Every finding on record at Salina Presbyterian Manor

Based on interviews and record review, the facility failed to provide adequate supervision to prevent a fall with serious injury for Resident (R) 1, who was at high risk for falls, received an anticoagulant (a class of medications used to prevent the blood from clotting), and required assistance with activities of daily living. On [DATE], Certified Nurse Aide (CNA) M assisted R1 into the bathroom in his room, sat R1 on the toilet, then left R1 alone in the bathroom. CNA M alerted Licensed Nurse (LN) G that R1 was in the bathroom. At 10:55 AM, CNA N entered R1's room and found R1 on the floor of the bathroom. R1 had hematoma (a collection of blood trapped in the tissues of the skin or in an organ, resulting from trauma) on the right side of his head. Emergency Medical Services (EMS) transported R1 to the hospital, where he was diagnosed with a subarachnoid bleed (a serious condition, typically caused by head injury, where blood collects between the skull and the surface of the brain). R1 died on [DATE] in the hospital. The facility's failure to provide adequate supervision for R1 placed him in immediate jeopardy. Findings included:- R1's Electronic Medical Record (EMR) documented he had diagnoses of hemiplegia (paralysis of one side of the body) and hemiparesis (muscular weakness of one half of the body) following a cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain) affecting the dominant right side, atrial fibrillation (rapid, irregular heart beat), aphasia (condition with disordered or absent language function), and transient ischemic attacks (TIA- temporary episode of inadequate blood supply to the brain). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R1 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated moderately impaired cognitive function. The MDS documented R1 required moderate to substantial assistance with all activities of daily living (ADLs), except eating. The MDS documented R1 had three falls during the look-back period. Both the Functional Abilities Care Area Assessment (CAA) and the Falls CAA dated [DATE] documented R1 required assistance with ADLs, R1 had impaired balance and transition during transfers, functional impairment during activities, and inability to move his right lower extremity. The CAA documented R1 had generalized weakness and decreased safety awareness. R1's Care Plan, initiated [DATE], lacked any focus, goals, or interventions related to R1 requiring assistance with ADLs. The care plan documented R1 would try to get up in the bathroom by himself and directed staff to ensure R1 had his pendant call light, and documented R1 was educated to pull the cord when he was finished ([DATE]). The care plan documented R1 had expressive aphasia (a communication disorder where you know exactly what you want to say but struggle to get the words out) and receptive aphasia (a language disorder where people have severe difficulty understanding written and spoken language) ([DATE]). The care plan directed staff to be conscious of R1's position in groups, activities, and the dining room to promote proper communication with others ([DATE]). The care plan documented R1 was a high fall risk related to gait and balance problems, incontinence, poor communication/comprehension, and vision and hearing problems. The care plan documented R1 was non-compliant with using his call light and often attempted to complete his ADLs independently [DATE]). The Fall Risk Assessment, dated [DATE], documented R1's fall risk score was 22.0, which indicated R1 was a high fall risk. The Medication Administration Record (MAR), dated [DATE], documented R1 was taking Eliquis (an anticoagulant medication) 5 milligrams (mg) daily and aspirin (a low daily dose of an anti-inflammatory drug thins the blood, making it highly effective in preventing heart attacks and strokes) 81 mg daily. The Health Status Note, dated [DATE], documented R1 left the facility via the facility van to go to the hospital for an echocardiogram. The Health Status Note, dated [DATE] at 10:35 AM, documented R1 returned to the facility from his echocardiogram (a graphic outline of the movements of the heart structures produced by ultrasound). The Health Status Note, dated [DATE] at 10:45 AM, documented staff alerted LN G that R1 was on the floor in his bathroom. LN G observed R1 lying on his buttocks on the floor with his head resting against the metal toilet paper holder. R1 was alert and oriented to person, place, time, and situation. R1 had his pants pulled up, but they were urine-soaked. Urine was found on the floor in front of the toilet. R1 had a small hematoma to the right back side of his head with a small amount of dried blood noted in the area. Active range of motion was noted in all extremities. R1 denied pain. Four staff assisted R1 from the floor to a standing position with a gait belt and assisted him into his wheelchair. R1's primary care physician was called, and they gave an order to send R1 to the emergency room via EMS for evaluation and treatment. A call was placed to R1's daughter to inform her of R1's status. Staff called 911 to have R1 transported