Every finding on record at Medicalodges Columbus

The facility reported a census of 29 residents, with three residents sampled and one resident reviewed for food served in a form that met the resident's individual needs. Based on interview and record review, the facility failed to provide Resident (R) 1 with the physician-ordered diet of mechanical soft food (a modified diet that consists of soft, easy-to-chew foods that require minimal chewing) on 02/08/26, when staff served R1 a whole chicken strip instead of ground meat per her orders. R1 consumed the chicken strip and began to choke. Staff performed the Heimlich maneuver (abdominal thrusts - a technique used to clear a blocked airway in conscious individuals) on R1 to dislodge the food. This deficient practice placed R1 in Immediate Jeopardy.Findings Included:- Review of the Electronic Medical Record (EMR) documented R1 had diagnoses of dysphagia (swallowing difficulty), oropharyngeal phase dysphagia (difficulty initiating a swallow, transferring food from the mouth to the throat, and into the esophagus), and Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure).R1's Significant Change Minimum Data Set (MDS), dated [DATE], documented R1 had a Brief Interview for Mental Status (BIMS) score of four, which indicated severe cognitive impairment. R1 required set-up or clean-up assistance for eating and required substantial to maximum staff assistance for oral hygiene. The assessment also documented R1 would cough or choke during meals or when swallowing medications and documented that she had a mechanically altered diet that required a change in the texture of the food.The Nutritional Status Care Area Assessment (CAA), dated 02/05/26, documented R1 was on a mechanically altered diet.The Cognitive Loss/Dementia CAA, dated 02/05/26, documented R1 had a BIMS score of four.R1's Care Plan, dated 02/04/25, directed staff to provide R1 with meals as ordered by her physician. An intervention dated 05/14/25 instructed staff to cut up R1's food and remind her to only take one bite at a time.R1's Care Plan included an intervention, dated 02/02/26, that instructed staff to provide her with a regular diet, mechanical soft texture with ground meat, and regular liquids. Ground meat was to be served with gravy or a sauce (no dry meat), no soft tortilla shells, no salad, no raw onions, no raw vegetables, and tortilla chips were to be crushed or broken. R1's EMR documented an order, dated 06/25/25, for a regular diet, mechanical soft with ground meat texture, regular consistency. The order directions documented for R1 to use hard plastic utensils, ground meat with gravy/sauce (no dry meat), no soft tortilla shells, no salad, no raw onion, to crush or break tortilla chips, and no raw vegetables.The 02/24/25 at 01:50 PM Progress Note documented Administrative Nurse B received an alert that R1 had a possible choking episode in the dining room. Staff observed R1 in her wheelchair, coughing, with blue coloring noted to her lips. Staff encouraged R1 to cough harder, and she was able to cough up a moderate amount of mushy substance. Administrative Nurse C suctioned R1, which resulted in a moderate amount of thick, clear mucus. After suctioning, R1's lips and skin were pink. The resident's physician ordered a chest X-ray.The 02/08/26 at 02:03 PM Nurse's Note documented R1 received a whole chicken strip for lunch, and she choked on a bite of chicken. The nurse was in the hall when staff hollered for the nurse and informed them of what was happening. Staff performed the Heimlich maneuver on R1 and were able to get the chicken piece dislodged and out. R1's lungs were assessed as clear to auscultation, bilaterally. R1 stated she was fine with no further issues.Certified Nurse Aide (CNA) M's Official Statement, dated 02/08/26, documented he was in the dining room feeding a resident and the resident announced R1 was choking. CNA M then assisted Consultant GG by lifting R1 up and performing the Heimlich maneuver. R1 spat the chunk of the food on the floor and told him she felt better. CNA M documented that another CNA notified the nurse, and the nurse then arrived and assessed R1's lungs.Consultant GG's Official Statement, dated 02/08/26, documented staff served R1 a whole chicken strip, and another resident told her R1 was choking. She then attempted the Heimlich, another CNA took over, and she yelled for the nurse who was in the hall.Dietary Staff BB's Official Statement, dated 02/08/26, documented R1 ordered a chicken strip, and he could not remember if she had ordered one before. He chopped one up and then set it aside and gave her a whole chicken strip because he could not remember if they were chopped for R1 or not.In an interview on 03/18/26 at 10:25 AM, Dietary Staff CC stated that there were cards that listed the proper dietary requirements, such as normal, pureed, or mechanical soft, for each resident. Dietary Staff CC stated the cooks made the plates for the residents based on the dietary order, and the dietary manager made the residents' dietary cards. She said once the plate was made, Dietary Staff CC would then ensure the proper dietary requirement, per the dietary card, were in place for each resident prior to serving the plates to the resident. Dietary Staff CC also said she was working on the day that R1 choked but did not remember any details.On 03/18/26 at 10:35 AM, Dietary Staff DD stated each resident had a dietary card, made by the dietary manager, and she had a card for each meal. She would prepare each resident's meal plate based on their specific dietary restrictions listed on the dietary card, such as pureed, mechanically soft, or regular. Dietary Staff DD said once the meal tray was made, the dietary aide finished preparing the meal tray with drinks and desserts and verified the proper meal consistency for each individual meal tray. Dietary Staff DD said a meal monitor provided a final verification the meal was properly prepared before the CNAs delivered the meals. Dietary Staff DD said the meal card stayed with the tray for verification.On 03/18/26 at 10:43 AM, Dietary Staff EE stated she received the provider orders related to dietary requirements, consistency, and specialized eating utensils. She then created a dietary card for each resident based on the provider's orders. Dietary Staff EE stated the dietary card was provided to the cook to make sure each resident's meal tray was based on the provider's dietary orders. She stated once the cook prepared the meal plates, the meal tray went to the dietary aide who prepared the drink and dessert and the dietary staff verified each resident received the proper dietary meal based on the resident's meal card. Dietary Staff EE said once the dietary aide completed the tray, a dietary monitor provided a final verification of the proper meal for each resident based on the meal card, and then the CNA delivered the meal tray to the resident. Dietary Staff EE further stated R1's meal card documented a mechanical soft diet with ground meat and confirmed staff did not thoroughly follow the processes on 02/08/26, and as a result, R1 received a full chicken strip.On 03/18/26 at 11:00 AM, CNA N stated during meals the CNAs made sure the residents were ready and set-up for meals, and the CNAs were provided the meal trays for each resident. CNA N said the CNA delivered the meal trays to each resident once a nurse, acting as a meal tray monitor, verified the proper meals were provided for each resident. CNA N also said the CNA verified the residents received the proper meal based on their dietary meal card.On 03/18/26 at 11:05 AM, Administrative Nurse D stated the dietary manager created dietary cards for each resident based on the provider's orders for each resident, and if the diet changed in any way, the dietary manager was provided with that update, and the staff changed the dietary card for the resident. Administrative Nurse D said the cook made the meal plate based on the dietary card, which stayed on the meal tray, and the tray went to the dietary aide who completed the drink preference and dessert based on the dietary card. Administrative Nurse D said once that process was completed the dining room monitor (a department head) provided the final meal verification, based on the diet card, and then provided the tray to a CNA to deliver the meal. Administrative Nurse D said the dining room monitor was implemented after the choking incident with R1 on 02/08/26.The facility policy Dietary Services: Nutrition and Diet Policies - Food Preparation and Serving Policies, dated 06/03/14, documented that foods were cut, chopped, or ground to meet individual needs.The facility policy Dietary Services: Nutrition and Diet Policies - Regular and Therapeutic Diets Offered documented that mechanical soft diets were offered for residents with chewing and/or swallowing difficulties. The policy further documented that meat, fish, and poultry should be chopped, flaked, or ground. On 03/18/26 at 03:15 PM, Administrative Nurse D received a copy of the Immediate Jeopardy [IJ] Template and was informed the facility's failure to provide R1 a mechanical ground diet as ordered resulted in a choking episode on 02/08/26, which placed R1 in IJ.The facility immediately identified and implemented the following corrective actions, completed on 02/09/26, which included:1. In-service education for dietary monitoring and proper diets served to each resident for all direct-care staff and kitchen staff, after R1's choking episode, and 1:1 education with the cook and dietary aide, disciplinary action for both.2. 1:1 in-service with all staff who serve in the dining room.3. Revamped dining room monitoring schedule to include a weekend manager for all meals.4. Verified all at-risk residents to ensure diets matched their diet cards.5. RELIAS educational training for the cook.6. Emergency QAPI meeting with the Director of Nursing, Administrator, and Medical Director.The following actions are the facilities plan for monitoring ongoing effectiveness:1. Review in the daily clinical excellence meeting for effectiveness.2. Review monthly at QAPI for ongoing compliance.3. Monitor quarterly at wellness review for ongoing compliance and effectiveness of the plan of correction.Due to the corrective actions the facility completed prior to the onsite visit, the deficient practice was deemed past non-compliance and existed at a J (isolated, immediate jeopardy) scope and severity.

The facility reported a census of 29 residents. Based on interview and record review, the facility failed to complete an annual performance review at least once every 12 months for two of the five Certified Nurse Aides (CNA) reviewed, CNA M and O, to ensure adequate appropriate cares and services provided to the residents of the facility. Findings included: - Review of five employee personnel files, employed by the facility for greater than one year, revealed the following concerns: 1. Certified Nurse Aide (CNA) M, hired 11/04/22, lacked an annual performance review in her personnel file. 2. CNA O, hired 11/27/23, lacked an annual performance review in her personnel file. On 02/10/25 at 10:03 AM, Administrative Nurse D confirmed the facility lacked annual evaluations for the two CNAs. The facility Employee Handbook included: Supervisors are to conduct performance evaluations of all full-time and part-time employees on an annual basis. The facility failed to complete an annual performance review at least every 12 months for these two CNAs, employed great than one year, to ensure appropriate cares and services were provided to the residents of the facility.

The facility reported a census of 29 residents. The sample included 15 residents. Based on observation, interview, and record review, the facility failed to maintain an effective infection control program related to the staff improper hand hygiene with wound dressing changes and catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) care. The facility failed to follow enhanced barrier precautions (a set of infection control measures that use gowns and gloves to reduce the spread of multidrug-resistant organisms (MDROs) in nursing homes) (EBP). This deficient practice had the potential to spread possible infections to the residents in the facility. Findings included: On 02/06/25 at 08:12 AM, Certified Medication Aide (CMA) U, Certified Nurse Aide (CNA) N, and Licensed Nurse (LN) G entered R11's room to transfer him and change the leg bag on the foley catheter to a full-sized bedside bag. The staff undressed him and changed out his catheter bag. They removed their gloves, but failed to preform proper hand hygiene before the put on new gloves and continued to dress R11 and got him ready to rest in bed. During an interview on 02/06/25 at 08:22 AM (CMA) U and (CNA) N revealed they forgot to put on the gown for EBP. Also discussed that they failed to preform hand hygiene after removing their gloves. CMA U stated they used to have hand sanitizer in the room on the shelf, but it was no longer there. On 02/06/25 at 10:09 AM, Licensed Nurse (LN) G performed a treatment and dressing change on R13. LN G washed hands with soap and water and dried with clean paper towels. Cleansed area with a gauze pad. LN G failed to peroform hand hygiene and change gloves prior to placing the clean dressing. On 02/10/25 at 12:46 PM, CNA P, was observed removing dirty sheets off R11's bed. CNA P confirmed she had just given R11 a bed bath and transferred him to his recliner, she did not wear the proper PPE. During an interview on 2/06/25 at 02:41 PM, CMA S stated that staff was required to use PPE when they cared for R11, and anyone that had a catheter or a wound and required EBP. CMA S stated that hand hygiene should always be done after gloves were removed. During an interview on 02/10/25 at 10:19 AM, CNA M reported that staff gown up and glove up every time they provided care for a resident with wounds or a catheter. CNA M reported that they were to always preform hand hygiene every time before they put on cloves and when they removed their gloves. During an interview on 02/10/25 at 11:20 AM, Administrative Nurse D confirmed that it was her expectation that all staff follow EBP and gown up when they completed care for a person with a catheter or an open wound. It was her expectation that all staff preform hand hygiene prior to putting on gloves and when they took them off and other times according to the policy, The facility failed to maintain an effective infection control program related to improper hand hygiene after removal of soiled gloves and failed to wear the proper PPE when staff cared for residents on EBP to prevent cross contamination in the facility.

The facility reported a census of 29 residents. The sample included 15 residents. Based on observation, interview, and record review the facility failed to maintain a functional emergency call system, which allowed residents to call for staff assistance from each resident's room, bedside, bathroom area, and/or bathing facilities and alarmed at a centralized staff work area. Findings included: - On 02/05/25 at 09:02 AM, Resident (R) 11 sat in his recliner with his emergency call light laying on the floor behind the table beside him. The emergency call light sat out of his reach. The resident reported he used his phone to call for assistance when his emergency call light did not work. On 02/05/25 at 09:26 AM, R15's emergency call light sat on the over-bed table and out of the resident's reach. On 02/05/25 at 10:16 AM, R16 stated the facility emergency call system did not always work and the resident reported using the phone to call for staff assistance at times. On 02/06/25 at 07:52 AM Licensed Nurse (LN) G and Certified Medication Aide (CMA) U reported they did not have pagers on them, which indicated a resident activated their emergency call light. CMA U stated there was a computer monitor, concealed by a curtain, which alerted staff a resident's emergency call light was activated and noted it could be seen in the commons area. On 02/06/25 at 07:57 AM CMA R stated she forgot to grab a pager to monitor resident emergency call lights. On 02/06/25 at 08:53 AM, during a call light observation with Maintenance Staff V to check the functionality of resident emergency lights revealed one resident room had a call light that only activated after three attempts and the shower room had two call lights, which did not work. Observation of call lights on 02/06/25 from 08:56 AM through 10:04 AM revealed 16 resident emergency call lights that malfunctioned by continuing to sound once deactivated, never activated on staff pagers, never activated on the facility computer, and/or did not activate at all. The observations included both resident rooms and bathrooms. During an interview on 02/06/25 at 10:06 AM, Maintenance Staff V stated he checked all of the staff pagers and call lights monthly. Maintenance Staff V completed a random weekly audit in addition to his monthly call light review. He reported in November or December he was notified of the resident emergency call lights not working and stated the facility immediately fixed the problem. Maintenance Staff V reported staff were taking the batteries out of the pagers and did not use them because they did not want to carry them. During an interview on 02/06/25 at approximately 11:30 AM, Administrative Staff A stated she was not aware of any current issues with the resident emergency call light system Administrative Staff A stated Administrative Nurse D and Maintenance Staff V checked all of the call lights about a week prior and everything was working properly. Administrative Staff A further stated she did not hear anything about staff choosing not to use their pagers. During an interview on 02/06/25 at 02:41 PM, CMA S stated the call lights and pagers worked most of the time. She stated the CNAs in the past did not carry the pagers and the residents got used to nobody answering them. The facility failed to provide a policy for the use of emergency call lights. The facility failed to maintain an emergency call system, which allowed residents to call for staff assistance from each resident's room, bedside, bathroom area, and/or bathing facilities and alarmed at a centralized staff work area.

