documented a BIMS score of three, which indicated severe cognitive impairment. R1 required extensive physical assistance with one staff for bed mobility, dressing, toileting, and personal hygiene; extensive physical assistance with two staff for transfers and walking in room; limited physical assistance with two staff for walking in corridor. R1 had two or more non-injury falls since last assessment. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 02/28/22, documented R1 had a BIMS score of three and was able to ambulate with use of walker. The Falls CAA, dated 02/28/22, documented R1 required limited assistance with one staff for activities of daily living (ADLs). R1 was unsteady with her gait and needed a walker and staff assistance for safety. The Care Plan dated 03/07/22, documented R1 required limited assistance of one staff with her ADLs, was unsteady with her gait, and needed a walker and staff assistance for safety. Staff continued to monitor R1 with one-to-one assistance with transfers and ambulation. The Care Plan directed R1 was limited assistance of one staff with ADLs and used a walker as an assistive device. The Care Plan dated 03/07/22, documented R1 was alert and very confused and was one-to-one with transfers. The Care Plan dated 03/07/22, documented R1 had a history of falling and directed staff assisted R1 one-to-one always for ambulation and transfers. The Progress Notes tab of R1's EMR revealed the following: A Nursing Note on 06/24/22 at 10:56 AM, documented at about 07:30 PM on Thursday 06/23/22, Certified Nurse Aide (CNA) M assisted R1 to get ready for bed. CNA M called for Licensed Nurse (LN) G, who responded immediately from nearby, and saw R1 lying on her side in front of her closet. R1's walker was close by, tipped over. CNA M stated that R1 was standing with her walker while CNA M turned the covers down on R1's bed when R1 became weak and went to her knees then onto her side. R1 denied pain and CNA M denied R1 hit her head. R1 was assessed for injuries at knees, shoulders, and elbows with no injuries noted. CNA M and LN G helped R1 into bed. The morning of 06/24/22, around 07:30 AM, CNA M reported a skin tear on R1's left elbow. CNA M reported she was there the previous night when R1 fell and did not see any blood on R1's arm at that time. R1 reported pain in the hip area. Administrative Nurse D assessed range of motion and R1 had pain upon rotation of left leg. R1 was sent to the emergency room (ER) for evaluation to rule out hip fracture. A Nursing Note on 06/24/22, at 12:12 PM, documented the hospital called the facility and reported R1 had a left side hip fracture. R1 needed surgery and the hospital was looking for another hospital to send R1 to. A Nursing Note on 06/28/22, at 01:36 PM, documented the nurse received report from the hospital. R1 had a left hip hemiarthroplasty (surgical procedure that involves replacing half of the hip joint) and had a healing incision to her left hip. The Summary of Care document from the hospital, dated 06/28/22, documented a diagnosis of closed fracture of the left hip. The facility's Investigation dated 06/29/22, documented around 07:30 PM, on Thursday 06/23/22, CNA M assisted R1 to get ready for bed. CNA M had just given R1 a shower and walked her back to her room. R1 used a walker with one-to-one staff assistance. CNA M reported R1 was standing with her walker and CNA M turned around to pull back the bed covers. When CNA M turned back around, R1 was falling, and CNA M could not reach her to stop the fall. LN G was just outside the door and was there to assess R1. R1 responded to LN G and stated she was fine. LN G's assessment revealed no injuries. R1 was assisted up and to the bed at that time and was able to take several steps into bed without incident. The next morning, R1 complained of more pain and directed the location to her left hip. Administrative Nurse D assessed R1 and noted pain upon rotation of left leg. R1's physician was notified at that time to obtain transfer to ER for evaluation. The ER notified the facility that R1 had left hip fracture and was to be transferred to another hospital. In a Witness Statement on 06/24/22, CNA M stated she gave R1 a shower around 06:30 PM then walked back to her room. R1 was standing in the middle of the room and CNA M went to her bed to pull down the covers. CNA M stated when she turned back around, R1 was falling. She stated she tried to get to R1 but was not fast enough and saw her fall to her left side onto the floor. CNA M stated she immediately called for the nurse who was right outside the door. The nurse assessed R1 then they assisted her to her bed. In a Witness Statement on 06/24/22, LN G stated at about 07:30 PM, on Thursday 06/23/22, CNA M assisted R1 to get ready for bed. LN G stated he was down the hall nearby when he heard CNA M call for him. He responded immediately and upon entering the room, saw R1 lying on her left side in front of the closet. R1's walker was tipped over nearby. LN G stated