to the emergency room. The Radiology Report, dated [DATE] at 12:09 PM, documented R1 had an acute subarachnoid bleed along the right side of his head, with the widest point measuring 2.5 cm. The Health Status Note, dated [DATE] at 12:49 PM, documented a call was placed to the hospital to check on the status of R1. The hospital nurse reported R1 had a bleed in his head and would possibly be transported to a higher level of care as the 2 cm bleed was pushing on R1's brain. The Health Status Note, dated [DATE] at 02:03 PM, documented a call was placed to the hospital to check on R1. The emergency room doctor informed facility staff that R1 had a 2 cm bleed in his head and was choosing to go on comfort measures. The hospital would keep R1 until R1 was able to get started on hospice and comfort care. The Health Status Note, dated [DATE] at 11:33 PM, documented the facility was informed by the hospital R1 had passed away there.CNA M's Notarized Witness Statement, dated [DATE], documented CNA M stated she brought R1 back to the facility from his appointment. She noted R1 told her they needed to hurry because he needed to go to the bathroom. CNA M documented she got R1 to his room so he could go to the bathroom, and R1 stood up with the grab bar and got on the toilet. CNA M said she went and told LN G that R1 was on the toilet. LN G's Notarized Witness Statement, dated [DATE], documented transportation staff notified her R1 was back and was using the bathroom. CNA N entered R1's room to get R1's lunch order then alerted LN G that R1 was on his bathroom floor. LN G stated upon entering R1's bathroom, R1 lay on his buttocks on the floor with his head resting against the metal toilet paper holder. R1 was fully dressed in blue jeans that were unzipped and buttoned. R1's jeans were urine-soaked. R1 had a shirt and tennis shoes on. R1 was alert and oriented. Urine was found on the floor in front of the toilet. R1 had a small hematoma to the back right side of his head with a small amount of blood, which appeared to be dry. Vital signs were obtained and were within normal limits for R1. A neurological assessment was completed. R1 had an active range of motion to all extremities. Administrative Nurse D and R1's daughter were notified. CNA N's Notarized Witness Statement, dated [DATE], documented CNA N entered R1's room to get his lunch order and found R1 lying on the bathroom floor. The CNA then went to the door, called for LN G, and informed her of the fall. R1 told CNA N he fell trying to clean up where he urinated on the floor. R1 stated he hit his head on the toilet paper holder. It took CNA N, a CNA from another hall, and the Certified Medication Aide (CMA) to help R1 up off the bathroom floor. The bathroom light was on. R1 laid on his back, his head was on the wall, and his feet were at the door. R1 was dressed in shoes, socks, jeans, and a shirt. R1 had his call pendant on, but he did not use it or his call light. R1 did not present with any pain when he stood up, other than where he hit his head. On [DATE] at 01:20 PM, CNA M stated after she and R1 got back from the hospital and out of the van, R1 said she needed to hurry because he really had to use the bathroom. CNA M stated she hurried and pushed R1 in his wheelchair to his room, got him in the bathroom, and helped him sit on the toilet. CNA M stated she thought she had given R1 his call light but could not remember. CNA M stated she told LN G R1 was back, and he was on the toilet and then she left the unit. CNA M stated she had been unaware R1 was non-compliant with using his call light when in the bathroom to call for help and said she did not know what amount of assistance R1 required. On [DATE] at 03:00 PM, Administrative Nurse D stated residents returning from an appointment after a procedure should not be left alone in the bathroom due to possible occurrences of weakness, fatigue, confusion, or anxiety. Staff should assist the residents with their needs immediately, remain present with them if they are in the bathroom, and ensure they are comfortable and in their bed or chair before leaving them. The facility's Falls Policy, revised [DATE], documented residents would be identified for risk of falls and interventions implemented to reduce risk. A Fall Risk Evaluation Tool is completed on admission, quarterly, when there is a significant change, and after a fall. A resident's high-risk status will be documented on the comprehensive plan of care or service plan. Review of the fall prevention reference sheet for ideas to implement and document in the care plan. On [DATE] at 03:30 PM, Administrative Staff A and Administrative Nurse D were provided the Immediate Jeopardy [IJ] Template and were notified the facility's failure to provide adequate supervision and assistance for R1 placed R1 in immediate jeopardy. The facility implemented education and retraining to staff regarding providing the appropriate level of staff assistance and supervision. The corrections were completed on [DATE], prior to the onsite survey therefore, the deficient practice was deemed past non noncompliance and remained at a scope and severity J (immediacy, isolated).