The facility reported a census of 29 residents with 15 residents selected for review. Based on observation, interview, and record review, the facility failed to accurately complete the [NAME] Data Set for three residents: Resident (R) 15 and R20 related to falls; R18 related to antidepressant medication. This placed the residents at risk for uncommunicated care needs. Findings included: - The Electronic Health Records (EHR) documented R15 had the following diagnoses that included cognitive communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), coronary artery disease (CAD- abnormal condition that may affect the flow of oxygen to the heart), hypertension (HTN-elevated blood pressure), muscle weakness, and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). The 11/04/24 Admission Minimum Data Set (MDS) documented a brief interview for mental status (BIMS) of 13, which indicated intact cognition and one non-injury fall from 10/30/24 thru 11/04/24. The 11/04/24 Falls Care Area Assessment (CAA) documented R15 was at risk for falls and received antidepressants for diagnosis of major depressive disorder. He has had one non injury fall since admission. He has not had a fall within the last year before admission. He is working with therapy to improve his strength and balance. The 11/2/24 at 01:13 AM Progress Note revealed staff found R15 on the floor in his room leaning back against his closet. R15 stated he was looking for his pants. The 11/2/24 at 11:10AM Progress Note revealed the nurse saw R15 in his room on the floor inside his door facing the door. He was unable to explain what happened. During an observation on 02/05/25 at 01:58 PM, R15 sat in his recliner with no call light within reach, The nurse was not outside the room at the nurses' station. During an interview on 02/10/25 at 11:20 AM, Administrative Nurse D confirmed that the MDS was incorrect. The facility utilized the Resident Assessment Instrument (RAI) for the completion of MDSs. The facility failed to accurately complete the MDS for (R)15 related to falls. This placed the resident at risk for uncommunicated care needs. - The Electronic Health Records (EHR) documented Resident (R) 1 had the following diagnoses that included spastic hemiplegia affecting left side (that causes muscle tightness and involuntary contractions in the limbs and extremities on one side of the body), bipolar disorder (major mental illness that caused people to have episodes of severe high and low moods), seizure (violent involuntary series of contractions of a group of muscles), The 11/21/24 Annual Minimum Data Set (MDS) documented R1 had a brief interview for mental status (BIMS) of 12, which indicated intact cognition and was always incontinent of bowel and bladder also documented that he had a restorative program for amputation/prosthesis care and splint care six days out of the seven days in the look back period of 11/16/24 to 11/21/24. The 11/21/24 Incontinence Care Area Assessment (CAA) documented R1 was always incontinent of bowel and bladder. The 02/06/25 Care Plan documented a restorative program for an ankle-foot orthotic (AFO- a custom-made brace that supports the foot, ankle, and lower leg) to the left leg while awake and a left hand splint at night. Also, a passive range of motion program before staff put on the splint and after staff removed the splint. Staff documented R1 wore the leg brace every day in the last 30 days except 1/10/25, 1/11/24, 1/12/25, 1/13/25, and 1/24/25. The 02/06/25 Care Plan documented R1 was incontinent at times, he used a urinal and a bed pan. The bowel and bladder task record for the time prior to the MDS documented R1 was continent of bladder six times and incontinence nine times from 11/15/24 to 11/21/24. It also documented that R1 was continent of bowel on 11/16/24 and 11/18/24, The Progress Notes on 8/14/2024 at 11:30 AM documented that R1 needed a referral for an appointment at Progressive Prosthetics and Orthotics in [NAME], Mo for a new AFO brace and shoes as his brace did not fit him properly anymore. The Progress Notes on 8/20/2024 at 01:34 PM documented Dr. [NAME] saw R1 and was to send the referral to Progressive Prosthetics and Orthotics for R1 to see about a new AFO brace and shoes. No new orders received at this time. The Progress Notes from 11/15/14 to 11/21/24 revealed R1 was sometimes continent of bowel and bladder during this time. The 1/31/25 at 2:28 PM Restorative Aide Note documented a program of a left hand splint to be put on at night and off in the morning and left leg AFO to be worn daily- put on in morning and off at night. Restorative Aide documented that R1 was doing well with program, he was able to complete all task, and was wearing the splints as ordered. Also documented he participated actively, did not refuse. During an observation on 02/05/25 at 02:08 PM, R1 sat in the dining area in his wheelchair and watched television, His legs were wrapped, and he had no brace or AFO on his left leg. During an interview on 2/06/25 at 02:41 PM, Certified Medication Aide (CMA) S verified that R1 can be continent of bowel and bladder, but that he has urgency. She also stated that he had not worn his brace in a while because it was too small and he needed a new one. Unable to remember how long. During an interview on 02/10/25 10:32 AM, CMA U confirmed that R1 did not have an amputation or prosthetic, and R1's AFO was too small for him and that they were to get a new one for him. Also confirmed that R1 could let you know that he has to toilet when he wanted to go. During an interview on 02/10/25 at 11:20 AM, Administrative Nurse D confirmed that R1 was sometimes continent of bowel and bladder, and he did notify staff that he needed to go but had urgency so sometimes they didn't make it in time. Administrative Nurse D confirmed that R1 did not have an amputation or prosthetic, and R1's AFO was too small for him. They were working with insurance to get a new one. Confirmed that it should not have been documented that the program was done, because it couldn't be done. She took over as the MDS Coordinator and has been working on fixing thing. The facility utilized the Resident Assessment Instrument (RAI) for the completion of MDSs. The facility failed to accurately complete the MDS for (R)1 related to continence status and restorative care. This placed the resident at risk for uncommunicated care needs. 34056 - Review of Resident (R)18's electronic medical record (EMR) revealed a diagnosis of major depressive disorder (major mood disorder which causes persistent feelings pf sadness). The Admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of four, indicating severe cognitive impairment. He received antipsychotic ((medications used to treat psychosis (any major mental disorder characterized by a gross impairment perception)), an antibiotic (medication used to treat infections) and an antiplatelet (medication used to prevent platelets from sticking together and decrease your body ' s ability to form blood clots) during the assessment period. The Psychotropic Drug Use Care Area Assessment (CAA), documented the resident's physician would review and make adjustments to the resident's psychoactive medications, as needed. The Quarterly MDS, dated [DATE], documented the staff assessment for cognition revealed modified independence with daily decision making. He received antipsychotic, antidepressant, antiplatelet and anticonvulsant (medications used to treat seizures) medications during the assessment period. The care plan, revised 09/27/24, instructed staff the resident took antidepressant medication due to being tearful at times. Staff were to allow the resident to express his feelings without judgement or criticism. Review of the resident's EMR revealed the following physician's order: Venlafaxine (an antidepressant medication), 75 milligrams (mg), by mouth (po), every day (QD), for MDD, ordered, 07/03/24. On 02/10/25 at 12:30 PM, Administrative Nurse D stated the 07/09/24 MDS, which lacked documentation of an antidepressant medication being given during the assessment period, was inaccurate. The facility utilized the Resident Assessment Instrument (RAI) for the completion of MDSs. The facility failed to complete an accurate MDS for this dependent resident who received antidepressant medication. - Review of Resident (R)20's electronic medical record (EMR) revealed a diagnosis of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure) and Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness). The Significant Change Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of zero, indicating severe cognitive impairment. She used a wheelchair for locomotion and was dependent on staff for chair to bed to chair transfers. She had one injury fall (except major) since the prior assessment. The Functional Abilities Care Area Assessment (CAA), dated 12/19/24, did not trigger. The Fall CAA, dated 12/19/24, documented the resident required staff assistance with all cares. The Annual MDS, dated [DATE], documented the resident had a BIMS score of one, indicating severe cognitive impairment. She used a wheelchair for locomotion and was dependent on staff for chair to bed to chair transfers. She had one injury fall (except major) since the prior assessment. The care plan, revised 11/29/24, instructed staff to use two staff and a gait belt while transferring the resident. Review of the resident's EMR, revealed the following Fall Assessments which placed the resident at a moderate risk for falls: 12/17/24 and 10/28/24. Review of the resident's EMR, revealed the following Fall Assessments which placed the resident at a high risk or falls: 11/30/24 and 04/21/24. Review of the resident's EMR, revealed the resident had an injury fall (except major) on 10/28/24, when she raised her electric recliner up and fell forward out of the chair. She received a reddened area to her mid, upper back. The resident's EMR lacked documentation of a fall for this resident between the dates of 12/05/24 and 12/19/24. On 02/10/25 at 09:03 AM, Administrative Nurse D stated the 12/19/24 MDS was inaccurate as the resident did not have a fall after 10/28/24. The facility utilized the Resident Assessment Instrument (RAI) for the completion of MDSs. The facility failed to complete an accurate MDS for this dependent resident with falls.

The facility reported a census of 29 residents with 15 residents selected for review. Based on observation, interview, and record review, the facility failed to identify, implement, and reevaluate fall prevention interventions to prevent falls including failing to provide a call light within reach for Resident (R) 15, when staff preformed unsafe transfers and failed to follow the care plan for R20, and failed to follow the care plan by failing to provide the call light within reach R17 and R18. This placed the residents at risk for falls with injury. Findings included: - The Electronic Health Records (EHR) documented R15 had the following diagnoses that included cognitive communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness), muscle weakness, diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), coronary artery disease (CAD- abnormal condition that may affect the flow of oxygen to the heart), hypertension (HTN-elevated blood pressure), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). The 11/04/24 Admission Minimum Data Set (MDS) documented a brief interview for mental status (BIMS) of 13, which indicated intact cognition and one non-injury fall from 10/30/24 thru 11/04/24. The 11/04/24 Falls Care Area Assessment (CAA) documented R15 was at risk for falls and received antidepressants for diagnosis of major depressive disorder. He has had one non injury fall since admission. He has not had a fall within the last year before admission. He is working with therapy to improve his strength and balance. The 1/19/25 Quarterly MDS documented a BIMS of 12, which indicated moderate cognitive impairment and two or more noninjury falls. The 02/05/25 Care Plan documented the following interventions: 11/2/24 ensure R15 had his call light within reach and encourage him to use it to ask for assistance. 11/2/24 move R15's room closer to the nurse's station. 11/10/24 transfer pole to be placed near R15's bed on his left side. 11/24/24 transfer bar and grab bars in resident's bathroom. 12/07/24 fall lacked an intervention on the care plan. 12/13/24 handlebar next to resident's closet. 12/15/24 his bed in the lowest position. 12/20/24 nonskid strips on the floor. 01/25/25 computed tomography scan (CT- a noninvasive medical imaging procedure that uses X-rays to create detailed pictures of the inside of the body) of his head in order received to check for suspected neuro deficit to determine if neuro consultation is needed. The Fall Risk Assessment for R15 documented between 11/02/24 and 02/08/25 documented scores between 9 and 22. Which indicated R15 was moderate to high risk for falls. The Progress Note on 11/02/24 at 01:13 AM documented a non-injury fall. The Fall Report documented a root cause analysis that he lost his balance and an intervention of a call light within reach. The Progress Note on 11/02/24 at 11:10 AM documented a non-injury fall. The Fall Report documented a root cause analysis confusion, post hospitalization and staff moved his room closer to the nurse's station. The Progress Note on 11/10/24 at 06:32 AM documented a non-injury fall. The Fall Report documented a root cause analysis that he lost his balance with an intervention of a transfer pole. The Progress Note on 11/24/24 at 03:43 AM documented a non-injury fall. The Fall Report documented a root cause analysis that he went to the bathroom unattended. with an intervention of a transfer pole and bar in the bathroom. The Progress Note on 12/07/24 at 01:05 AM documented a non-injury fall. There was no Fall Report that documented a root cause analysis, and it lacked an intervention. The Progress Note on 12/13/24 at 05:30 PM documented a fall that sent him to the ER. The Fall Report documented a root cause analysis that he lost his balance with an intervention of nonskid strips and a fall mat. The fall on 12/15/24 lacked a Progress Note. The Fall Report documented no root cause analysis, but an intervention of bed in lowest position. The Progress Note on 1/20/25 09:35 PM documented a non-injury fall. He was wearing slippery socks and got up to go to the bathroom. The Fall Report documented a root cause analysis that he lost his balance ant they put strips on the floor. The Progress Note on 1/25/25 at 10:46 PM documented a non-injury fall. The Fall Report documented a root cause analysis of suspected [NAME] deficit (an impairment or loss of function in the nervous system, affecting the brain, spinal cord, nerves, or muscles). During an observation on 02/05/25 at 09:26 AM, R15 was lying bed, the call light was on his over bed table that was several feet out of reach. He was asked where it was, he stated the call light was down there somewhere and pointed toward the head of the bed. There was no transfer bar beside his bed. During an observation on 02/05/25 at 01:58 PM, R15 sat in his recliner with no call light within reach. During an interview on 02/10/25 at 10:19 AM, Certified Nurse Aide (CNA) M reported that she looked at the care plan to know how to care for a resident. She reported that R15 had a fall mat, and they do frequent checks. During an interview on 02/10/25 at 12:49 PM, Licensed Nurse (LN) G reported that interventions for falls was group effort. Confirmed there was not a transfer pole beside his bed in his room. During an interview on 02/10/25 at 11:20 AM, Administrative Nurse D was notified that R15 did not have his call light, she reported he should have his call light and she would fix that. She confirmed that the transfer pole was not in his room, it is on back order, also confirmed that R15 did not have the head CT yet even though it was the intervention for the fall on 01/25/25. Administrative D confirmed that there must be an appropriate intervention for each fall to keep the resident safe. The facility's Falls Management policy dated 12/2018, revised 12/2020 documented the plan of care was to address individualized resident focus, goals, and interventions directed towards reducing the resident's risk if injury and potential recurrence of falls. The resident's plan of care was to be reviewed and revised with each fall occurrence and a new intervention or interventions implemented. The facility failed to implement new interventions to prevent falls after several falls. This deficient practice placing her at risk for further falls. - Resident (R) 17's Electronic Health Record (EHR) revealed diagnoses, which included: dementia (progressive mental disorder characterized by failing memory, confusion), muscle weakness, reduced mobility, abnormal gait (manner or style of walking), osteoporosis (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk), osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain), and diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin). The 01/16/25 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of five, which indicated severely impaired cognition. R17 required supervision or touch assistance with activities of daily living (ADL) to include dressing, toileting hygiene, footwear, personal hygiene and standing. The MDS documented R17 had one injury fall since the prior assessment. The 01/16/25 Falls Care Area Assessment (CAA) documented R17 had a fall with a head laceration that required staples. The CAA revealed therapy worked with R17 to improve her strength and balance. The CAA noted the resident was a fall risk and staff were to assist her as needed. The 01/16/25 Cognitive Loss/Dementia CAA documented R17 had a BIMS score of five. The CAA noted R17 usually understood others, others usually understood her, and staff were to assist with her cares as needed. The 02/06/25 Care Plan documented the following fall prevention interventions including to keep the call light with the resident's reach and educate the resident to use the call light. The Fall Risk Evaluation for R17, documented the resident was at moderate to high risk for falls. The Progress Note on 06/18/24 at 11:21 PM revealed R17 experienced a non-injury fall, where R17 said she sat down on the arm of her chair and slid off. The Progress Note on 09/19/24 at 06:03 AM revealed R17 experienced a non-injury fall, where R17 said she raised her electric chair too high and slid out. The Progress Note on 11/05/24 at 04:04 PM revealed R17 lost her balance, fell , hit her head, and was taken to the hospital by EMS, where she required staples to close the laceration. During an observation on 02/06/25 at 09:07 AM Maintenance Supervisor V checked the call lights in R17's room, with the surveyor. The call light in R17's room was activated by Maintenance Supervisor V but did not display on the computer monitor or alert to the staffs pager. The call light for R17's bathroom did not activate either. During an interview on 02/06/25 at 02:41 PM, CMA S stated the call lights and pagers worked most of the time. CMA S stated the CNAs in the past did not carry the pagers and the residents got used to nobody answering them. CMA S said the facility implemented a pager sign out book to get staff to grab a pager, a couple of months ago, and wrote staff up if they did not have a pager. CMA S said as far as she was aware, this fixed the problem. During an interview on 02/06/25 at 11:30 AM, Administrative Staff A was notified of the call lights that were not working. Administrative Staff A said Administrative Nurse D and Maintenance Staff V looked at the call lights about a week prior and they were working. Administrative Staff A stated that R17 preferred the hand bell. The surveyor informed her the handbell was not within R17's reach During an interview on 02/06/25 at 12:00 PM, Administrative Nurse D said she was aware some of the call lights got stuck on and would not reset. Administrative Nurse D stated Maintenance Saff V checked all of the call lights within the last month, and they were all working. Administrative Nurse D said some of the call lights needed batteries at that time. During an observation and interview on 02/06/25 at 02:26 PM, R17 sat in her recliner with her call light and hand bell out of her reach. The call light cord was loosely wound on the floor under the call light box. The surveyor handed the resident the call light, and R17 pushed the call light button. When asked, R17 reported she used the call light and she had used the hand bell a couple of times. R17 continued to push the call light button and said, It doesn't work right. You have to keep pushing the button and she continued to push it. At 02:58 PM on 02/06/25, no staff had responded to answer R17's call light. R17 kept pushing the call light button and said the staff will come eventually. The staff did stop by R17's room but not in response to the light. R17 stated, See. I told you. The call light display monitor did not show the call light was activated for R17. The facility policy Electronic Care Plan dated 12/2020, documented the resident's person-centered plan of care is an active working document that reflects the care needs and the resident's voice. The facility failed to follow the fall prevention interventions to prevent falls for cognitively impaired R17, who had a history of falls at facility, when the facility staff did not ensure R17's call light was within reach and functioning. This deficient practice placed R17 at risk for further falls with injury. 34056 - Review of Resident (R)20's electronic medical record (EMR) revealed a diagnosis of Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness). The Significant Change Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of zero, indicating severe cognitive impairment. She was dependent on staff for chair-to-bed-to-chair transfers. The inaccurate MDS documented the resident had one injury (except major) fall since the prior assessment. The Functional Abilities Care Area Assessment (CAA), dated 12/19/24, did not trigger. The Fall CAA, dated 12/19/24, documented the resident required staff assistance with cares. The Annual MDS, dated [DATE], documented the resident had a BIMS score of four, indicating severe cognitive impairment. She was dependent on staff for chair-to-bed-to-chair transfers. She had one injury (except major) fall since the prior assessment. The fall care plan, revised 11/29/24, instructed staff the resident required one to two staff assistance with transfers and the use of a gait belt. The staff were to ensure the resident's call light was within reach at all times while she was in her room. Review of the resident's EMR revealed fall assessments, dated 10/28/24 and 12/17/24, which placed the resident at a moderate risk for falls. Fall assessments, dated 04/21/24 and 11/30/24, placed the resident at a high risk for falls. Review of the resident's EMR, revealed the resident had an injury (except major) fall in her room from her recliner on 10/28/24. Staff informed the nurse the resident's electric lift chair with the lift chair in the upper most position and the resident on the floor in front of the electric chair. Upon assessment, the resident had a reddened area to her spine. The resident had no further injuries, was able to move all of her extremities per her normal and her vital signs (VS) were within normal range (WNR). Staff initiated neurology checks (a medical assessment that evaluates the function of a patient's nervous system by testing their mental status, muscle strength, coordination, sensation, reflexes, and other neurological functions), which were all WNR. The interdisciplinary team (IDT) initiated a new intervention to keep the resident's lift chair unplugged when the resident was in the chair to prevent her from raising the chair on her own. Review of the resident's EMR revealed an Electric Recliner Assessment, dated 11/05/24, which documented the resident did not have the physical or cognitive ability to safely operate the electric recliner. No other Electric Recliner Assessments were available in the resident's EMR. Review of the resident's EMR, from 01/12/25 through 02/09/25, revealed the resident required substantial/maximal to dependent staff assistance with chair to bed to chair transfers. Review of the resident's EMR, from 01/12/25 through 02/09/25, revealed the resident required substantial/maximal to dependent staff assistance with going from sitting to standing. On 02/06/25 at 09:35 AM, Certified Medication Aide (CMA) S transferred the resident from her wheelchair to her electric recliner with extensive assistance and the use of the gait belt. The resident was unable to bear weight during the transfer. The electric recliner remained plugged in when the CMA left the room following cares. The controller to the electric recliner rested on the arm of the chair. On 02/06/25 at 10:47 AM, the resident sat in her electric recliner in her room. The electric recliner remained plugged in and the controller to the recliner rested on the arm of the chair. On 02/06/25 at 01:18 PM, Certified Nurse Aide (CNA) N and Licensed Nurse (LN) G transferred the resident from her wheelchair to her bed with extensive assistance and the use of a gait belt. The resident was unable to bear her full weight during the transfer. On 02/06/25 at 09:39 AM, CMA S stated staff were not to unplug the resident's electric recliner. Staff were to use the chair plugged in at all times. CNA S stated the resident was able to bear some weight during transfers but was unable to bear her full weight. On 02/06/25 at 01:18 PM, CNA N stated the resident could only bear minimal weight during transfers. Staff left the resident's electric recliner plugged in all of the time. On 02/06/25 at 01:18 PM, LN G stated the resident was not able to fully bear weight during transfers. LN G was unsure if the resident's electric recliner was to be plugged in or not. On 02/10/25 at 09:03 AM, Administrative Nurse D stated the intervention for the fall on 10/28/24 was to keep the lift chair unplugged when the resident sat in the chair. Administrative Nurse D stated a resident should be able to bear weight during a transfer for the transfer to be considered safe. The facility would possibly need to utilize the full body lift with the resident. Administrative Nurse D stated the 11/05/24 Electric Recliner Assessment, was the only assessment available. The facility policy for Falls Management, revised 12/2022, included: The plan of care shall address individualized resident focus, goals, and interventions directed towards reducing the resident's risk of injury and potential reoccurrence of falls. The facility policy for Assessments, revised 11/2024, included: The Electric Recliner Assessment shall be completed with use of the electric recliner initiation then quarterly, and as needed. The facility failed to practice safe transfers for this dependent resident who was unable to bear weight during transfers. Furthermore, the facility failed to complete an Electric Recliner Assessment for this confused resident who was found to be physically and cognitively unable to safely operate the electric lift chair. - Review of Resident (R)18's electronic medical record (EMR) revealed a diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion). The Admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of four, indicating severe cognitive impairment. The resident had no limitation in range of motion (ROM). He used a walker for mobility. He required substantial/maximal assistance of staff for lying to sitting to the side of the bed, sit to stand and chair/bed-to-chair transfers. The resident had no falls since the prior assessment. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 07/09/24, documented the resident had a diagnosis of dementia and had the potential for falls. The Quarterly MDS, dated [DATE], documented the staff assessment for cognition revealed modified independence with daily decision making. He had limited ROM on one side of his lower extremity (LE) and used a walker and a wheelchair. He required substantial/maximal assistance of staff for lying to sitting to the side of the bed, sit to stand and chair/bed-to-chair transfers. The resident had two or more non-injury falls since the prior assessment. The fall care plan, revised 12/24/24, instructed staff to ensure the call light was within reach of the resident and to encourage him to use it for assistance. Staff were to keep a non-skid substance in the resident's recliner to prevent him from sliding and to install a transfer pole between his bed and recliner. Review of the resident's EMR revealed Fall Assessments dated 07/03/24, 12/15/24 and 12/24/24, which placed the resident at a high risk for falls. Review of the resident's EMR revealed a Fall assessment dated [DATE], which placed the resident at a moderate risk for falls. Review of the resident's EMR revealed the resident had a non-injury fall in his room on 12/15/24 when he slid off his recliner seat and landed on the floor on his buttocks in front of his recliner. Review of the resident's EMR revealed the resident had a non-injury fall in his room on 12/25/24 when he fell to the floor while attempting to get out of bed unassisted. On 02/06/25 at 07:31 AM, the resident rested in bed. His call light was not within the resident's reach. On 02/06/25 at 01:29 PM, the resident rested in bed. His call light was not within the resident's reach. On 02/06/25 at 12:00 PM, Administrative Nurse D stated she knew some of the call lights would not turn off but was unaware there were so many call lights that did not work. The facility lacked a policy for call lights. The facility failed to ensure this dependent resident had a call light within reach for him to utilize to call for staff assistance.