CNA M reported that R1 had been standing alone when she appeared to weaken, went down on her hands and knees, then down to the floor. He stated CNA M reported R1 had not hit her head. LN G stated R1 responded to speech and stated she was fine. His initial assessment revealed no obvious injuries so R1 was lifted with two staff from the floor and walked with two staff to the bed. LN G stated for the short distance of two to three steps, she was able to bear weight on both legs with no indication of pain. R1 was helped to lie down on her back and LN G continued his assessment. LN G stated each leg was lifted and rotated, the knee was bent, then rotated outward at which time R1 did not complain of pain or show any signs of pain. On 07/06/22 at 11:30 AM, R1 sat in wheelchair at table in dining room. Staff assisted her with positioning. On 07/06/22 at 01:30 PM, CNA N stated if a resident was one-to-one with ambulation and transfers, staff needed to be with the resident and always kept their eyes on the resident. On 07/06/22 at 01:52 PM, LN G stated CNA M helped R1 get ready for bed. He stated he was close by on the unit at the time and heard CNA M call for him. LN G stated when he entered R1's room, she was lying on the floor. LN G stated CNA M reported R1 was standing with walker when CNA M turned to pull the blankets down on bed and R1 had weakened then fell to hands and knees onto the floor. LN G completed an initial assessment, no injuries and no complaints of pain. LN G stated staff lifted R1 two-to-one assist and walked her to bed; R1 did bear weight. He stated he continued R1's assessment and did not see any injuries. LN G stated if a resident was one-to-one staff assistance, staff were always expected to keep hands/eyes on resident. On 07/06/22 at 02:47 PM, Administrative Nurse D stated R1 fell on [DATE]. When she came in on 06/24/22, CNA M reported a skin tear on R1 then reported R1 fell on [DATE]. She stated staff reported to her that R1 was not acting the same, was not walking very well, and acted as though she was in pain. Administrative Nurse D stated she completed an assessment and observed slight rotation in left foot and painful with movement. She stated she expected staff to be cautious if R1 was standing with her walker as R1 had a history of being combative if staff touched her. The facility's Universal Risk for Falls Protocol policy, dated 2014, directed universal fall precautions were put into place for residents identified without risk and low risk for falls. The facility's High Risk Fall Protocol policy, dated 2014, all household team members were notified when a resident was at high risk for falls. The facility failed to ensure R1 remained free from accidents when facility staff failed to provide one-to-one assistance during ambulation and transfer for R1. This deficient practice resulted in R1 falling in her room and fracturing her left hip. On 06/24/22 the facility completed the following corrections: Education was provided to all clinical staff regarding resident mobility and monitoring, safe transfers and ambulation. This deficient practice was cited as past non-compliance.

The facility identified a census of 63 residents. The sample included 3 residents. Based on observation, record review, and interview, the facility failed to protect residents from potential abuse when a staff member reported an allegation of abuse by another staff member. Direct care staff H reported an allegation of abuse by licensed nursing staff J, and the staff member continued providing resident care for the remainder of his/her shift. This deficient practice placed all residents in the facility in immediate jeopardy. Findings included: - Resident #1's May 2017 physician's orders [REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 4, which indicated severely impaired cognition. He/she did not display behaviors toward staff and/or residents. The resident required extensive assistance of one staff member with most activities of daily living, such as ambulation, dressing and toilet use, used a wheelchair for mobility, and was able to walk on his/her own with assistance. Review of the facility investigation dated 5/3/2017 revealed on 4/26/17 at 10:40 P.M. direct care staff H sent a message on the phone to administrative licensed nursing staff E which indicated licensed nurse J allegedly abused resident #1. Direct care staff H's witness statement recorded resident #1 told staff H he/she would have been all right, but that {he/she} came in and jerked me around. Staff H thought the resident referred to licensed nurse J. The investigation documented administrative licensed nurse E received the text message allegation the next morning on 4/27/17 at 6:51 A.M. At this time, nurse E called direct care staff H, and left a message to return the call immediately. Direct care staff H responded at 12:13 P.M. on 4/27/17 (approximately 11 hours and 55 minutes later). On 5/3/17 at 12:04 P.M. direct care staff I assisted resident #1 from the