Based on interviews and record review, the facility failed to ensure Resident (R) 3 received quality treatment and care in accordance with professional standards of practice. On 04/27/26, Licensed Nurse (LN) G failed to follow wound vac (a vacuum-assisted wound treatment that applies gentle suction to a wound to help it heal) treatment orders for the treatment of R3's third, fourth and fifth right toe amputations (surgical removal of a body part), which caused R3's surgical wound to worsen and require intravenous (IV-administered directly into the bloodstream via a vein) antibiotic administration. Findings included:- R3's Electronic Medical Record (EMR) documented R3 had diagnoses of peripheral vascular disease (PVD- slow and progressive circulation disorder causing narrowing, blockage, or spasms in a blood vessel), osteomyelitis (local or generalized infection of the bone and bone marrow) of the right foot, and surgical aftercare for amputation of the third, fourth, and fifth toes. R3's admission Minimum Data Set, dated 04/06/26, documented R3 had a Brief Interview for Mental Status score of 15, which indicated intact cognition. The MDS documented R3 required substantial assistance for toileting, bathing, transfer, and bed mobility. The MDS documented R3 had a surgical wound and received dressing changes. The Functional Abilities Care Area Assessment (CAA), dated 04/10/26, documented R3 required staff assistance with activities of daily living (ADLs) due to impaired balance and transitions during transfers and functional impairment with activity. The CAA documented R3 had generalized weakness and decreased safety awareness. R3's Care Plan, initiated 04/06/26, directed staff to encourage R3 to elevate her legs, notify the provider if there is no sign of improvement on the current wound regimen, and provide wound care per treatment orders (04/06/26). The care plan documented R3 had a surgical wound related to the surgical amputation of toes. The plan directed staff to provide education to R3 and her family regarding the wound and treatment plan, and R3's wound would be assessed weekly by the wound care nurse (04/12/26). The plan documented R3 had osteomyelitis in her right foot and ankle and directed staff to administer IV antibiotics as ordered, administer antipyretics (medication used to prevent, reduce, or relieve a fever) per orders, monitor R3's temperature and pulse three times a day, and monitor R3's mental status and cognitive function throughout the day and communicate any decline (04/29/26). The admission Summary Note, dated 04/06/26, documented the incision site to R3's right foot, which measured eight centimeters (cm) in length and had eight sutures. Toes three, four, and five were amputated. A wound vac was applied on admission after the wound nurse took photos of the wound before the wound vac placement. The Treatment Administration Record (TAR), dated April 2026, documented the wound vac dressing change: cleanse right foot with wound cleanser and pat dry, apply skin prep (liquid skin protectant) to peri (area around)-wound tissue, apply wound vac drape (an airtight adhesive film used in negative pressure wound therapy) to dorsal (back) foot and around surgical incision, cover surgical incision with Adaptic (a non-adhering dressing that helps protect regenerating skin), cover incision covered with Adaptic with small foam tracking onto the dorsal foot, cover with wound vac drape and apply track pad (connects the wound dressing to the vacuum machine) to dorsal foot, cover with multi-layer foam, secure tubing with kerlix (stretchy gauze bandage)and Ace wrap (a stretchable wrap used to apply localized stable pressure to a body part) every Monday, Wednesday, and Friday. Call if the wound deteriorates or shows signs and symptoms of infection. The wound vac should have