The facility reported a census of 29 residents with 15 residents sampled including five residents reviewed for unnecessary medications. Based on observation, record review and interview, the facility failed to monitor four Residents (R)12, R 17, R 18, and R 30, for use of antipsychotic medications (drugs used to treat psychosis-related conditions and symptoms), regarding the facility's failure to complete informed consents for the use of psychotropic (medications used to treat mental illnesses by affecting the chemical makeup of the brain and nervous system) and antipsychotic medications. Furthermore, the facility failed to monitor the use of an antianxiety (a class of medications used to treat anxiety disorders and related symptoms like excessive worry, fear, and tension) medication. Findings included: - Review of Resident (R)12's electronic medical record (EMR) revealed diagnoses which included: depression (a mood disorder that causes a persistent feeling of sadness and loss of interest) and anxiety (an emotion characterized by feelings of worry, unease, or fear, often in anticipation of a future threat or event). The Annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of two, indicating severe cognitive impairment. She received antianxiety medication (a class of medications used to treat anxiety disorders and related symptoms like excessive worry, fear, and tension) and antidepressant medication (medications used to treat mental illnesses by affecting the chemical makeup of the brain and nervous system) during the assessment period. The Psychotropic Drug Use Care Area Assessment (CAA), dated 10/10/24, documented the resident received antidepressant and antianxiety medications. The Quarterly MDS, dated 01/09/25, documented the resident had a BIMS score of two, indicating severe cognitive impairment. She received antianxiety and antidepressant medications during the assessment period. The psychotropic medications care plan, revised 01/03/25, instructed staff to monitor and document any side effects of the resident's antianxiety and antidepressant medications and to notify the physician of any adverse reactions. Review of the resident's EMR revealed the following physician's orders: Prozac (an antidepressant medication), 10 milligrams (mg), by mouth (po), every day (QD), for a diagnosis of depression, ordered 11/02/20. Xanax (an antianxiety medication), 0.25 mg, po, at bedtime (HS), for a diagnosis of anxiety, ordered 03/13/24. Review of the resident's Medication Administration Record (MAR) from 01/01/25 through 02/06/25, revealed the resident received the medications, as ordered. Review of the resident's EMR revealed the facility lacked a signed and dated Informed Consent for the use of psychotropic medications. On 02/05/25 at 12:12 PM, the resident sat at the dining table in her wheelchair. No indication of tearfulness or anxiety. On 02/06/25 at 07:39 AM, Certified Medication Aide (CMA) U combed and styled the resident's hair before breakfast. The resident chatted and interacted with the CMA during her cares. No obvious outward evidence of depression or anxiety displayed at that time. On 02/11/25 at 11:05 AM, Administrative Nurse D stated the Informed Consent forms were not completed and signed for the residents who received psychotropic medications. The facility policy for Behavior Management and Psychotropic Medications, revised 11/2024, included: An informed consent will be completed for the use of psychotropic medications that affect brain activity for the residents prior to initial administration of the medication. The facility failed to complete an Informed Consent for this dependent resident who received psychotropic medications. - Review of Resident (R)18's electronic medical record (EMR) revealed the following diagnoses: dementia (progressive mental disorder characterized by failing memory, confusion) and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). The admission Minimum Data Set (MDS, dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of four, indicating severe cognitive impairment. She received antipsychotic medication during the assessment period. (This inaccurate) MDS failed to document the resident received antidepressant medications throughout the assessment period.) The Psychotropic Drug Use Care Area Assessment (CAA), dated 07/09/24, documented the resident's medications would be reviewed by the pharmacy consultant and adjustments completed, as needed (PRN). The Quarterly MDS, dated 01/02/25, documented the staff assessment for cognition revealed modified independence for daily decision making. She received antipsychotic and antidepressant medications during the assessment period. The care plan for psychotropic medications, revised 09/27/24, instructed staff the resident took antidepressant medications for tearfulness and an antipsychotic medication for agitation (feeling of aggravation or restlessness brought on by a provocation or a medical condition). Review of the resident's EMR revealed the following physician's orders: Venlafaxine (an antidepressant medication), 75 milligrams (mg), by mouth (po), every day (QD), for a diagnosis of depression, ordered 07/03/24. Seroquel (an antipsychotic medication) 25 mg, po, twice daily (BID), for a diagnosis of depression, ordered 07/03/24. Review of the residents Medication Administration Record (MAR) from 01/01/25 through 02/06/25, revealed the resident received the medications, as ordered. Review of the resident's EMR revealed the facility lacked a signed and dated Informed Consent for the use of psychotropic medications. On 02/05/25 at 11:57 AM, Certified Medication Aide (CMA) U propelled the resident in his wheelchair to the dining room for lunch. The resident had no obvious outward indications of tearfulness or agitation. On 02/11/25 at 11:05 AM, Administrative Nurse D stated the Informed Consent forms were not completed and signed for the residents who received psychotropic medications. The facility policy for Behavior Management and Psychotropic Medications, revised 11/2024, included: An informed consent will be completed for the use of psychotropic medications that affect brain activity for the residents prior to initial administration of the medication. The facility failed to complete an Informed Consent for this dependent resident who received psychotropic medications. - Review of Resident (R)17's electronic medical record (EMR) revealed the following diagnoses: major depressive disorder (MDD-major mood disorder which causes persistent feelings pf sadness) and anxiety (emotion characterized by feelings of worry, unease, or fear, often in anticipation of a future threat or event). The Annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of five, indicating severe cognitive impairment. She received antidepressant medication (medications used to treat mental illnesses by affecting the chemical makeup of the brain and nervous system) during the assessment period. The Psychotropic Drug Use Care Area Assessment (CAA), dated 01/16/25, documented the resident received antidepressant medication for a diagnosis of MDD. The Quarterly MDS, dated 10/24/24, documented the resident had a BIMS score of five, indicating severe cognitive impairment. She received an antidepressant medication during the assessment period. Review of the resident's EMR revealed the following physician's order: Fluoxetine (an antidepressant medication), 60 milligrams (mg) one-half tablet, by mouth (po), every day (QD), for a diagnosis of MDD, ordered 1/14/23. Review of the resident's Medication Administration Record (MAR) from 01/01/25 through 02/06/25, revealed the resident received the medications, as ordered. Review of the resident's EMR revealed the facility lacked a signed and dated Informed Consent for the use of psychotropic medications. On 02/11/25 at 11:05 AM, Administrative Nurse D stated the Informed Consent forms were not completed and signed for the residents who received psychotropic medications. The facility policy for Behavior Management and Psychotropic Medications, revised 11/2024, included: An informed consent will be completed for the use of psychotropic medications that affect brain activity for the residents prior to initial administration of the medication. The facility failed to complete an Informed Consent for this dependent resident who received psychotropic medications. - Review of Resident (R)30's electronic medical record (EMR) revealed the following diagnoses: anxiety (emotion characterized by feelings of worry, unease, or fear, often in anticipation of a future threat or event) and major depressive disorder (MDD-major mood disorder which causes persistent feelings of sadness) and insomnia (the inability to sleep). The Annual Minimum Data Set (MDS), dated [DATE], documented the resident admitted to the facility on [DATE] and had a Brief Interview for Mental Status (BIMS) score of five, indicating severe cognitive impairment. He received antidepressant (a class of medications used to treat mood disorders) and antianxiety medications (a class of medications that calm and relax people) during the assessment period. The Psychotropic Drug Use Care Area Assessment (CAA), dated 12/16/24, documented the resident received antidepressant and antianxiety medications. The care plan for psychotropic medications instructed staff the resident took an antidepressant for insomnia and an antianxiety medication for agitation. Review of the resident's EMR revealed the following physician's order: Lorazepam (a class of medications that calm and relax people), 05 milligrams (mg), by mouth (po), every six hours, as needed (PRN), for a diagnosis of anxiety, ordered 12/09/24. Mirtazapine (class of medications used to treat mood disorders), 15 mg, po, at bedtime (HS), for a diagnosis of insomnia, ordered 12/10/24. Review of the resident's Medication Administration Record (MAR) from 12/09/24 through 02/06/25, revealed the resident's Mirtazapine medication was given as ordered. Review of the resident's Medication Administration Record (MAR) from 12/09/24 through 02/06/25, revealed the resident's Lorazepam was given 14 times with effective results. However, documentation failed to document any behaviors at the time of the antianxiety medication administration. Review of the resident's EMR revealed the facility lacked a signed and dated Informed Consent for the use of psychotropic medications. On 02/11/25 at 11:05 AM, Administrative Nurse D stated the Informed Consent forms were not completed and signed for the residents who received psychotropic medications. The facility policy for Behavior Management and Psychotropic Medications, revised 11/2024, included: An informed consent will be completed for the use of psychotropic medications that affect brain activity for the residents prior to initial administration of the medication. The facility failed to complete an Informed Consent for this dependent resident who received psychotropic medications.

The facility reported a census of 29 residents with 15 residents included in the sample. Based on observation, record review and interview, the facility failed to develop and implement a comprehensive person-centered care plan for one Resident (R)20, regarding the use of an electric recliner. Findings included: - Review of Resident (R)20's electronic medical record (EMR) revealed a diagnosis of Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness). The Significant Change Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of zero, indicating severe cognitive impairment. She was dependent on staff for chair-to-bed-to-chair transfers. The inaccurate MDS documented the resident had one injury (except major) fall since the prior assessment. The Functional Abilities Care Area Assessment (CAA), dated 12/19/24, did not trigger. The Fall CAA, dated 12/19/24, documented the resident required staff assistance with cares. The Annual MDS, dated [DATE], documented the resident had a BIMS score of four, indicating severe cognitive impairment. She was dependent on staff for chair-to-bed-to-chair transfers. She had one injury (except major) fall since the prior assessment. The comprehensive care plan, revised 11/29/24, lacked staff instruction regarding the resident's use of an electric recliner in her room. Review of the resident's EMR revealed fall assessments, dated 10/28/24 and 12/17/24, which placed the resident at a moderate risk for falls. Fall assessments, dated 04/21/24 and 11/30/24, placed the resident at a high risk for falls. Review of the resident's EMR, revealed the resident had an injury (except major) fall in her room from her recliner on 10/28/24. Staff informed the nurse the resident's electric lift chair with the lift chair in the upper most position and the resident on the floor in front of the electric chair. Upon assessment, the resident had a reddened area to her spine. The resident had no further injuries, was able to move all of her extremities per her normal and her vital signs (VS) were within normal range (WNR). Staff initiated neurology checks (a medical assessment that evaluates the function of a patient's nervous system by testing their mental status, muscle strength, coordination, sensation, reflexes, and other neurological functions), which were all WNR. The interdisciplinary team (IDT) initiated a new intervention to keep the resident's lift chair unplugged when the resident was in the chair to prevent her from raising the chair on her own. Review of the resident's EMR revealed an Electric Recliner Assessment, dated 11/05/24, which documented the resident did not have the physical or cognitive ability to safely operate the electric recliner. No other Electric Recliner Assessments were available in the resident's EMR. Review of the resident's EMR, from 01/12/25 through 02/09/25, revealed the resident required substantial/maximal to dependent staff assistance with chair to bed to chair transfers. Review of the resident's EMR, from 01/12/25 through 02/09/25, revealed the resident required substantial/maximal to dependent staff assistance with going from sitting to standing. On 02/06/25 at 09:35 AM, Certified Medication Aide (CMA) S transferred the resident from her wheelchair to her electric recliner with extensive assistance and the use of the gait belt. The resident was unable to bear weight during the transfer. The electric recliner remained plugged in when the CMA left the room following cares. The controller to the electric recliner rested on the arm of the chair. On 02/06/25 at 10:47 AM, the resident sat in her electric recliner in her room. The electric recliner remained plugged in and the controller to the recliner rested on the arm of the chair. On 02/06/25 at 01:18 PM, Certified Nurse Aide (CNA) N and Licensed Nurse (LN) G transferred the resident from her wheelchair to her bed with extensive assistance and the use of a gait belt. The resident was unable to bear her full weight during the transfer. On 02/06/25 at 09:39 AM, CMA S stated staff were not to unplug the resident's electric recliner. Staff were to use the chair plugged in at all times. CNA S stated the resident was able to bear some weight during transfers but was unable to bear her full weight. On 02/06/25 at 01:18 PM, CNA N stated the resident could only bear minimal weight during transfers. Staff left the resident's electric recliner plugged in all of the time. On 02/06/25 at 01:18 PM, LN G stated the resident was not able to fully bear weight during transfers. LN G was unsure if the resident's electric recliner was to be plugged in or not. On 02/10/25 at 09:03 AM, Administrative Nurse D stated the facility did not complete an Electric Recliner Assessment for this dependent resident upon her admission to the facility. The only Electric Recliner Assessment the facility had was the one completed on 11/05/24. Administrative Nurse D stated the Electric Recliner Assessment should have been completed upon the resident's admission and then quarterly and with significant changes, thereafter. The facility policy for Assessments, revised 11/2024, included: The Electric Recliner Assessment shall be completed with use of the electric recliner initiation then quarterly, and as needed. The facility policy for Electronic Care Plan, revised 12/2020, included: The resident's care plan shall promote quality care and quality of life to attain the highest practical level of independence and dignity to each resident by facilitating communication about the resident's barriers, strengths, voice, choice and needs. The facility failed to develop and implement a comprehensive person-centered care plan for this dependent resident who utilized an electric recliner in her room.