bathroom. He/she was well dressed, comfortable with staff, calm, and in good spirits. On 5/3/17 at 12:10 P.M. the resident denied any mistreatment by staff. On 5/3/17 at 3:15 P.M. administrative licensed nurse E stated he/she was asleep when direct care staff H messaged him/her. He/she did not know why staff H did not report the allegation to the other nurse. Nurse E stated staff had training on abuse protocols and staff should know to immediately report all abuse allegations to the administrator. On 5/3/17 at 3:23 P.M. direct care staff H stated when he/she assisted the resident off of the toilet, the resident was crying and holding his/her head. It was storming outside when he/she went in to the bathroom to see the resident (resident with fear of storms). Staff H stated the resident appeared sad, seated with his/her head in his/her hands, looked up, and had tears in his/her eyes. Staff H asked the resident if he/she was ok, and he/she said, I would be ok if that {staff} would stop coming in and jerking me around. Staff H then assisted him/her out of the bathroom and to bed. The resident said, If I am going to be treated like this, I might as well curl up and die. Staff H denied the resident said anybody mistreated him/her. Direct care staff H stated if someone came up behind the resident and touch him/her, it agitated him/her; the only difference this time was the resident continually talked as staff H helped him/her to bed. Direct care staff H further stated he/she did not report the incident to the administrator, because the administrator was out of state, and he/she wanted a second opinion about the situation. On 5/3/17 at 3:30 P.M. administrative licensed nurse D stated he/she was not aware of the situation until approximately 11:30 A.M. on 4/27/17 (approximately 25 hours after staff H was aware of the alleged abuse). On 5/3/17 at 3:35 P.M. administrative staff A stated he/she expected all staff to report all allegations of abuse directly to him/her verbally. The facility's Abuse Neglect and Exploitation policy, revised October 2016, recorded the facility ensured all alleged violations were reported immediately to the administrator of the facility. The policy recorded any alleged perpetrator who was an employee of the facility, accused or alleged of abuse, neglect, or exploitation, would be immediately suspended from employment, would leave the employment property, and not return to the property until the investigation by the facility and law enforcement was completed and the incident was resolved. The facility failed to protect residents in the facility from potential abuse when a resident reported an allegation of abuse against a staff member, and the staff member continued providing care to the residents for the remainder of his/her shift (approximately 7 hours and 20 minutes). This deficient practice placed the residents in the facility in immediate jeopardy. The facility was determined to be in past-noncompliance when the facility suspended licensed nursing staff J and provided abuse and in-service training to staff on 4/28/17.

The facility had a census of 51 residents The sample included 16 residents. Based upon observations, record review and interviews the facility failed failed to place timely and effective interventions for 2 (#41, #49) of 3 residents sampled for falls and failed to ensure chemicals/products were not accessible for 11 of 12 independent mobile residents that resided on the Special Care Unit of the facility. Findings included: - Resident #41's quarterly Minimum Data Set (MDS) 3.0 dated 5/8/14 identified the resident had short and long term memory problems, severely impaired cognition, rejected care 4 to 6 days but less than daily of the 7 day assessment period, wandered on a daily basis, required limited staff assistance with bed mobility, locomotion on/off the unit, eating, and personal hygiene, was independent with transfers, walking in the room/corridor, toilet use and personal hygiene, and required extensive staff assistance with dressing. The MDS identified the resident was not steady but able to stabilize without staff assistance when moved from a seated to standing position, walking, turning around while walking, moving on/off the toilet and surface to surface transfers and had not falls since the prior assessment. The resident's Activity of Daily Living Care Area Assessment (CAA) dated 9/11/13 included the resident could not make decisions and had severely impaired cognition. The resident's Fall CAA dated 9/11/13 included the resident ambulated as desired and occasionally wandered from room to room on the secure unit due to a decline in his/her cognitive status which increased his/her fall risk. The resident's Fall Assessments dated 8/28/13, 11/20/13, and 2/12/14 identified the resident scored 4, on 5/8/14 the resident scored 8, and on 6/6/14 and 6/17/14 the resident scored 13, according to the legend a score of 10 or above represented the resident was at a high risk for falls. The resident's temporary