The facility reported a census of 29 residents with 15 residents selected for review. Based on observation, interview, and record review, the facility failed to accurately revise Resident (R) 15's care plan after falls and failed to revise R 11's care plan for pressure ulcer care. This placed the residents at risk for uncommunicated care needs. Findings included: - The Electronic Health Records (EHR) documented R15 had the following diagnoses cognitive communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness), muscle weakness, diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), coronary artery disease (CAD- abnormal condition that may affect the flow of oxygen to the heart), hypertension (HTN-elevated blood pressure), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). The 11/04/24 Admission Minimum Data Set (MDS) documented a brief interview for mental status (BIMS) of 13, which indicated intact cognition and one non-injury fall from 10/30/24 thru 11/04/24. The 11/04/24 Falls Care Area Assessment (CAA) documented R15 was at risk for falls and received antidepressants for diagnosis of major depressive disorder. He has had one non injury fall since admission. He has not had a fall within the last year before admission. He is working with therapy to improve his strength and balance. The 1/19/25 Quarterly MDS documented a BIMS of 12, which indicated moderate cognitive impairment and two or more noninjury falls. The 02/05/25Care Plan documented the following fall interventions: 11/2/24 ensure R15 had his call light within reach and encourage him to use it to ask for assistance. 11/2/24 move R15's room closer to the nurse's station. 11/10/24 transfer pole to be placed near R15's bed on his left side. 11/24/24 transfer bar and grab bars in resident's bathroom. 12/07/24 fall lacked an intervention on the care plan. 12/13/24 a handlebar next to resident's closet. 12/15/24 bed in the lowest position. 12/20/24 nonskid strips on the floor. 01/25/25 computed tomography scan (CT- a noninvasive medical imaging procedure that uses X-rays to create detailed pictures of the inside of the body) of his head in order received to check for suspected neuro deficit to determine if neuro consultation is needed. Record review revealed this had not been completed. They Fall Risk Assessment documented R15 fluctuated between moderate to high risk for falls. The Progress Note on 11/02/24 at 01:13 AM documented a non-injury fall. The Fall Report documented a root cause analysis that he lost his balance and an intervention of a call light within reach. The Progress Note on 11/02/24 at 11:10 AM documented a non-injury fall. The Fall Report documented a root cause analysis confusion, post hospitalization and staff moved his room closer to the nurse's station. The Progress Note on 11/10/24 at 06:32 AM documented a non-injury fall. The Fall Report documented a root cause analysis that he lost his balance with an intervention of a transfer pole. The Progress Note on 11/24/24 at 03:43 AM documented a non-injury fall. The Fall Report documented a root cause analysis that he went to the bathroom unattended. with an intervention of a transfer pole and bar in the bathroom. The Progress Note on 12/07/24 at 01:05 AM documented a non-injury fall. There was no Fall Report that documented a root cause analysis, and it lacked an intervention. The Progress Note on 12/13/24 at 05:30 PM documented a fall that sent him to the ER. The Fall Report documented a root cause analysis that he lost his balance with an intervention of nonskid strips and a fall mat. The fall on 12/15/24 lacked a Progress Note. The Fall Report documented no root cause analysis, but an intervention of bed in lowest position. The Progress Note on 1/20/25 09:35 PM documented a non-injury fall. He was wearing slippery socks and got up to go to the bathroom. The Fall Report documented a root cause analysis that he lost his balance ant they put strips on the floor. The Progress Note on 1/25/25 at 10:46 PM documented a non-injury fall. The Fall Report documented a root cause analysis of suspected [NAME] deficit (an impairment or loss of function in the nervous system, affecting the brain, spinal cord, nerves, or muscles). During an observation on 02/05/25 at 09:26 AM, R15 was lying in bed the call light was on his over bed table that was several feet out of reach. He was asked where it was, he stated the call light was down there somewhere and pointed toward the head of the bed. There was no transfer bar beside his bed. During an observation on 02/05/25 at 01:58 PM, R15 sat in his recliner with no call light within reach. During an interview on 02/10/25 at 10:19 AM, Certified Nurse Aide (CNA) M reported that she looked at the care plan to know how to care for a resident. She reported that R15 had a fall mat and they do frequent checks. During an interview on 02/10/25 at 12:49 PM, Licensed Nurse (LN) G reported that interventions for falls was group effort. Confirmed there was not a transfer pole beside his bed in his room. During an interview on 02/10/25 at 11:20 AM, Administrative Nurse D was notified that R15 did not have his call light, she reported he should have his call light. She would fix that. She confirmed that the transfer pole was not in his room, it is on back order, also confirmed that R15 did not have the CT scan yet. Administrative D confirmed that there must be an appropriate intervention for each fall to keep the resident safe. The facility's Falls Management policy dated 12/2018, revised 12/2020 documented the plan of care was to address individualized resident focus, goals, and interventions directed towards reducing the resident's risk if injury and potential recurrence of falls. The resident's plan of care was to be reviewed and revised with each fall occurrence and a new intervention or interventions implemented. The facility failed to revise R15's care plan after falls. This placed the resident at risk for uncommunicated care needs. This deficient practice had the potential to have a negative effect on the overall physical and psychosocial well-being of the resident in the facility. - Resident (R)11's Electronic Health Record (EHR) revealed diagnoses included diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness), morbid obesity (serious condition of excessive body weight that seriously impacts the health and well-being), and chronic kidney disease (CKD- a long-term condition where the kidneys gradually lose their ability to filter waste products and excess fluid from the blood). The 04/25/24 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 14, which indicated intact cognition. R11's total severity score of zero, indicating no depression. R11 had a Foley catheter (tube inserted into the bladder to drain urine into a collection bag) in place and was always incontinent of bowel. R11 required set up assistance for oral care and eating. R11 was dependent on staff assistance with toileting hygiene, dressing, transfers, and extensive staff assistance with bed mobility. R11 had a chair cushion and a pressure reducing mattress. No pressure areas at that time. The 04/25/24 Pressure Ulcer/Injury Care Area Assessment (CAA) documented R11 had a Foley catheter (tube inserted into the bladder to drain urine into a collection bag) in place and was always incontinent of bowel. He had a mild risk of developing a pressure wound. He had a low air loss mattress. The 02/05/25 Care Plan documented. R11 had a stage two pressure ulcer to his buttock and directed the following interventions: Pressure reducing mattress. Wheelchair cushion when in wheelchair. Given multivitamin. Follow treatment orders. Registered dietician to consult. The 01/25/25 Physician Orders included an order for wound care to evaluate and treat for a Keloid (an overgrown scar) to R11's buttocks. The wound care provider note with a date of service 01/16/25, identified the wound a stage two pressure ulcer. The 01/30/25 Skin Condition Note noted shearing to an area of scar tissue that had reoccured along with shearing to the inner right buttock.The assessment documented R11 had a low air loss mattress and a cushion in his recliner. During an observation on 02/06/25 at 08:02 AM, R11 sat in his motorized scooter next to his room and waited to be assisted to bed. His motorized scooter, his recliner, and his manual high back wheelchair did not have a seat cushion. During an interview on 02/10/25 11:08 AM, R11 reported he did not have a cushion for his recliner, wheelchair, or motorized scooter. He reported he tried a cushion a couple months ago for about an hour or an hour and a half and it did not work. During an interview on 02/10/25 at 10:32 AM, Certified Medication Aide (CMA) U reported that R11 did not have a cushion and did not want a cushion. During an interview on 02/10/25 at 12:49 PM, Licensed Nurse (LN) G reported that R11 did not have a cushion in his recliner. During an interview on 02/11/24 at 8:31AM, Administrative Nurse D confirmed the care plan for R11 was incorrect, he did not have a cushion in his recliner, his high back wheelchair, or either of his motorized scooters, The facility's Wound Prevention and Management policy last updated 12/2018, documented the purpose of the policy was to develop interventions to decrease the incidence of residents who develop pressure ulcers. The policy documented residents that utilize a wheelchair will have a pressure reducing cushion. The facility's Electronic Care Plans policy revised 12/2020, documented that the facility was to develop a plan of care to attain and maintain the highest practical level of physical, psychological, emotional, and social wellbeing for each resident in the facility. The resident's person-centered plan of care was an active working document that reflects the care needs and resident's voice. The facility failed to revise R11's care plan to reflect the care need for the pressure area. This placed the resident at risk for uncommunicated care needs. This deficient practice had the potential to have a negative effect on the overall physical and psychosocial well-being of the resident in the facility.

The facility reported a census of 29 residents with 15 residents sampled, including two residents reviewed for skin issues. Based on observation, interview and record review, the facility failed to leave the shoes off one Resident (R)13, regarding the resident having abrasions (process of scraping or wearing something away) on the second toe of the right foot and the second and third toe of the left foot. Findings included: - Review of Resident (R)13's electronic medical record (EMR) revealed the following diagnoses: Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure) and peripheral vascular disease (PVD- slow and progressive circulation disorder causing narrowing, blockage, or spasms in a blood vessel). The Annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 12, indicating moderately impairment. He required substantial to maximal staff assistance with putting on and taking off his footwear. The Functional Abilities Care Area Assessment (CAA), dated 09/19/24, documented the resident worked with restorative and required staff assistance with Activities of Daily Living (ADL) cares, at times. The Pressure Ulcer CAA, dated 09/19/24, documented staff would perform skin assessments per facility protocol. The Medicare Five-Day MDS, dated [DATE], documented the resident had a BIMS score of 12, indicating moderately impaired cognition. He required supervision to touching assistance of staff with lying to sitting to standing and walking 150 feet. The care plan for skin, revised 01/05/25, instructed staff the resident had skin abrasions (process of scraping or wearing something away) to his second and third toe of his left foot and the second toe of his right foot. Staff were to leave the resident's shoes off and only have him wear non-skid socks until the abrasions were healed. Review of the resident's EMR revealed the following physician's orders: Apply skin preparation (a skin disinfectant) to the resident's bilateral (both sides) toes, twice daily (BID), until healed, ordered 01/05/25. Resident to only wear non-skid socks until bilateral toe abrasions are healed, ordered 01/05/25. Review of the resident's EMR revealed a nursing note which documented: red abrasions to bilateral toes with a new order in place. Intervention for resident to only wear non-skid socks until healed. Staff are aware of the new intervention. On 02/05/25 at 09:03 AM, the resident sat in his wheelchair in the commons area. The resident wore white Velcro tennis shoes. On 02/05/25 at 02:31 PM, the resident sat in the recliner in his room. The resident wore white Velcro tennis shoes. On 02/06/25 at 08:05 AM, the resident sat at the dining room table and wore his white Velcro tennis shoes. On 02/10/25 at 10:07 AM, the resident sat in the recliner in his room and wore his white Velcro tennis shoes. On 02/10/25 at 11:19 AM, Licensed Nurse (LN) H entered the resident's room to administer the ordered treatment to the resident bilateral toes. LN H removed the resident's Velcro tennis shoes and socks to reveal his right foot, second toe wound measured 0.5 by 0.4 centimeters (cm), and had a tannish scab (a dry, rough protective crust that forms over a cut or wound during healing) covering the entire wound bed. The left foot second toe wound measured 1.0 by 0.5 cm and had a dark red scab covering the entire wound bed. The left foot third toe wound measured 0.3 by 0.2 cm and had a reddish colored scab covering the entire wound bed. The resident tolerated the treatment without signs or symptoms of pain or discomfort. On 02/06/25 at 03:37 PM, Certified Medication Aide (CMA) T stated the resident wore his shoes every day. On 02/06/25 at 03:39 PM, Certified Nurse Aide (CNA) S stated the resident currently had abrasions on some of his toes, but he was able to wear shoes. On 02/10/25 at 10:09 AM, CNA M stated the resident was not to wear tennis shoes due to abrasions on his toes. Staff were to only put non-skid socks on him. On 02/10/25 at 10:17 AM, Licensed Nurse (LN) H stated the resident was not to wear shoes due to the abrasions on his toes. On 02/10/25 at 10:40 AM, Administrative Nurse D stated the abrasions on the resident's toes were caused by ill-fitting shoes which have been removed from the facility by family. It was the expectation for staff to not put shoes on him until the areas to his toes were healed. The facility policy for wound Prevention and Management, revised 12/2018, included: If identified at risk or with actual alterations in skin integrity of feet, footwear will be addressed for appropriateness. The facility failed to leave the shoes off Resident (R)13 as ordered due to the abrasions on the second toe of the right foot and the second and third toe of the left foot.

The facility reported a census of 29 residents with 15 residents sampled, including four residents reviewed for pressure ulcers (PU). Based on interview, record review and observation, the facility failed to care and services to promote the healing of an existing PU for one Resident (R)13, regarding a stage II (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed) PU behind the left ear and R 11, for failure of ensuring the resident had a pressure reducing cushion to his wheelchair. Findings included: - Review of Resident (R)13's electronic medical record (EMR) revealed a diagnosis of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure). The Annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 12, indicating moderately impaired cognition. He used a walker and a wheelchair for locomotion. He was at risk for the development of pressure ulcers (PU) with no unhealed PUs at the time of the assessment. The Pressure Ulcer Care Area Assessment (CAA), dated 09/19/24, documented the resident had a mild risk for the development of PUs. The Medicare Five-Day MDS, dated [DATE], documented the resident had da BIMS score of 12, indicating moderately impaired cognition. He required supervision to touching assistance of staff to ambulate 150 feet. He was at risk for the development of PUs with no unhealed PUs at the time of the assessment. The skin care plan, revised 12/13/24, instructed staff the resident was at risk for skin breakdown and had a stage II ((partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed) PU to his left ear. Review of the resident's EMR revealed BRADEN assessments (a tool used to assess a patient's risk of developing pressure ulcers), which placed the resident at a moderate risk for the development of PUs completed on, 12/15/24 and 12/30/24. Review of the resident's EMR revealed the following physician's orders: Cleanse the PU behind the left ear with hypochlorous acid (a disinfective and sanitizer), apply Triple Antibiotic Ointment (TAO-a medicated ointment), and cover the wound with a gauze pad (a thin, loosely woven fabric pad), every day (QD), until healed, ordered 01/22/25. Pad the earpiece of resident's glasses and oxygen tubing, every day, related to PU behind left ear, ordered 01/22/25. On 02/06/25 at 08:05 AM, the resident sat in his wheelchair at the dining room table. The resident wore his glasses, but lacked padding behind his left ear, as ordered. On 02/06/25 at 10:09 AM, Licensed Nurse (LN) G entered the resident's room to do the PU treatment to the resident's left ear. The resident wore his glasses, but lacked padding behind his left ear, as ordered. On 02/10/25 at 10:07 AM, the resident sat in the recliner in his room. The resident wore his glasses, but lacked padding behind his left ear, as ordered. On 02/06/25 at 03:37 PM, Certified Medication Aide (CMA) T the resident was to have padding behind his left ear due to a PU. CMA T stated she was unsure why the padding was not in place. On 02/06/25 at 03:39 PM, CMA S stated the resident was to have padding behind his left year, but the padding was in place at that time. On 02/10/25 at 10:09 AM, Certified Nurse Aide (CNA) M confirmed the padding to the resident's glasses was not in place. On 02/06/25 at 10:09 AM, Licensed Nurse (LN) G stated the PU to the back of the resident's left ear was caused by oxygen tubing and his glasses. The resident no longer used the oxygen but continued to wear his glasses. The resident was to have padding behind his left ear while wearing his glasses but confirmed the padding was not always in place. On 02/10/25 at 10:40 AM, Administrative Nurse D stated it was the expectation for the staff to have the padding in place to the resident's left ear until the wound healed. The facility policy for wound Prevention and Management, revised 12/2018, included: The facility shall develop interventions to decrease the incidence of residents who develop pressure ulcers. The plan of care will address problems, goals, and interventions directed towards prevention of pressure ulcers and/or skin integrity concerns identified. The facility failed to provide care and services to promote the healing of an existing PU, regarding padding to the back of this resident's left ear. 51334 - Resident (R)11's Electronic Health Record (EHR) revealed diagnoses included diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness), morbid obesity (serious condition of excessive body weight that seriously impacts the health and well-being), and chronic kidney disease (CKD- a long-term condition where the kidneys gradually lose their ability to filter waste products and excess fluid from the blood). The 04/25/24 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 14, which indicated intact cognition. R11's total severity score of zero, indicating no depression. R11 had a Foley catheter (tube inserted into the bladder to drain urine into a collection bag) in place and was always incontinent of bowel. R11 required set up assistance for oral care and eating. R11 was dependent on staff assistance with toileting hygiene, dressing, transfers, and extensive staff assistance with bed mobility. R11 had chair cushion and a pressure reducing mattress. No pressure areas at that time. The 04/25/24 Pressure Ulcer/Injury Care Area Assessment (CAA) documented R11 had a Foley catheter (tube inserted into the bladder to drain urine into a collection bag) in place and was always incontinent of bowel. He had a mild risk of developing a pressure wound. He had a low air loss mattress. The 02/05/25 Care Plan documented. R11 had a stage two pressure ulcer to his buttock and directed the following interventions: Pressure reducing mattress. Wheelchair cushion when in wheelchair. Give multivitamin. Follow treatment orders. Registered dietician to consult. The 01/15/25 Physician Orders included an order for wound care to evaluate and treat for a Keloid to R11's buttocks. The 01/16/25, wound care provider note identified the wound on his buttock as a stage two pressure ulcer. The Wellness Meeting Note dated 1/16/2025 at 02:25 PM, documented R11 was working with Wound Care Plus to assess his skin flap area on buttock that he has had for years to see if there was anything else to relieve pressure/pain to that area. The 01/30/25 Skin Condition Note an area of scar tissue to the right buttock that had shearing was reoccurring. Also had shearing to inner buttock. Assessment documented a low air loss mattress and a cushion in his recliner. During an observation on 02/06/25 at 08:02 AM, R11 sat in his motorized scooter next to his room and waited to be assisted to bed. His motorized scooter, his recliner, and his manual high back wheelchair did not have a seat cushion. During an interview on 02/10/25 11:08 AM, R11 reported he did not have a cushion for his recliner, wheelchair, or motorized scooter. He reported he tried a cushion a couple months ago for about an hour or an hour and a half and it did not work. During an interview on 02/10/25 at 10:32 AM, Certified Medication Aide (CMA) U reported that R11 did not have a cushion and did not want a cushion. During an interview on 02/10/25 at 11:20 AM, Administrative Nurse D acknowledged that wound measurements had not been done and wound tracking and measuring was not up to standards, she was taking over wounds and was working on getting it in order. During an interview on 02/10/25 at 12:49 PM, Licensed Nurse (LN) G reported that R11 does not have a cushion in his recliner. During an interview on 02/11/24 at 8:31AM, Administrative Nurse D confirmed the care plan for R11 was incorrect, he did not have a cushion in his recliner, his high back wheelchair, or either of his motorized scooters. The facility's Wound Prevention and Management policy last updated 12/2018, documented the purpose of the policy was to develop interventions to decrease the incidence of residents who develop pressure ulcers. The policy documented residents that utilize a wheelchair will have a pressure reducing cushion. The facility's Electronic Care Plans policy revised 12/2020, documented that the facility was to develop a plan of care to attain and maintain the highest practical level of physical, psychological, emotional, and social wellbeing for each resident in the facility. The resident's person-centered plan of care was an active working document that reflects the care needs and resident's voice. The facility failed to properly assess the pressure ulcer and revise R11's care plan to reflect the care need for the pressure area. This placed the resident at risk for uncommunicated care needs.

The facility reported a census of 29 residents with 15 residents selected for review. Based on observation, interview, and record review, the facility failed to keep the residents free from unnecessary drugs when they gave an excessive dose of a medication without provider notification that medications were held, this caused adverse complications for resident (R) 17 and R134. This placed the residents at risk for future adverse complications. - Resident (R) 17's Electronic Health Record (EHR) revealed diagnoses, which included hypertension (HTN-elevated blood pressure) and dementia (progressive mental disorder characterized by failing memory, confusion). The 01/16/25 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of five, which indicated severely impaired cognition. R17 required set up assistance for eating and required supervision or touching assistance with activities of daily living (ADLs) to include dressing, toileting hygiene, footwear, personal hygiene and standing. R17 had one injury fall. Review of the 02/06/24 Care Plan documented antihypertensive (class of medication used to treat high blood pressure) medications had a BBW. Review of the Physician Orders on 02/06/25 documented the following medications: Metoprolol Succinate (medication that treats high blood pressure) extended release 100 mg one tablet by mouth one time a day for hypertension. Start date 05/03/23. Clonidine HCl (medication that treats high blood pressure) Oral Tablet 0.1 MG one tablet by mouth three times a day hypertension. Start date 05/05/23. End date 01/21/25. Instructions to hold for systolic blood pressure (SBP- top number, the force your heart exerts on the walls of your arteries each time it beats) < (less than)130. Diltiazem HCl (medication that treats high blood pressure) extended-release tablet 120 mg. Give 1 tablet by mouth one time a day for hypertension. Start date 01/18/24. Instructions to hold for pulse < 60. Lisinopril (medication that treats high blood pressure) 20 mg one tablet by mouth one time a day for hypertension. Start date 05/21/24. Instructions to hold for SBP < 130. Clonidine HCl oral tablet 0.1 mg one tablet by mouth two times a day for hypertension. Start date 01/21/25. Review of the EMAR revealed: Diltiazem was held two times in August without provider notification. Diltiazem was held four times in October 2024 without provider notification. Diltiazem was held four times in November 2024 without provider notification. Diltiazem was held three times in December 2024 without provider notification. Diltiazem was held three times in January 2025 without provider notification. Lisinopril was held one time in October 2024 without provider notification. Lisinopril was held four times in November 2024 without provider notification. Metoprolol was held two times in August 2024 without provider notification. Metoprolol was held three times in October 2024 without provider notification. Metoprolol was held four times in November 2024 without provider notification. Metoprolol was held three times in December 2024 without provider notification. Metoprolol was held three times in January 2025 without provider notification. Clonidine HCl 0.1 mg three times a day was held 54 times in August without provider notification. Clonidine HCl 0.1 mg three times a day was held 37 times in September without provider notification. Clonidine HCl 0.1 mg three times a day was held 53 times in October 2024 without provider notification. Clonidine HCl 0.1 mg three times a day was held 56 times in November 2024 without provider notification. Clonidine HCl 0.1 mg three times a day was held 56 times in December 2024 without provider notification. Clonidine HCl 0.1 mg three times a day was held 30 times in January 2025. It was decreased to Clonidine HCl 0.1 mg two times a day on 01/21/25 and was held five more times in January without provider notification. The September EMAR had B/P documented from 94/67 to 187/103 without a documented assessment or provider notification. The October EMAR had B/P documented from 91/47 to 172/83. The November EMAR had B/P documented from 101/54 to 173/99. The December EMAR had B/P documented from 90/42 to 176/84. The January EMAR had B/P documented as low as 99/49 to 180/81. Review of Progress note from 08/01/24 to 02/06/25 revealed documentation of the following B/P with no documentation of assessment or physician notification. On 08/05/24 at 04:29 PM a Progress Note documented a B/P of 93/48. On 08/06/24 at 02:27 PM a Progress Note documented a B/P of 92/57. On 08/11/24 at 01:19 PM a Progress Note documented a B/P of 87/41. On 09/03/24 at 01:34 PM a Progress Note documented a B/P of 90/57. On 10/07/24 at 02:06 PM a Progress Note documented a B/P of 93/46. On 10/20/24 at 02:32 PM a Progress Note documented a B/P of 93/49. On 11/07/24 at 01:28 PM a Progress Note documented a B/P of 97/45. On 11/14/24 at 01:39 PM a Progress Note documented a B/P of 94/81. On 11/15/24 at 01:17 PM a Progress Note documented a B/P of 98/79. On 11/17/24 at 07:58 AM a Progress Note documented a B/P of 91/54. On 11/17/24 at 11:20 AM a Progress Note documented a B/P of 97/47. On 11/20/24 at 01:16 PM a Progress Note documented a B/P of 94/56 On 11/26/24 at 07:16 PM a Progress Note documented a B/P of 91/50. On 11/27/24 at 07:08 Pm a Progress Note documented a B/P of 93/76. On 11/29/24 at 02:02 PM a Progress Note documented a B/P of 95/54. On 11/30/24 at 07:23 PM a Progress Note documented a B/P of 96/53. On 12/06/24 at 07:09 PM a Progress Note documented a B/P of 92/44. On 12/10/24 at 02:02 PM a Progress Note documented a B/P of 91/63. On 12/19/24 at 01:05 PM a Progress Note documented a B/P of 90/56. On 12/23/24 at 01:09 PM a Progress Note documented a B/P of 79/51. On 01/07/25 at 01:32 PM a Progress Note documented a B/P of 93/52. On 01/12/25 at 03:17 PM a Progress Note documented a B/P of 90/54. On 01/20/25 at 11:58 AM a Progress Note documented a B/P of 98/57. On 01/21/25 at 01:02 PM a Progress Note documented a new order from the provider to decrease Clonidine to BID (with same parameters) due to med being held so often. During an interview on 02/10/25 at 12:39 PM, Administrative Nurse D revealed it was her expectation that staff would notify the provider if a medication was held or not given for any reason and that staff would document provider notification in the EHR. During an interview on 02/10/25 at 12:49 PM, Licensed Nurse (LN) G stated she notified the provider every time she held a medication and documented it in the EHR. When a medication is held, the provider should always be notified, During an interview on 02/10/25 at 03:58 PM, LN H stated he would notify the physician every time he held a medication and document it in the EHR. The facility lacked a policy on physician notification. The failed to keep the residents free from unnecessary drugs when they gave an excessive dose of an antihypertensive medication without notifying the provider of holding medications, this caused adverse complications for resident (R) 17. This placed the resident at risk for future adverse complications. - Resident (R) 134's Electronic Health Record (EHR) revealed diagnoses, which included diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin) The Admission Minimum Data Set (MDS) was not completed. Review of the 02/06/24 Care Plan documented R134 had a risk for hypoglycemia and hyperglycemia. Review of the Physician Orders on 02/06/25 documented the following medications: Lantus Subcutaneous Solution 100 units/ml (Insulin Glargine) (medication to lower blood sugar levels) 40 units subcutaneously two times a day related to diabetes. Started on 02/04/25. Novolog Flex Pen Subcutaneous Solution Pen-injector 100 units/ml (Insulin Aspart) (medication to lower blood sugar levels) 10 units subcutaneously before meals related to diabetes type two. Start date 02/04/25. Instructions to hold if R134 did not eat or if blood sugar was less than 110. Review of the EMAR revealed Novolog was held on the days and time following times: On 02/04/25 the morning dose was held for a blood sugar level of 90. On 02/05/25 the morning dose was held for a blood sugar level of 63. On 02/05/25 the supper dose was held for a blood sugar level of 88. On 02/06/25 the morning dose was held for a blood sugar level of 87. On 02/07/25 the supper dose was held for a blood sugar level of 99. On 02/08/25 the morning dose was held for a blood sugar level of 86. On 02/09/25 the morning dose was held for a blood sugar level of 68. On 02/09/25 the supper dose was held for a blood sugar level of 94. On 02/10/25 the morning dose was held for a blood sugar level of 72. Review of Progress note from 02/03/25 to 02/06/25 revealed the provider was notified only on the 02/05/25 that the insulin dose was held. During an interview on 02/10/25 at 12:39 PM, Administrative Nurse D revealed it was her expectation that staff would notify the provider if a medication was held or not given for any reason and that staff would document provider notification in the EHR. During an interview on 02/10/25 at 12:49 PM, Licensed Nurse (LN) G stated she notified the provider every time she held a medication and documented it in the EHR. When a medication is held, the provider should always be notified. During an interview on 02/10/25 at 03:58 PM, LN H stated he would notify the physician every time he held a medication and document it in the EHR. The facility lacked a policy on physician notification. The failed to keep the residents free from unnecessary drugs when they failed to notify the provider that insulin required to be held nine times in ten days, this had the risk for adverse complications for resident (R) 17. This placed the resident at risk for future adverse complications.

The facility reported a census of 30 residents. The sample included three residents reviewed for accidents. Based on observation, interview, and record review, the facility failed to ensure dependent Resident (R) 1 remained free from accidents when Certified Nurse Aide (CNA) M transferred R1 without a second staff member present to assist in a mechanical lift transfer. CNA M further failed to secure one of the leg straps to the mechanical lift, which caused R1 to fall from the lift, face forward onto the floor. These failures resulted in a laceration (a tear in skin) to the left ear that measured 2.0 centimeters (cm) by 0.1 cm, a hematoma (collection of blood trapped in the tissues of the skin or in an organ, resulting from trauma) to the left temple, and an acute left hip fracture (broken bone) involving the proximal (nearer to a point of reference or attachment) femoral (thigh bone) neck. This deficient practice placed the resident in immediate jeopardy. Findings include: - R1's Physician Order Sheet (POS) dated 07/01/24, revealed diagnoses included cerebral palsy (progressive disorder of movement, muscle tone or posture caused by injury or abnormal development in the immature brain, most often before birth), osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain), and osteoporosis (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk). The 12/14/23 Annual Minimum Data Set (MDS), documented the resident had moderately impaired cognition. R1 required a wheelchair for mobility and a mechanical lift for transfers due to functional limitations in bilateral (both) lower and upper extremities. The resident was totally dependent on staff for Activities of Daily Living (ADL). The ADL Functional/Rehabilitation Potential CAA, dated 12/14/23, documented the resident required assistance with ADL. The 06/13/24 Quarterly MDS documented the resident had moderately impaired cognition, required a wheelchair for mobility, and a mechanical lift for transfers. R1's Fall Care Plan, dated 03/24/24, instructed staff that R1 had potential for falls. The plan further instructed staff to keep the resident's bed in a low position and the fall alert tag on the wheelchair. The resident had a reclining high-back wheelchair propelled by staff and utilized a mechanical lift for transfers. R1's ADL Care Plan, dated 03/25/24, instructed staff R1 required assistance related to her debility due to cerebral palsy. The revised ADL Care Plan dated 05/23/24, instructed staff the resident required the mechanical lift for transfers. R1's Fall Risk Assessment, dated 12/18/23, documented a score of 12, which indicated a moderate risk for falls. R1's Skin/Wound Condition Assessment, dated 07/09/24, documented a laceration to her left ear that measured 2.0 cm by 0.1 cm and a hematoma to her face (left side of head [temple]). Review of R1's pelvis X-ray report, dated 07/09/24, documented possible occult left femoral neck fracture (upper part of the hip joint), with noted minimal offset of the left femoral neck. The report also noted the presence of osseous (bone) demineralization consistent with osteoarthrosis (chronic arthritis without inflammation). Review of R1's maxillofacial (face and jaw) computed tomography scan (CT scan- test in which x-ray technology is used to make multiple cross-sectional views of organs, bone, soft tissue and blood vessels) on 07/09/24 documented edema (swelling resulting from an excessive accumulation of fluid in the body tissues) and a hematoma in the soft tissues along the left face and calvarium (upper domelike portion of the skull that excludes the lower jaw and facial parts). Review of R1's pelvis CT scan on 07/09/24 documented an acute left hip fracture involving the femoral neck. Review of the 07/09/24 at 08:50 PM Nursing Note revealed on 07/09/24 at 06:00 PM, Licensed Nurse (LN) G heard a noise and Certified Nurse Aide (CNA) M yelled for her. LN G went to the resident's room and observed the resident lying on the floor near the closet on her stomach with the mechanical lift above her. The lift sheet was still attached to the mechanical lift, except one strap at the bottom that had come loose, and the resident had fallen out of the lift sheet and onto the floor. CNA M reported she thought one of the straps broke on the mechanical lift but upon inspection it was still intact, appeared to be in good condition, but was not attached to the mechanical lift. The mechanical lift was raised approximately four feet (ft) in the air. CNA M reported the resident hit her head on the floor when the resident fell out of the lift sheet. LN G observed a raised area on the left side of R1's head (temple) which measured 4.5 centimeters (cm) by 5.5 cm. The resident had a skin tear to the left upper front of her ear and was bleeding. The laceration measured 2.0 by 0.1 cm. No other areas noted to her skin at the time of the assessment. The resident was non-verbal and was unable to explain what happened. LN G, CNA M, and CNA N assisted R1 from the floor to her bed with the mechanical lift. Emergency Medical Services (EMS) transported R1 to the Emergency Department (ED). Review of the 07/09/24 at 06:30 PM Administrator Note revealed Administrative Staff A was advised that CNA M transferred R1 utilizing the mechanical lift and a loop was not secured on the left side that caused the resident to fall forward onto the left side of her head. At 06:45 PM, Administrative Staff A arrived at the facility and inspected the newer appearing lift sling. The lift sling appeared to not have tears or concerns. The lift sling was within expiration date. The resident laid in her bed waiting for an ambulance transfer, with LN G at her bedside, and staff noted a hematoma to the left side of R1's head. Administrative Nurse D assessed the resident upon ambulance arrival and EMS transported R1 shortly after. Review of the 07/09/24 at 09:07 PM Nurse Note by Administrative Nurse D, revealed Administrative Nurse D assessed the resident with Emergency Medical Services (EMS) staff, prior to the resident leaving the facility. Administrative Nurse D noted R1 had a hematoma on the left side of her head above her left ear and a small skin tear to her left ear. When asked if the resident was in pain, R1 nodded her head yes. When asked if her head hurt, the resident nodded her head yes. When asked if her back hurt, the resident nodded her head yes. EMS then transported the resident to acute care. During an interview on 07/11/24 at 12:01 PM, Certified Nurse Aide (CNA) M reported on the day of R1's fall nursing staff were elsewhere, she was rushing, and attempted to transfer the resident from the recliner to the resident's bed with the mechanical lift by herself. CNA M reported the left leg strap was not secured at the time of the transfer. The resident flipped forward out of the lift sling onto the floor, landed on her stomach, and CNA M then screamed for the charge nurse, LN G. LN G assessed the resident prior to CNA M and LN G transferring the resident with the mechanical lift from the floor to the resident's bed. CNA M stated R1 had a hematoma on the left side of her temple and a laceration on her left ear that caused the ear to bleed. CNA M said she should not have utilized the mechanical lift by herself and said there should be two nursing staff for mechanical lift transfers and three nursing staff members if the resident had a catheter. CNA M reported that Administrative Nurse D educated her that evening related to the facility's Skills Check-Total Dependent Lift that included the expectation to always have two staff during transfer with the mechanical lift, for safety. CNA M stated that she was suspended her that evening. During an interview on 07/11/24 at 12:06 PM, CNA N reported she was in another resident's room when she heard CNA M yell for help. When she got to R1's room, she observed R1 on the floor on her stomach. CNA N confirmed it took two staff to transfer a resident with a mechanical lift. During an interview on 07/11/24 at 12:08 PM, LN G reported she heard a thud and CNA N yelled for help. LN G reported when she entered R1's room, she observed R1 on the floor on her stomach. R1 had a hematoma on her left temple and a laceration to her left ear. LN G said the facility called EMS to transport the resident to the ED. During an interview on 07/11/24 at 01:36 PM, Administrative Nurse D confirmed the facility expected the nursing staff to always have two nursing staff during transfers with a mechanical lift. Administrative Nurse D said the nursing staff should not transfer residents with one staff utilizing the mechanical lift. During an interview on 07/11/24 at 04:01 PM, Administrative Staff A reported staff notified her on 07/09/24 at approximately 06:50 PM and she arrived at the facility at 07:00 PM. Administrative Staff A said she inspected the mechanical lift and found no mechanical failure, and she removed CNA M from the floor and interviewed her. CNA M reported to her that she had not attached one of the lift sling clips to the mechanical lift that caused the resident to slide out of the sling, onto the floor, landing on her stomach. This caused a hematoma on R1's left temple, laceration to her left ear, and the CT (computed tomography) scan showed an acute left femoral neck fracture. The facility's Skills Check-Total Dependent Lift included the expectation to always have two staff during transfer with the mechanical lift, for safety. On 07/11/24 at 04:47 PM, the IJ template was provided to Administrative Staff A and notified the facility failure to ensure dependent Resident (R)1 remained free from accidents when Certified Nurse Aide (CNA) M transferred R1 without a second staff to assist in a mechanical lift transfer and CNA M further failed to secure one of the leg straps to the mechanical lift, which caused R1 to fall from the lift, face forward onto the floor. These failures resulted in a laceration to R1's left ear, a hematoma to R1's left temple, and an acute left hip fracture. This deficient practice placed the resident in immediate jeopardy. The immediate jeopardy was determined to first exist on 07/09/24 at 08:50 PM, when CNA N transferred R1 without another staff member present. The facility identified and implemented the following corrective actions, completed on 07/10/24: On 07/09/24 at 07:00 PM, the facility suspended CNA N. The facility updated R1's care plan related to ADL, on 07/09/24. An immediate quality assurance and performance improvement (QAPI) meeting held on 07/09/24 at 10:40 PM. Nursing staff education provided on 07/09/24 at 08:00 PM through 07/10/24 at 05:00 PM related to mechanical lift skills check offs and training. Due to the corrective actions the facility completed prior to the onsite visit, the deficient practice was deemed past non-compliance and existed at a J scope and severity.