care plan included on 2/24/14 the resident sat on the floor in the hallway and staff monitored the resident's ambulation if the resident paced and encouraged rest periods. The resident's care plan dated 5/8/14 revealed the resident was at risk for falls. The interventions in place since 2/26/14 included: staff administered the resident's medications as physician ordered, staff maintained the environment free of clutter, monitored the resident for acute illnesses which resulted in a fall, monitored the resident for pain and medicated the resident as the physician ordered, and staff encouraged the resident to be as independent as possible. Staff provided 1 on 1 staff assistance if the resident was restless or appeared exhausted or unsteady on his/her feet and staff assisted the resident to bed if the resident appeared exhausted or gave the resident other options such as sitting in his/her recliner. Staff offered the resident snacks, drinks, and activities if the resident was restless to ensure the resident's safety. An handwritten entry dated 4/21/14 included staff provided 1 on 1 staff assistance when the resident was outside. The resident's temporary care plan dated 6/2/14 included the facility transferred the resident to a local hospital for a pelvic fracture. An entry dated 6/6/14 included the resident was up as tolerated, staff encouraged bed rest, the facility obtained a physical and occupational therapy evaluations and the resident utilized a bed alarm and PSA (personal safety alarm). An entry dated 6/17/14 included the resident was readmitted to the facility after hospitalization and the resident utilized a bed alarm and PSA at all times. A nurse's note date 1/13/14 and timed 9:30 A.M. documented staff heard a noise in the resident's room, the resident was in bathroom, attempted to use the toilet, and leaned against the wall. The resident was unsteady, confused, and had garbled speech. A nurse's note dated 2/24/14 and timed 12:50 A.M. documented the resident attempted to sit on the floor and fell back onto his/her buttock. Interventions included staff monitored the resident when the resident paced at night, encouraged rest periods and offered the resident's food and fluids. A nurse's noted dated 4/20/14 (time unknown) documented the resident sat outside on the back patio with a staff member, the resident stood up, started to walk and lost his/her balance, fell back onto the chair and hit his/her head on the back of the seat. Interventions included staff provided 1 on 1 staff assistance when the resident was outside. A nurse's note dated 5/3/14 and timed 9:00 P.M. documented the resident ambulated independently but was unsteady at times. A nurse's note dated 6/2/14 and timed 12:00 A.M. documented the resident ambulated in the hallway, turned and tripped up on his/her feet, fell to the floor and sustained a laceration to his/her right leg. A nurse's note dated 6/3/14 and timed 8:10 A.M. documented the resident fell on the floor at his/her doorway, sustained an abrasion to his/her left knee, and guarded his/her left hip. The resident grimaced when staff touched his/her left hip and had possible rotation. A nurse's note dated 6/3/14 and timed 8:20 A.M. documented the facility obtained a physician's orders [REDACTED]. Review of the facility's investigation included staff visually checked the resident on a hourly basis after the resident fell on [DATE] at 12:00 A.M. and administrative nursing staff cautioned the licensed nurse to be sure he/she documented the visual checks. A radiology report dated 6/3/14 included the resident's history included pain and past falls. Radiology views demonstrated the resident had a nondisplaced fracture of his/her left superior superior pubic ramus. Review of the resident's clinical record lacked evidence the facility assessed/reviewed/revised the resident's care plan to determine the cause of the falls and/or implemented interventions after the resident fell on [DATE] at 12:00 A.M. and prior to the resident's fall on 6/3/14 at 8:10 A.M. that resulted in a nondisplaced pelvic fracture. A nurse's noted dated 6/6/14 and timed 4:00 P.M. included the resident was readmitted to the facility. On 7/1/14 at 10:05 A.M. the resident's bed alarm sounded. Observation revealed licensed nurse H did not respond to the alarm until 10:10 A.M. Licensed nurse H after he/she responded to the alarm, stated he/she was off the unit, responded to the alarm upon his/her return to the unit and the 2 direct care staff assigned to the unit were assisting another resident on the unit and therefore did not respond to the alarm. On 7/2/14 at 4:05 P.M. the resident sat in a chair in the television area of the unit and observation revealed the PSA or chair alarm were not in place. On 7/3/14 at 1:30 P.M. direct care staff O stated the facility placed the PSA and bed alarm after the resident returned from the hospital with a [DIAGNOSES REDACTED]. Direct care staff O stated prior to the resident's fracture, the resident ambulated independently and staff ambulated with the resident if he/she was emotional. On 7/3/14 at 3:47 P.M. administrative nursing staff D stated prior to the resident's fracture, the resident ambulated independently. Administrative nursing staff D stated after the resident fell on [DATE] staff monitored the resident on an hourly basis but did not document the hourly checks, the resident fell again the next morning and sustained a pelvic fracture. Administrative nursing staff D confirmed the resident's clinical record lacked evidence the facility reviewed/revised the resident's care plan after the resident fell on [DATE] at 12:00 P.M. On 7/3/14 at 4:12 P.M. licensed nurse H stated prior to the resident's fracture staff kept a close eye on the resident when he/she ambulated. The facility failed to implement effective interventions for this resident at risk for falls and who sustained a pelvic fracture. - Resident #49's annual Minimum Data Set ((MDS) dated [DATE] identified the resident scored 3 (severely impaired cognition) on the Brief Interview for Mental Status, displayed physical behavior and rejected care 1 to 3 days of the 7 day assessment period. The MDS identified the resident required extensive staff assistance for bed mobility, walking in the room, and locomotion on/off the unit, was totally dependent upon staff for transfers, dressing, personal hygiene and toilet use and did not walk in the corridor. The MDS recorded the resident was not steady and was only able to stabilize with staff assistance when moved from seated to standing position, walking, turning around while walking and moving on/off the toilet and had no falls since the prior assessment. The resident's Fall Care Area assessment dated [DATE] included the resident was at risk for falls, was occasionally incontinent of bowel and bladder, and was unsteady during transfers. The resident's care plan included the resident was at risk for falls and the following interventions were in place since 4/4/14: staff monitored the resident's acute illness which may result in falls, assisted the resident with toileting as he/she allowed, monitored the resident for medication side effects, and staff provided range of motion to the resident's hand. The resident required 2 staff assistance with transfers (effective 5/28/14), due to behaviors, staff checked the resident's floor for items and ensured items were not on the resident's floor because the resident bent over to pick up the items which placed the resident at risk for falls. The resident had a personal safety alarm (PSA) and pad alarm in his/her bed at all times to alert staff of the resident's movement and the resident utilized a PSA in his/her wheelchair. The pad alarm was crossed out indicating it was discontinued but the care plan did not reveal the date staff discontinued the bed alarm. If the resident leaned over or was sleepy staff monitored the resident in the living room and made sure his/her PSA string was at a shorter length to alert staff. The resident utilized an electric low bed with a floor mat next to his/her bed. At times the resident placed himself/herself on the floor and was able to get himself/herself off of the floor and back in to his/her chair. The resident was non-compliant with using his/her call light, and was able to ambulate with his/her wheelchair on his/her own at times and transferred self into his/her wheelchair without asking for staff assistance. An entry dated 6/23/14 included staff applied a bed alarm to the resident's bed. A nurse's note (NN) dated 7/8/13 and timed 5:30 (A.M. or P.M. unknown) included the resident was on the floor on his/her left side next to the closet. The resident's gown was off and the PSA was attached to the resident's gown. The resident sustained [REDACTED]. A NN dated 7/21/13 and timed 11:00 A.M. documented the high risk team met to discuss the resident's fall on 7/8/13. The resident was restless and took his/her gown off and the PSA was attached to the resident's gown. The resident had a low electric bed with mats on the floor and staff performed 30 minute checks when the resident was restless and the resident's physician resumed the resident's Paxil (an antidepressant medication). A NN dated 10/26/13 and timed 6:45 AM documented the resident laid on the floor in his/her room near the dresser and the resident had a laceration above his/her left eyebrow area, below his/her left eye, and a skin tear on his/her left forearm. Interventions included staff changed the time of the resident's Risperdal (an antipsychotic medication), applied a bed alarm to the resident's bed since the resident disconnected the PSA at times and continued 30 minute checks when the resident was in bed. A NN dated 10/26/13 and timed 7:15 A.M. documented staff transferred the resident to a local hospital. A NN dated 10/26/13 and timed 9:00 A.M. documented the resident returned to the facility, had sutures to his/her left upper eye area, and bruising around his/her left eye area. A NN dated 12/15/13 and