The facility reported a census of 32 with 14 residents selected for review which included two residents reviewed for dressing changes. Based on observation, interview and record review, the facility failed to ensure timely dressing changes for one, resident (R)4, of the two residents reviewed. Findings included: - Review of Resident (R)4's medical record revealed diagnosis included osteomyelitis (bone infection) of a bone in the spine. The Admission Minimum Data Set, was in progress for completion. The Admitting Care Plan, dated 05/04/23, instructed staff to administer ceftriaxone (an antibiotic) intravenously (directly into the blood stream) through the PICC (peripherally inserted central venous catheter) line every 24 hours, flush the PICC line, and change the dressing per the physician's orders. The Physician Orders, dated 05/04/23, instructed staff to administer ceftriaxone (an antibiotic), two grams, intravenously, through the PICC line every 24 hours, flush the line with 10 milliliters of normal saline before and after the antibiotic and change the PICC line dressing using sterile (a technique to eliminate contact with microorganisms that may contaminate the site) technique, every seven days. Observation, on 05/23/23 at 08:30 AM, revealed Licensed Nurse (LN)G administered the ceftriaxone to R4 through her PICC line. The dressing on the PICC line site documented a date of 05/03/23, and the edges of the dressing contained gray discolorations and evidence of areas of nonadherence. Interview, on 05/24/23 at 11:24 AM, with LN revealed, revealed staff typically should change the PICC line dressings every seven days. Interview, on 05/24/23 at 11:30 AM, with Administrative Nurse D, confirmed lack of dressing change for this resident every seven days as ordered by the physician and per facility policy. Administrative Nurse stated she added the dressing change to the resident's Treatment Administration Record (TAR) on 05/23/23. The facility policy Dressing Change for Vascular Access Devices, dated August 2021, instructed staff to change central venous access devices at established intervals and immediately if the integrity of the dressing was compromised. The facility failed to ensure staff provided this resident's PICC line dressing change every seven days, as ordered by the physician, to ensure the resident did not experience adverse effects or infection.

The facility reported a census of 32 residents with 14 residents sampled. Based on observation, interview and record review, the facility failed to serve one Resident (R)26 the physician ordered diet. Findings included: - Review of Resident (R)26's electronic medical record (EMR), revealed a diagnosis of dysphagia (swallowing difficulty). The admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. She required supervision with setup help for eating. The resident had swallowing issues which included coughing or choking and pain when swallowing. She had a mechanically altered diet which required a change in her food texture. She had no natural teeth or tooth fragments. The Nutritional Status Care Area Assessment (CAA), dated 12/25/22, documented the resident had a regular, mechanical soft diet with ground meats with gravy due to a diagnosis of dysphagia. The quarterly MDS, dated [DATE], documented the resident had a BIMs score of 12, indicating moderately impaired cognition. She required setup help only with eating and had no swallowing disorder. She had a mechanically altered diet which required a change in her food texture. She had no natural teeth or tooth fragments. The care plan for nutrition, revised 03/17/23, instructed staff the resident had a regular diet with mechanical soft foods with ground meats. Staff were to ensure the resident had plenty of gravy on her ground meat. Review of the resident's EMR, revealed a physician's order, which included: Regular mechanical soft diet with ground meat texture, add gravy to ground meat, for diagnosis of dysphagia, ordered 12/21/22. Review of the speech therapy (ST) report, dated 02/15/23, documented the resident preferred a mechanical soft diet with ground meat. On 05/23/23 at 12:31 PM, Certified Nurse Aide (CNA) N served the resident lunch, which consisted of a chicken strip cut into bite size pieces with gravy, cottage cheese and spanish rice with a cinnamon roll on the side. The resident fed herself a few bites of the spanish rice and cottage cheese without difficulty. On 05/23/23 at 12:40 PM, the resident stated she was unable to eat the chicken strip as she would not be able to chew and swallow the large pieces. She would have eaten the chicken strip if it had been ground. On 05/23/23 at 01:07 PM, Dietary staff BB stated the chicken strip had not been ground, as was the resident's order. Dietary staff BB stated the chicken strip should not have been served to the resident. On 05/23/23 at 01:09 PM, Dietary staff CC stated she had not ground the chicken strip because the machine she used for ground meat was dirty at the time she served the resident her lunch. On 05/23/23 at 01:21 PM, CNA N stated she noticed the meat was not ground but thought it was alright for the resident to have since the kitchen served it for the resident. On 05/24/23 at 03:36 PM, Licensed Nurse (LN) stated the resident was to have ground meat due to issues with swallowing. On 05/24/23 at 07:50 AM, Administrative Nurse D stated it was the expectation that residents be served the diet ordered by their physician. The facility policy for Diet Orders, undated, included: Each resident shall have a diet order prescribed by the physician and documented in the health record. The facility failed to serve this dependent resident the diet ordered by her physician.

The facility reported a census of 30 residents. Based on observation and interview, the facility failed to ensure sanitary food preparation and storage for the residents of the facility. Findings included: - Observation of the initial kitchen tour, on 09/20/21 at 09:47 AM, revealed the following items of concern in the refrigerator: Nine single serving containers of salsa dated 08/31/21 (20 days old). Tomato soup in a quart container, half full, labeled 08/30/21 (21 days old). Potato salad in a quart container, half full, labeled 08/30/21 (21 days old). The walk-in refrigerator contained an opened box of individually packaged butter positioned directly on the floor of the refrigerator. Three packages of white bread, with best by dates of 09/16/21 and two with the date of 09/19/21. One partial loaf of bread with best by date of 09/16/21. Three packages of hot dog buns with best by dates of 08/26/21 and two with best by dates of 09/12/21. Interview, on 09/20/21 at 09:57 AM, with dietary staff CC, confirmed the above refrigerated items should be stored three to five days after opening and confirmed the baked good items were past the best by date. Environmental tour of the kitchen on 09/22/21 at 02:26 PM, with Dietary Staff BB, revealed the following areas of concern: The deep fat fryer with dirt and grime on the fryer. Interview, at that time with Dietary Staff BB revealed it had not been used for approximately one month due to lack of cleaning/lack of staff. The four shelved cart holding spices contained debris and dust on all four shelves and the wheels contained an accumulation of grime. Three food service carts with beverages, tableware, and cooking implements contained shelves with dust/grime and wheels with accumulation of grime. The stove contained seven control knobs with grime and dust accumulation and six burners with an accumulation of grime and grease. Nine dish racks contained discolorations and scratches making sanitation difficult. Interview, on 09/22/21 at 03:00 PM, with Dietary Staff BB, confirmed the above areas in need of cleaning for sanitation and reveled staff follow the cleaning schedule for the above areas of concern, but due to lack of dietary staff, some issues were missed. Dietary Staff BB confirmed the baked goods were past their best by date and the above noted refrigerated items were beyond their storage time for safe consumption. The facility did not provide a policy for food storage. The facility policy Sanitation of Dining and Food Service Areas, dated 2016, instructed staff to uphold the sanitation in the dining areas according to a thorough,written schedule. The Cleaning Rotation, dated 2016, indicated stove top and food carts cleaned daily and shelves cleaned weekly. The facility failed to store and prepare food in a sanitary manner to prevent food borne illness for the residents of the facility.

The facility reported a census of 30 residents with 15 residents sampled, including six residents reviewed for activities. Based on observation, interview, and record review, the facility failed to provide an ongoing program of individualized activities for five Residents (R)5, R 8, R 15, R 23, R 79, of the six sampled residents. Findings included: - The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 7, indicating impaired cognition. It was somewhat important to do her favorite activities, go outside to get fresh air and participate in religious services. She required extensive assistance of one staff for locomotion on and off of the unit. The Activities Care Area Assessment (CAA), dated 03/28/21, documented the resident had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly MDS, dated [DATE], documented the resident had a BIMS score of 7, indicating impaired cognition. She required total assistance of one staff on and off of the unit. She was always incontinent of bowel and bladder. The care plan for activities, dated 06/18/21, instructed staff that the resident enjoyed talking with her family and 1:1 visits. Review of the resident's electronic medical record (EMR), under the Tasks tab, revealed one time of a staff member having a conversation with the resident. No other activities were documented as provided for the resident from 08/23/21 through 09/29/21. Review of the resident's Activity Assessment, dated 09/15/21, located under the Assessment tab of the resident's EMR, included the resident enjoyed reading her bible, visiting, learning classes and entertainment. She enjoyed watching TV and listing to the radio. On 09/21/21 at 10:51 AM, the resident sat in her wheelchair in her room. The TV was on, however, the resident was not watching it. On 09/20/21 at 01:00 PM, an activity of Book Reading took place in the facility. Staff did not invite the resident to attend. On 09/22/21 at 10:00 AM, an activity of Bingo took place in the facility. Staff did not invite the resident to attend. On 09/20/21 at 01:37 PM, Certified Nurse Aide (CNA) MM stated, the resident did not participate in activities. On 09/20/21 at 01:37 PM, CNA Q stated, the resident did not participate in activities because she was not able to do much on her own. On 09/21/21 at 04:20 PM, CNA O stated, the resident did not go to any activities in the facility. On 09/22/21 at 12:07 PM, CNA NN stated, activities are all documented in the resident's EMR. She does as much 1:1 with the residents as she can. At this time, there are not many activities for residents who require assistance. On 09/22/21 at 01:57 PM, Licensed Nurse (LN) G stated, the facility did not offer many activities for resident's who were unable to do things on their own. On 09/23/21 at 08:44 AM, Administrative Nurse D stated, it was the expectation for dependent residents to have some type of stimulation. The facility lacked an activities policy. The facility failed to provide an ongoing program of individualized activities for this dependent resident. - The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. It was somewhat important for him to listen to music he liked, be around animals such as pets, to keep up with the news, and to go outside when the weather was good. He required total assistance of one staff for locomotion on and off of the unit. The Activities Care Area Assessment, dated 01/07/21, did not trigger. The quarterly MDS, dated [DATE], documented the resident had a BIMS score of 3, indicating severely impaired cognition. He required extensive assistance of one staff for locomotion on and off of the unit. The activities care plan, dated 07/02/21, instructed staff to remind and encourage the resident to attend activities. Staff were to ensure the resident had an activity calendar in his room. Staff were to offer to visit with him 1:1 each day to encourage him to join in a group activity. Review of the resident's electronic medical record (EMR), under the Tasks tab, revealed the resident participated in conversation with staff twice from 08/24/21 thorough 09/21/21. No other activities were documented as provided for the resident. Review of the Activity Assessment, located in the resident's electronic medical record (EMR), dated 07/06/21, included that the resident enjoyed church services, visiting with others, entertainment, country music and pet visits. On 09/21/21, 09/22/21, and 09/23/20 at 10:00 AM, an activity of Bingo took place in the facility. Staff did not invite the resident to attend. On 09/20/21 at 03:14 PM, the resident sat in his darkened room with his eyes open. The TV was turned off, no music was playing, no activity calendar was in his room. On 09/21/21 at 04:47 PM, Certified Nurse Aide (CNA) O stated, the resident did not participate in activities. On 09/22/21 at 12:07 PM, CNA NN stated, activities are all documented in the resident's EMR. Shee does as much 1:1 with the residents as she can. At this time, there are not many activities for residents who require assistance. On 09/22/21 at 01:57 PM, Licensed Nurse (LN) G stated, in the past, the resident participated in activities all of the time, especially Bingo. Currently, there are not many activities available for resident's who aren't able to do things on their own. On 09/23/21 at 08:44 AM, Administrative Nurse D stated, it was the expectation for dependent residents to have some type of stimulation. The facility lacked an activities policy. The facility failed to provide an ongoing program of individualized activities for this dependent resident. - Review of R 79's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS,) dated 09/06/21, assessed the resident with severe cognitive impairment, and verbal behavior directed toward others, on one to three days, of the seven day look back period. The resident required extensive assistance for mobility with impairment in functional range of motion in both sides of the lower extremities. The resident received five days of antipsychotic, and antianxiety medications during the seven day look back period. The Activity Care Area Assessment (CAA), dated 09/06/21, assessed the resident with severe impaired cognitive function and a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had clear speech and usually understood staff. The resident had agitation and anxiety and yelled at staff. One-on-one activities will be offered to the resident. The Care Plan, reviewed 09/16/21, instructed staff to encourage the resident to attend activities and become integrated and involved with life in the facility. Staff instructed to encourage the resident to visit with other residents and attend activities to keep busy. Observation, on 09/20/21 at 08:00 AM, revealed the resident positioned in his wheelchair in the common tv area, with his eye closed. The resident responded to his name by opening his eyes slowly. Observation, on 09/20/21 at 10:00 AM, revealed the resident continued seated in his wheelchair in the common tv area with his eyes closed. The tv was playing a country western music advertising commercial. Observation, on 09/21/21 at 12:10 PM, revealed the resident opened his eyes during the noon meal, but remained somnolent while CNA M fed the resident. Observation, on 09/21/21 at 12:52 PM, revealed CNA O and CNA N transferred the resident to bed with the mechanical lift. The resident remained somnolent. Interview with CNA N revealed she did not know what activity staff should provide to the resident. Interview, on 09/21/21 at 04:00 PM with CNA P, revealed the resident had yelling behaviors when first admitted , but now was cooperative and sleepy most of the time. Interview on 09/23/21 at 09:15 AM, with Licensed Nurse (LN) G, revealed the resident had yelling behaviors when first admitted , but now was somnolent through the day. LN G did not know what activities staff provided to the resident as he did sit in his wheelchair in the common tv area but did not know if he listened to the tv. Interview, on 09/23/21 at 10:45 AM, with Administrative Nurse D, revealed she would expect staff to provide activities to the resident. Interview, on 09/23/21 at 9:00 AM with Administrative Nurse F, revealed staff should provide one on one activities for the resident, and the resident did not attend bingo or group activities. The facility did not provide a policy for activities. The facility failed to provide this dependent resident with activity to enhance the quality of her life. - Review of resident (R)23's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .) The Significant Change Minimum Data Set (MDS), dated [DATE], assessed the resident with severe impairment of cognitive function. The resident's preferences per staff interview revealed the resident liked animals, music, groups, outdoor and religious activities. The resident required extensive assistance of two staff for transfer and bed mobility and was dependent of staff for locomotion. The Activities Care Area Assessment (CAA), dated 08/19/21, assessed the resident with severe impaired cognitive function with clear speech, usually understands and was usually understood. The resident required total assistance with activities of daily living and was on hospice services. Staff to offer one on one activities. The Care Plan, reviewed 09/13/21, instructed staff to remind the resident of activities and allow the resident to attend activities/participate at her choice. The resident likes to join the bingo and move and stretch activity. Observation, on 09/20/21 at 8:30 AM, revealed the resident seated in her wheelchair in the assistive feeding room. The resident attempted to hold her cup and drink out of it. The resident responded to Certified Nurse Aide (CNA) MM who assisted the resident to drink from her cup. Observation, on 09/20/21, at 10:00 AM, revealed the resident seated in her wheelchair, in the common tv area. The resident's eyes were closed, and she dropped a stuffed puppy onto the floor. The activity bingo was taking place in the dining area. Interview, on 09/21/21 at 03:00 PM, with CNA M revealed the resident does not attend activities and did not watch/listen to tv. Interview, on 09/21/21 at 4:20 PM with CNA P, revealed staff got the resident out of bed for supper last, and returned her to bed first after the evening meal due to fall risk. Interview, on 09/22/21 at 12:18 PM, with Activity Staff Z, revealed the resident did not talk much, and did hold onto a stuffed dog. The resident liked to look out a window and used to like looking at the birds in the cage in the dining room when she used to wait for bingo to start. Activity Staff Z revealed she did not provide an activity of watching the birds. Interview, on 09/23/21 at 08:46 AM with Administrative Nurse D, revealed she would expect some activity for the resident. Interview, on 09/23/21 at 9:00 AM with Administrative Nurse F, revealed staff should provide one on one activities for the resident, and the resident did not attend bingo or group activities since her significant change in status after COVID-19 illness. The facility did not provide a policy for activities. The facility failed to provide this dependent resident with activity to enhance the quality of her life. - Review of resident (R) 15's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .) The Admission Minimum Data Set (MDS), dated [DATE], assessed the resident had severe cognitive impairment. Staff assessed the resident's activity preferences as listening to music and going outside, being around animals and groups of people and religious services. The Psychosocial Care Area Assessment (CAA), dated 07/02/21, assessed the resident had clear speech at times and understood verbal communications. The Care Plan, reviewed 08/13/21, instructed staff the resident had cognitive loss that affected her memory and the resident needed to develop a trusting therapeutic relationship with others. Staff need to establish a regular daily schedule. The care plan lacked specific activities for the resident. Observation, on 09/20/21 at 10:00 AM, revealed the resident in her wheelchair in the common tv area. The resident made repetitive monotonal noises and did not focus on the television. Staff provided residents with bingo in the dining room at that time. Observation, on 09/21/21 at 08:30 AM, revealed the resident seated in her wheelchair in the assisted dining room. The resident had word salad and had repetition of noises. The resident propelled herself around the table and touched objects on the table. Interview, on 09/22/21 at 12:15 PM with Activity Staff Z, revealed the resident was unable to verbalize activity preferences and could not complete an activity assessment as family did not come in to interview. Activity Staff Z stated the resident liked to hold a baby doll at times and thought staff provided laundry for the resident to fold, but she dropped the items on the floor. Activity Staff Z stated she thought about a keyboard for the resident. Interview on 09/23/21 at 08:46 AM, with Administrative Nurse D, revealed she would expect staff to provide activities to the resident. The facility did not provide a policy for activities. The facility failed to provide this confused resident with activity to enhance the quality of her life.

The facility reported a census of 30 residents with 15 residents sampled, including one resident reviewed for dignity. Based on observation, interview, and record review, the facility failed to provide dignity for one Resident (R)8, by failure to cover his indwelling urinary catheter bag (tube placed in the bladder to drain urine into a collection bag), leaving it exposed for others to see. Findings included: - The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. He required extensive assistance of two staff for toileting and had an indwelling urinary catheter. The Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA), dated 01/07/21, documented the resident had a suprapubic catheter (catheter inserted directly into the bladder through the abdomen) for a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly MDS, dated [DATE], documented the resident had a BIMS score of 3, indicating severe cognitive impairment. He required extensive assistance of two staff for toileting and had an indwelling urinary catheter. The Activities of Daily Living (ADL) care plan, dated 07/02/21, instructed staff to perform catheter care every shift. On 09/20/21 at 03:14 PM, the resident sat in his wheelchair in his room. His catheter collection bag hung underneath his wheelchair and lacked coverage with a dignity bag. The urine in the catheter collection bag was visible to anyone who walked past his room in the hallway. On 09/21/21 at 08:30 AM, the resident sat in his wheelchair in the dining room eating breakfast. His catheter collection bag hung underneath his wheelchair and lacked coverage with a dignity bag. The urine in the catheter collection bag was visible to anyone in the dining room or in the hallway. On 09/21/21 at 04:47 PM, the resident sat in his wheelchair in his room. His catheter collection bag hung underneath his wheelchair and lacked coverage with a dignity bag. The urine in the catheter collection bag was visible to anyone in the dining room or in the hallway. On 09/21/21 at 04:47 PM, Certified Nurse Aide (CNA) O stated, staff would put the resident's catheter collection bag in the dignity bag when the resident was in bed. When the resident was up in his wheelchair, staff would hang the bag underneath his wheelchair without coverage of a dignity bag. On 09/22/21 at 01:57 PM, Licensed Nurse (LN) G stated, the resident's catheter collection bag should be kept in a dignity bag at all times. On 09/23/21 at 08:44 AM, Administrative Nurse D stated, it was the expectation for staff to put the catheter collection bag in a dignity bag at all times to protect the dignity of the resident. The facility lacked a policy regarding the use of dignity bags for indwelling catheter collection bags. The facility failed to provide dignity with coverage, for this dependent resident's urine in the indwelling urinary catheter collection bag.

The facility reported a census of 30 residents with 15 selected for review. Based on observation, interview and record review, the facility failed to ensure the development of an individualized comprehensive care plan for activities for three sampled residents (R)79, R 23 and R15. Findings included: - Review of R 79's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS,) dated 09/06/21, assessed the resident with severe cognitive impairment, and verbal behavior directed toward others, on one to three days, of the seven day look back period. The resident required extensive assistance for mobility with impairment in functional range of motion in both sides of the lower extremities. The resident received five days of antipsychotic, and antianxiety medications during the seven day look back period. The Activity Care Area Assessment (CAA), dated 09/06/21, assessed the resident with severe impaired cognitive function and a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had clear speech and usually understood staff. The resident had agitation and anxiety and yelled at staff. One-on-one activities will be offered to the resident. The Care Plan, reviewed 09/16/21, instructed staff to encourage the resident to attend activities and become integrated and involved with life in the facility. Staff instructed to encourage the resident to visit with other residents and attend activities to keep busy. The care plan lacked individualized interventions for activities of interest for this resident. Observation, on 09/20/21 at 08:00 AM, revealed the resident positioned in his wheelchair in the common tv area, with his eye closed. The resident responded to his name by opening his eyes slowly. Observation, on 09/20/21 at 10:00 AM, revealed the resident continued seated in his wheelchair in the common tv area with his eyes closed. The tv was playing a country western music advertising commercial. Observation, on 09/21/21 at 12:10 PM, revealed the resident opened his eyes during the noon meal, but remained somnolent while CNA M fed the resident. Interview, on 09/21/21 at 12:52 PM, with CNA N revealed she did not know what activity staff should provide to the resident. Interview, on 09/21/21 at 04:00 PM with CNA P, revealed the resident had yelling behaviors when first admitted , but now was cooperative and sleepy most of the time. CNA P did not know what activities staff provided to the resident. Interview on 09/23/21 at 09:15 AM, with Licensed Nurse (LN) G, revealed the resident had yelling behaviors when first admitted , but now was somnolent through the day. LN G did not know what activities staff provided to the resident as he did sit in his wheelchair in the common tv area but did not know if he listened to the tv. Interview, on 09/23/21 at 10:45 AM, with Administrative Nurse D, revealed she would expect staff to provide activities to the resident. Interview, on 09/23/21 at 9:00 AM with Administrative Nurse F, revealed staff should provide one on one activities for the resident, and the resident did not attend bingo or group activities. Administrative Nurse F stated staff developed the Care Plan for activities based on the MDS, CAA and family interview. The facility used the RAI (resident assessment instrument) manual for the care plan development. The facility failed to provide this dependent confused resident with a comprehensive individualized care plan for activities to enhance the quality of his life. - Review of resident (R)23's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .) The Significant Change Minimum Data Set (MDS), dated [DATE], assessed the resident with severe impairment of cognitive function. The resident's preferences per staff interview revealed the resident liked animals, music, groups, outdoor and religious activities. The resident required extensive assistance of two staff for transfer and bed mobility and was dependent of staff for locomotion. The Activities Care Area Assessment (CAA), dated 08/19/21, assessed the resident with severe impaired cognitive function with clear speech, usually understands and was usually understood. The resident required total assistance with activities of daily living and was on hospice services. Staff to offer one on one activities. The Care Plan, reviewed 09/13/21, instructed staff to remind the resident of activities and allow the resident to attend activities/participate at her choice. The resident likes to join the bingo and move and stretch activity. The care plan lacked activities for the significant change in the resident's status. Observation, on 09/20/21 at 8:30 AM, revealed the resident seated in her wheelchair in the assistive feeding room. The resident attempted to hold her cup and drink out of it. The resident responded to Certified Nurse Aide (CNA) MM who assisted the resident to drink from her cup. Observation, on 09/20/21, at 10:00 AM, revealed the resident seated in her wheelchair, in the common tv area. The resident's eyes were closed, and she dropped a stuffed puppy onto the floor. The activity bingo was taking place in the dining area. Interview, on 09/21/21 at 03:00 PM, with CNA M revealed the resident does not attend activities and did not watch/listen to tv. Interview, on 09/21/21 at 4:20 PM with CNA P, revealed staff got the resident out of bed for supper last, and returned her to bed first after the evening meal due to fall risk. CNA P did not know what activities the staff should provide to the resident. Interview, on 09/22/21 at 12:18 PM, with Activity Staff Z, revealed the resident did not talk much, and did hold onto a stuffed dog. The resident liked to look out a window and used to like looking at the birds in the cage in the dining room when she used to wait for bingo to start. Activity Staff Z revealed she did not provide an activity of watching the birds. Interview, on 09/23/21 at 08:46 AM with Administrative Nurse D, revealed she would expect some activity for the resident and provide an appropriate care plan Interview, on 09/23/21 at 9:00 AM with Administrative Nurse F, revealed staff should provide one on one activities for the resident, and the resident did not attend bingo or group activities since her significant change in status after COVID-19 illness. Administrative Nurse D confirmed the care plan for the significant change in status did not update to reflect the resident's current status. The facility used the RAI (resident assessment instrument) manual for the care plan development. The facility failed to provide this dependent confused resident with a comprehensive individualized activity care plan to enhance the quality of her life. - Review of resident (R) 15's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .) The Admission Minimum Data Set (MDS), dated [DATE], assessed the resident had severe cognitive impairment. Staff assessed the resident's activity preferences as listening to music and going outside, being around animals and groups of people and religious services. The Psychosocial Care Area Assessment (CAA), dated 07/02/21, assessed the resident had clear speech at times and understood verbal communications. The Care Plan, reviewed 08/13/21, instructed staff the resident had cognitive loss that affected her memory and the resident needed to develop a trusting therapeutic relationship with others. Staff need to establish a regular daily schedule. The care plan lacked individualized activities for the resident. Observation, on 09/20/21 at 10:00 AM, revealed the resident in her wheelchair in the common tv area. The resident made repetitive monotonal noises and did not focus on the television. Staff provided residents with bingo in the dining room at that time. Observation, on 09/21/21 at 08:30 AM, revealed the resident seated in her wheelchair in the assisted dining room. The resident had word salad and had repetition of noises. The resident propelled herself around the table and touched objects on the table. Interview, on 09/22/21 at 12:15 PM with Activity Staff Z, revealed the resident was unable to verbalize activity preferences and could not complete an activity assessment as family did not come in to interview. Activity Staff Z stated the resident liked to hold a baby doll at times and thought staff provided laundry for the resident to fold, but she dropped the items on the floor. Activity Staff Z stated she thought about a keyboard for the resident. Interview on 09/23/21 at 08:46 AM, with Administrative Nurse D, revealed she would expect staff to provide activities to the resident. Interview, with Administrative Nursing staff E, revealed the care plan was developed after the MDS assessment completed and should include activities of interest for the resident. The facility used the RAI (resident assessment instrument) manual for the care plan development. The facility failed to provide a comprehensive care plan for individualized activities for this confused resident activities to enhance the quality of her life.

The facility reported a census of 30 residents with 15 residents sampled, including two residents sampled for bowel and bladder incontinence. Based on observation, interview, and record review, the facility failed to provide appropriate peri-care (cleansing of genitals and anal area) to prevent urinary tract infections for one of the two sampled residents, Resident (R)5. Findings included: - The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] The annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 7, indicating severe cognitive impairment. The resident required extensive assistance of two staff for toilet use and she was always incontinent of bowel. The Activities of Daily Living Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 03/28/21, documented the resident required staff assistance of two for toilet use. The Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA), dated 03/28/21, documented the resident was incontinent of bowel and wore briefs for protection. The care plan for incontinence, dated 06/18/21, instructed staff to provide peri-care as needed (PRN). Review of the resident's electronic medical record (EMR), under the Tasks tab, included the resident had several incontinent bowel movements (BM) from 08/25/21 through 09/22/21 which required 1-2 staff for assistance with peri-care. On 09/20/21 at 01:37 PM, Certified Nurse Aides (CNA) Q and MM, entered the resident's room to perform peri-care following a bowel incontinence episode. The staff removed the resident's brief, dirty with a large amount of loose BM, and began to clean the resident. Both staff used one wipe for multiple swipes of the BM while cleaning the resident. Staff would wipe the resident from back to front during the hygiene cares. On 09/20/21 at 01:37 PM, CNA MM stated, he would use one wipe for multiple swipes when performing peri-care at times, depending on how much of a hurry he was in and also to conserve the wipes. CNA confirmed he had wiped the resident with a motion from the back through to the front a few times due to being in a hurry. On 09/20/21 at 01:37 PM, CNA O stated, she would swipe more than once with a wipe, but would fold the wipe in between swipes. On 09/22/21 at 01:57 PM, Licensed Nurse (LN) G stated, when doing peri-care staff should only use one wipe per one swipe. The facility does not have a shortage of supplies. There are plenty of wipes. On 09/23/21 at 08:44 AM, Administrative Nurse D stated, when doing peri-care staff are expected to wipe front to back and use one wipe for one swipe. Wipes should not be folded and reused. The facility does not have a shortage of supplies. The facility lacked a policy for peri-care. The facility failed to provide appropriate peri-care hygiene to prevent urinary tract infections, for this dependent resident with bowel incontinence.