timed 11:10 P.M. included the resident laid on the floor in his/her room and all appropriate safety devices were in place. Interventions included staff placed the resident on 15 minute checks for 24 hours and staff moved the resident's nightstand closer to his/her recliner. A NN dated 12/18/13 and timed 5:30 P.M. documented the resident sat in a dining room chair with the alarm attached. A visitor noticed the resident stood from the chair and the alarm sounded and when staff arrived the resident sat on the floor. A high risk note dated 12/23/13 and timed 2:00 P.M. documented the high risk team met to discuss the resident's fall on 12/18/13. Staff ensured the resident sat in a recliner or a wheelchair, and continued the prior fall protocol. A NN dated 3/26/14 and timed 9:15 A.M. included the resident sat on the floor in the living room on his/her left side in front of his/her wheelchair. A direct care staff heard the alarm and when he/she turned around the resident was on the floor. The resident sustained [REDACTED]. Interventions included staff monitored the resident for sleepiness and shortened the PSA string. A NN dated 6/20/14 and timed 11:25 (A.M. or P.M. unknown) stated staff walked up the hallway to redirect a resident and heard resident #49 yelled "Help, hey, Help". Staff entered the resident's room and the resident sat on the floor with the PSA in his/her hand and the resident had a bruise on his/her left leg. Staff performed 15 minutes checks for 24 hours and lowered the resident's bed. Interventions included staff ordered a bed alarm and placed the bed alarm on the resident's bed on 6/23/14. A NN dated 6/23/14 and timed 11:00 A.M. documented the high risk team met and discussed the resident's fall on 6/20/14. Staff found the resident on the floor in his/her room, the resident had a history of [REDACTED]. was left in the low position and staff monitored the resident more frequently if the resident was restless. On 7/1/14 at 3:37 P.M. the resident sat in his/her wheelchair and the PSA was in place. On 7/2/14 at 7:10 A.M. the resident laid in his/her bed and the PSA, fall mat, and bed alarm were in place. On 7/3/14 at 7:10 A.M. the resident laid in bed. Observation revealed the PSA, bed alarm and floor mat were in place. At 8:30 A.M. the resident was in bed and the resident's breakfast tray was on the bedside table in front of the resident. Observation revealed the PSA and the bed alarm were in place and the floor mat behind the head of the resident's bed. At 9:15 A.M. the resident laid in bed, the beside table removed, the PSA and bed alarm were in place and the floor mat continued behind the head of the resident's bed. On 7/3/14 at 12:19 P.M. administrative nursing staff D confirmed the resident's care plan dated 4/4/14 included the resident used a bed alarm but the alarm was discontinued but he/she did not know why or when the facility discontinued the bed alarm. Administrative nursing staff D stated the facility reapplied the bed alarm on 6/23/14 after the resident fell on [DATE]. At 12:49 P.M. administrative nursing staff D stated he/she spoke with licensed nurse H regarding the bed alarm and he/she did not recall when the facility discontinued the resident's bed alarm and staff thought the resident broke the alarm. Administrative nursing staff D stated the resident continued to use the PSA in bed and in the wheelchair prior to 6/23/14. On 7/3/14 at 1:26 P.M. direct care staff O stated the resident utilized the PSA, a fall mat, and bed alarm when in bed, and the PSA in the wheelchair. Direct care staff O stated the facility placed the bed alarm approximately 3 weeks ago. On 7/3/14 at 4:25 P.M. licensed nurse H stated the resident utilized a bed alarm, PSA and fall mat when in bed. Licensed nurse H stated at one time the facility discontinued the bed alarm and recently reapplied the bed alarm. Licensed nurse H stated the facility discontinued the bed alarm after the resident took the alarm apart. The facility failed to place timely and effective fall interventions in place for this resident with a history of falls. - On 6/23/14 during the initial tour of the facility from 9:40 A.M. until 10:15 A.M. observation revealed the following located in an unlocked cabinet in the unlocked shower room on the special care unit: a 1/2 container of a 4 ounce tube of Renew skin repair cream plus essential oils, (2) 3/4 full containers of 4 ounces of Rensow Vitamin A & D ointment, a 3/4 full container of 2 ounces of Zinc Oxide Ointment. Review of all of the above containers revealed a warning for external use only and keep out of the reach of children. In case of accidental ingestion contact a physician or the poison control center right away. During interview with licensed nurse H at that time he/she confirmed the above and stated the creams/ointments were normally locked in the treatment cart. The facility failed to ensure products with warning labels were inaccessible to cognitively impaired residents that were independently mobile.