The facility reported a census of 30 residents with three residents selected for review for falls. Based on observation, record review, and interview, the facility failed to provide planned interventions and/or assistive devices to prevent an injury fall for one of the three residents reviewed. The facility failed to implement planned interventions of placement of the Resident (R) 3's wheelchair pedals on her wheelchair while the resident was out of her room. In addition, after the injury fall, the facility failed to position a footboard on the resident's wheelchair to prevent further falls . Findings included: - Resident (R) 3's 10/23/19 signed Physician order [REDACTED]. She re-admitted to the facility on [DATE], with the following [DIAGNOSES REDACTED]. The annual Minimum Data Set (MDS), dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of eight, indicating impaired cognition. She required limited assistance of staff for activities of daily living (ADL's). She required a walker and wheelchair for mobility. The resident's balance was unsteady. The resident had one non-injury fall during the assessment. The Falls Care Area Assessment (CAA), dated 01/09/19, revealed the resident had cognitive and ADL impairments. She had a fall since her last MDS. Her gait/balance with transitions and walking were unsteady. The resident was a fall risk. The Quarterly MDS, dated [DATE], documented the resident had a BIMS score of seven which revealed severely impaired cognition. She required extensive assistance from staff for transfers, toileting, and walking. Her gait remained unsteady, and she used a walker and a wheelchair for mobility. The Care Plan for ADL function, dated 08/05/19, included staff to ensure pedals were on the resident's wheelchair, originated on 10/05/16. After the resident's injury fall, the care plan's update included staff to apply a foot board on the resident's wheelchair when the resident was out of the room and to remove the footboard when the resident was in her room. The Fall Risk Assessment, dated 08/16/19, revealed a score of 16, which placed the resident as a high risk for falls. Review of the Risk Progress Note, located in the electronic medical record (EMR) documented staff toileted the resident in a common area bathroom on 11/21/19. Staff propelled the resident from the bathroom towards the resident's room. Staff failed to place the resident's feet onto the wheelchair pedals, related to the wheelchair pedals not engaged (in the down position) and were in the up position. The facility's root cause for the resident's fall determined as staff propelled the resident, without her feet on the wheelchair pedals, the resident's foot hit the floor, and she fell out of the wheelchair. Review of the facility's undated investigation, revealed on 11/21/19, staff failed to place the resident's wheelchair pedals down for the resident to rest her feet on and the resident toppled forward out of her wheelchair. The resident received a 5-centimeter (cm) by 6 cm skin tear to her left hand, a 2 by 4 cm skin tear to her left forearm, a 3 by 4 cm skin tear to her left (facial) cheek, and a 0.5 by 1 cm laceration to her left temple. The resident was hosptalized on [DATE] and returned to the facility on [DATE]. On 11/21/19, the CT scan (an X-ray image made using a form of tomography in which a computer controls the motion of the X-ray source and detectors, processes the data, and produces the image) of the resident's cervical spine, revealed a [MEDICATION NAME] two (T2) compression fracture . The Nurse Practitioner (NP) orders included a soft cervical collar for use, when upright, ordered 11/27/19. On 12/02/19 at 8:25 AM, the resident was in her bed. The resident's left side of her forehead had abrasions and intact sutures on a laceration to the left side of her forehead. The resident had bruises that extended from the left side of her forehead down and over her left eye. The resident's left hand had a skin tear, her left forearm with two skin tears, and above the left elbow with a skin tear. The resident attempted to rub her forehead, and a family member intervened. The resident reported she had a headache. On 12/02/19 at 9:37 AM, Certified Nurse Aide (CNA) M and CNA N, transferred the resident from her bed to the wheelchair. Staff engaged the wheelchair pedals, however, failed to apply the footboard to the wheelchair. CNA M verified she was taking the resident for a shower. The resident complained of a headache. Staff failed to apply the soft cervical collar to the resident's neck, when staff assisted her out of the bed. On 12/02/19 at 11:30 AM, therapy staff worked with the resident. The resident did not have a foot board on her wheelchair pedals, or a cervical collar to her neck. On 12/02/19 at 12:13 PM, a family member propelled the resident in the hallway. The resident had her feet on the foot pedals, however, the resident's wheelchair lacked a footboard as care planned while the resident was out of her bedroom. Administrative Nurse D verified staff failed to apply the resident's footboard on the wheelchair pedals. On 12/02/19 at 02:05 PM, CNA N and CNA O, transferred the resident in the common's bathroom. The resident lacked a soft cervical collar to her neck. On 12/03/19 at 8:25 AM, a family member reported the resident had a fall that required hospitalization after staff forgot to put the resident's wheelchair pedals into the proper position, and the resident fell forward out of her wheelchair. She reported the resident required hospitalization and she returned with four sutures to her [MEDICAL CONDITION]. On 12/02/19 at 09:25 AM, Administrative Nurse D, reported two staff toileted the resident in the common's bathroom and staff propelled the resident from the bathroom towards her room. Staff failed to put the resident's wheelchair pedals down for the resident to rest her feet on. The resident's feet went to the floor, the resident fell forward, out of the chair, and onto the floor, resulting in laceration that required sutures to her forehead, and a possible T2 fracture. On 12/02/19 at 09:29 AM, CNA P, reported she propelled the resident from the common's bathroom to her room in a wheelchair, approximately 50 feet from the resident's room. While staff propelled the resident in the wheelchair, the resident stomped her foot down and she fell forward to the floor. She verified she failed to have the wheelchair pedals in the right position, because staff was going to transfer her to her bed. On 12/02/19 at 09:34 AM, CNA Q reported she assisted CNA P with the resident's toileting needs. She verified staff failed to engage the resident's wheelchair pedals before propelling the resident to her room, because she forgot to engage the wheelchair pedals. The resident required hospitalization . On 12/02/19 at 09:37 AM, CNA N reported staff should keep the resident's feet on the wheelchair pedals when staff propelled the resident in her wheelchair. On 12/02/19 at 01:46 PM, CNA LL reported staff should apply the resident's foot pedals and foot board on the wheelchair when propelling the resident in her wheelchair. On 12/02/19 at 01:53 PM Licensed Nurse G reported staff should have used the wheelchair pedals to prevent the resident from falling. The resident received a laceration on her head. The resident transferred to the hospital after she fell and received approximately three sutures to the [MEDICAL CONDITION]. She did not touch her head to count the sutures, because the resident was in too much pain when she returned. She is on routine and as needed pain medication. She verified the NP ordered a soft cervical collar for the resident when she was out of bed. On 12/02/19 at 03:00 PM, Nurse Practitioner KK, reported the resident went face forward out of her wheelchair and received sutures for a laceration on her forehead. The resident admitted to the hospital, and the hospital completed a CT scan, and confirmed she had a T2 compression fracture. Nurse Practitioner KK stated she ordered a soft collar for six weeks while she was out of bed, or in bed as needed, if she complained of pain. If staff had the wheelchair pedals engaged, the resident probably would not have fallen out of her wheelchair. The facility's policy for Falls Management, dated 12/2017, documented the facility would minimize the risk for resident falls and reduce injuries associated with resident falls. The plan of care addressed individualized resident focus, goals, and interventions directed towards reduction of resident's risk of injury and potential re-occurrence of falls. The facility failed to implement planned interventions of staff placement of the resident's wheelchair pedals in the down position while the resident was up in her wheelchair and out of her room. In addition, after the injury fall, the facility failed to position a footboard on the resident's wheelchair, to prevent further falls.

The facility reported a census of 35 residents. The sample included 13 residents, with 2 residents sampled for nutrition. Based on observation, interview, and record review, the facility failed to ensure 1 (#28) of the 2 sampled residents maintained adequate nutrition. The resident experienced a significant weight loss, a total of 15 pounds/10.49% weight loss in 180 days. Findings included: - The signed physician's orders [REDACTED].#28, admitted on [DATE], with the following [DIAGNOSES REDACTED]. The admission MDS (minimum data set), dated 6/20/18, documented the resident had a BIMS (brief interview for mental status) score of 5, which indicated severely impaired cognition. The resident required supervision of 1 staff for eating. He/she was 63 inches tall, and weighed 145 pounds. The resident received a mechanically altered diet (foods that are altered by whipping, blending, grinding, chopping, or mashing so the food is easy to chew and swallow). The cognitive CAA (care area assessment), dated 6/20/18, documented the resident had disorganized thinking, confusion, and forgetfulness. The resident received a mechanical soft diet. The RD (registered dietician) assessment, dated 6/12/18, documented the resident had nutritional risks, related to a potential for poor intake. The resident's intake was poor. He/she recommended fortified foods (process of adding micronutrients (essential trace elements and vitamins) to food). The quarterly MDS, dated [DATE], revealed the resident had a BIMS of 12, revealed moderate impairment for decision making. The resident required supervision with eating. He/she weighed 124 pounds, and had experienced a weight loss, and not on a prescribed weight-loss regimen. (14.48% weight loss in 6 months. The dietary profile, completed by the dietary manager, dated 12/14/18, documented the resident required a mechanical soft diet, red napkin program, high calorie snack three times a day, and house supplement daily. His/her appetite increased recently. The resident weighed 125.6 pounds. The ADL (activity of daily living) care plan, dated 12/18/18, documented the resident required staff to remind/cue the resident to eat. Offer snacks to increase the resident's intake. Monitor weight and report to the resident's physician. Provide snacks, and refer to the dietician as needed. The physician's orders [REDACTED].>1.) 6/29/18 High calorie snack three times a day, Mechanical soft with ground meats/gravy, red napkin program, may have regular sausage, hamburger and chicken nuggets, ordered 6/13/18. 2.) [MEDICATION NAME], 15 milligrams, daily at bedtime, for [MEDICAL CONDITION], ordered 6/29/18. 3.) House supplement daily, ordered 11/15/18. Review of the clinical records, from 6/12/18 to 1/8/19, documented on 6/12/18, staff weighed the resident, and he/she weighed 145 pounds. On 7/10/18, staff weighed the resident, and he/she weighed 143 pounds, a 2 pound weight loss, and a total of 5.03% (percent) weight loss in 28 days ( a 1.3% weight loss). On 8/6/18, staff weighed the resident, and he/she weighed 135.8 pounds, a 7.2 pound weight loss, a total of 5.03% weight loss in less than 1 month. On 9/11/18, staff weighed the resident, and he/she weighed 138.6, a 2.8 pound weight gain. On 10/3/18, staff weighed the resident, and he/she weighed 137.8, a 0.8 pound weight loss. On 11/2/18, staff weighed the resident, and he/she weighed 133.4 pounds, a 4.4 pound weight loss. On 12/3/18, staff weighed the resident, and he/she weighed 122.8 pounds, a 10.6 pound weight loss. On 1/2/19, staff weighed the resident and he/she weighed 128 pounds, a weight gain of 5.2 pounds, however, a total of 10.49% weight loss since 7/10/18. On 1/9/19, staff weighed the resident, and he/she weighed 128.6 pounds. Review of the Medication Administration Record, [REDACTED]. On 1/7/19, staff changed the snack from 10:00 am, 4:00 pm, and 6:00 pm, to 10:00 am, 2:00 pm, and bedtime. Review of the registered dietician notes, from 8/10/18 to 12/11/18, identified the resident lost weight, and on 11/9/18 and 12/11/18, the resident continued to lose weight. The resident's meal intake varied from 0 to 100%. On 8/10/18, the RD documented interventions were in place. On 12/11/18, he/she recommended the addition of fortified foods. Continue to monitor the resident's weight. On 1/7/19 at 12:31 pm, staff served the resident a hall tray. The resident slept in his/her bed, with the hall tray at his/her bedside. The resident ate one to two bites of pudding, and fell asleep. On 1/7/19 at 1:26 pm, the resident's food tray remained at his/her bedside, and the resident ate approximately 50% of his/her pudding. The resident remained in bed, asleep. On 1/8/19 at 8:18 am, staff served the resident a bowl of cold cereal, no other food was on the food tray. The resident fed him/herself the cold cereal, and lacked staff cueing, as care planned for his/her nutritional risk. Staff failed to offer the resident any other food items, including fortified foods. On 1/8/19 at 12:20 pm, staff served the resident a room tray of ground Salisbury steak, noodles, mixed vegetables, coffee, milk, and cake. His/her eating utensils had a red napkin around the utensils. Staff failed to assist the resident with the meal. On 1/8/19 at 1:40 pm, the resident's meal remained untouched. Licensed nursing staff S entered the resident's room, and failed to offer to warm up his/her meal, or offer the resident an alternative food choice. The utensils remained wrapped in the red napkin. The resident ate 0%. On 1/8/19 at 5:09 pm, a total of 4 hours and 49 minutes later, staff removed the untouched food from his/her room. The red napkin remained around the utensils. On 1/8/19 at 5:14 pm, direct care staff K, reported staff should pick up hall trays after meals. On 1/9/19 at 9:27 am, direct care staff J, reported he/she was unaware if the resident ate his/her snacks. The resident required cueing at every meal. The resident doesn't stay awake long enough to eat. Staff will pick his/her meal choices if the resident did not like the choices, but might still eat a few bites. The resident required a lot of time for eating any meal. At times, the resident complained that his/her food had turned cold. Staff seldom warmed the resident's meal, and staff reported he/she did not ask the resident for alternate food choices. On 1/9/19 at 12:34 pm, licensed nursing staff I reported the resident was probably losing weight. The red napkin around the utensils identified the resident as a nutritional risk, and alerted staff to monitor the resident's intake of food. Staff should offer the resident alternatives, and the resident ate slow, and would take the resident a good hour for him/her to eat a meal. Staff should warm the resident's food up after 15 minutes, to maintain the temperature, because he/she ate slowly. The resident required set up assistance for his/her meals. The facility did not use snack carts, and did not ask each resident if they would want a snack, because snacks were available only if the resident informed staff they were hungry. On 1/10/19 at 10:07 am, administrative nursing staff B, verified the resident lost weight. If staff could keep the resident awake, the resident ate fairly well. He/she was unaware if the resident's medications of [MEDICATION NAME] for pain, or [MEDICATION NAME] for his/her itch (both of which have side effects of extreme drowsiness), affected the resident's sleeping/ eating. The resident requires a lot of time for eating, because he/she ate slowly, sometimes over 1 hour to complete his/her meals. Staff does not offer to warm up his/her plates of food. Staff should supervise the resident with all his/her meals, to increase his/her consumption of food. On 1/10/19 at 11:00 am, dietary staff C identified the resident was at risk for weight loss, because the resident slept a lot. Staff served the resident fortified foods as he/she was on the red napkin program. Staff should warm up the resident's food if the food sat more than 10 minutes. On 1/15/19 at 12:58 pm, physician's consultant staff BB, reported the resident slept a lot because of pain management. Staff should supervise, cue, and assist the resident with meals. If staff would assist the resident, and make sure the meals were the correct temperature, then the weight loss may have been avoidable. The facility's policy for weight assessment and intervention, revised (YEAR), documented the interdisciplinary team would strive to prevent, monitor, and intervene for the undesirable weight changes of residents. The facility failed to cue and assist the resident, as care planned, failed to keep the resident's food at an acceptable temperature, and failed to offer alternatives for this resident who lost weight, to ensure the resident maintained adequate nutrition. The resident experienced a significant weight loss, a total of 15 pounds/10.49% weight loss in 180 days.

The facility reported a census of 44 residents. The sample included 19 residents, including 3 with pressure ulcers. Based on observation, interview and record review, the facility failed to identify, adequately assess, and provide timely treatment to prevent the development of and promote healing of a facility acquired pressure ulcer for 1 (#51) of these 3 residents sampled for pressure ulcers. Findings included: - The facility admitted resident #51 on 7/26/13. [DIAGNOSES REDACTED]. On admission, on 7/26/13, the facility competed a Braden pressure sore risk assessment at 19 which indicated low risk. The 7/26/13 admission care plan included, "No risk for skin breakdown. Current skin impairment d/t (due/to) decreased mobility, heel protectors both heels, pressure reduction mattress, [MEDICAL CONDITION] (swelling) 1+ in bilateral lower extremities." The 8/2/13 MDS (minimum data set) admission assessment identified the resident with cognition intact, extensive assist required for bed mobility, transfers, walking, toilet use and personal hygiene. Supervision with eating. R/F (risk for) pressure ulcer/none present. The 8/13/13 care area assessment for this resident included, "Pressure ulcer Braden score 19 low risk, (resident) is continent of bowel and bladder. Eats 75-100% of meals. At risk for skin issues d/t decreased mobility. Area (neoplasm) on left heel (inner aspect) that is raised and is being treated with triple antibiotic ointment and covered with [MEDICATION NAME] (dressing). This is not an open area. Dr. indicated it was not a pressure area." The 8/20/13 care plan included, At risk for skin breakdown d/t decreased mobility due to pain. Heel protectors both feet, low air mattress. Well fitting footwear. Propelled w/c (wheelchair) him/her self. Skin treatment per orders. Watch for signs of pressure. The nurses notes documented : On 8/18/13 at 8:21 P.M., "Called to res. (resident's) room by CNA (certified nurse aide) assessed foot and observed open area 1.5 cm (centimeter) x 1.5 cm and 0.2 cm deep area covered by bandaid. No tx (treatment) in TAR (treatment administration record) for the right outer ankle. Res. reported he/she applied bandaid, the first time he/she told nurse. His/Her child brought him/her the bandaid he/she reported. Faxed MD (medical doctor)..." The 8/19/13 (no time documented), the resident out of the facility to the doctors office. "Continue pressure ulcer care with salves, seeing granulation tissue developing over the next 2 to 3 weeks." On 8/21/13 the skin assessment of the outer right ankle, "Measured 1.5 cm x 1.9 cm with small amount of drainage noted. Dressing changed to Santyl with collagen and foam..." On 8/27, "...Rt. ankle 1.5 cm x 1.3 cm 75% slough with 25 % beefy red tissue." 9/2/13 " ...Rt. ankle 0.9 cm x 0.8 cm with no depth noted. Wound bed is 100% yellow slough (a form of dead tissue separating from an ulcer)." 9/9/13, "...Rt. ankle 0.7 cm x 0.6 cm with an amount of drainage. Wound bed 90% slough." On 9/16/13 upon facility entrance, licensed nursing staff B reported the resident (#51) with an unstageable pressure ulcer on the outer right ankle that developed while in the facility. Nurses notes, on 9/17/13, documented, "...Rt. ankle 0.8 cm x 0.8 cm 25 % slough." On 9/18/13 at 9:15 am, observation revealed physician D debrided (the removal of dead tissue) the right ankle wound. At that time, physician D reported the wound continued as an unstageable wound due to yellow slough. "Without the slough it would probably be a (stage) 3. I believe the pressure area due to friction from rubbing up and down on the sheets." On 9/19/13 at 9:25 A.M., licensed nurse I acknowledged, "The aides are suppose to do a skin observation during shower time and report anything different to the nurse. Usually if there isn't a skin issue, the nurse doesn't do any assessments and leaves it up to the shower aide to report anything they note. They were not taking the bandaid off when they showered him/her or when they assisted him /her and (staff) never reported it (the area or the bandaid). He/she was treating it him/her self ... He/she has been on evening showers for a long time...The resident's (child) brought him/her the bandaid's." On 09/19/13 at 10:50 am. licensed nurse B stated, "I did an investigation...(the resident) had been getting his/her shower on the evening shifts and they were not taking the bandaid off or questioning why he/she had the bandaid. Normally the bath aide would tell the nurse of any problems noted. Since the area was found I have educated the staff to take all bandaid's off at shower time or check with the charge nurse to see what they are doing with any skin area. If we don't know about it we can't take care of it." At that time, nurse B looked and did find any bath sheets for the resident. On 9/19/13 at 5:10 P.M., the resident's child reported he/she was unable to remember when he/she took the bandaid's to the facility for him/her. "I didn't know about the ankle problem until we went to the doctor's office on the 19th." The undated facility policy and procedure, "Wound Care/Pressure Ulcers," documented, "...Nursing staff will observe for and report skin issues and utilize the "bath sheets" during routine bathing..." Twenty-three days after the resident's admission to the facility, certified nurse aide K reported to licensed wound nurse J that staff K had discovered a pressure ulcer on the outer right ankle of resident # 51. The resident saw the physician the following day for the unstageable pressure area that developed while in the facility. The facility failed to identify, adequately assess and provide timely treatment for [REDACTED].