negative 125 milligrams of Mercury (mmHg) continuous suction, medium intensity. The order was started on 04/08/26 and discontinued on 04/09/26. The Health Status Note, dated 04/08/26, documented R3 left the facility for a wound care clinic appointment and returned at 01:30 PM with no new orders. The Skin/Wound Note, dated 04/09/26, documented the facility received the wound care clinic progress note. The note documented the wound vac stopped. And staff implemented daily dressing changes. R3's orders were updated to reflect this, and the wound vac was placed in the mail room to be returned. The April 2026 TAR documented an order dated 04/09/26 (discontinued on 04/16/26) for wound care for the ulcer to the right foot: Apply Normlgel Ag (an antimicrobial silver wound gel) to the wound bed, apply slightly moistened Aquacel AG (a soft, sterile dressing), Adaptic, and an ABD Pad (thick absorbent dressing). Roll with gauze and secure with tape. Change Daily and as needed (PRN) if soiled or dislodged in the morning for the right foot ulcer. Call [hospital] if wound deteriorates or shows s/s of infection The April 2026 TAR documented a start date of 04/17/26 for wound care for R3's right foot. Cleanse with Hibiclens (antiseptic skin cleanser) using gentle flush and scrub method, apply skin sealant topically to skin, apply Normgel Ag to the wound bed, place hydrocolloid (waterproof, self-adhesive medical dressing) to the peri wound and dorsal foot for redness, apply wound vac to continuous at negative 125 mmHg, apply offloading shoe, change every Monday, Wednesday, and Friday. This order was discontinued on 04/23/26. The April 2026 TAR documented a start date of 04/24/26 for wound care for R3's right foot. Cleanse with Hibiclens using gentle flush and scrub method, apply skin sealant topically to skin, apply a nickel size amount of Normgel Ag to the wound bed, apply Adaptic over the bone, place a thin hydrocolloid to the peri wound and dorsal foot for redness, apply wound vac to continuous at negative 125 mmHg, apply offloading shoe, change every Monday, Wednesday, and Friday. The Health Status Note, dated 04/27/26, documented R3 had the wound vac to her right foot changed. R3 tolerated the dressing change well with minimal discomfort noted during the wound care. R3 complained about a lot of pain after the wound care was completed. The old dressing was removed without difficulty. The wound bed had a large amount of slough (dead tissue, usually cream or yellow in color) and a small amount of granulation tissue (new tissue formed during wound healing). No foul odor was noted. The peri wound was slightly macerated (softening and breaking down of skin because of prolonged exposure to moisture). The wound was cleansed as ordered and staff applied a new foam dressing and secured with occlusive drape. The wound vac tubing connected without an air leak and negative pressure therapy resumed at 125 mmHg continuous pressure per provider order. The Wound Care Clinic Progress Note, dated 04/29/27, documented upon initial assessment R3's wound measured 6.1 cm by 4.6 cm by 1.5 cm. The wound was deep to the bone. Upon removal of the dressing, the wound clinic identified that Aquacel AG had been placed underneath the wound vac. The note documented the facility needed to be educated. The note documented that overall, the area had deteriorated and increased in size since R3's last appointment. R3 had increased fascial necrosis (premature, irreversible death of cells and living tissue) and noted that R3 reported significantly increased pain to the area. The clinic completed debridement (medical removal of dead, damaged, or infected tissue to improve the healing potential for the remaining healthy tissue) of some of the necrotic (dead tissue) tissue was completed but due to pain some of the necrotic tissue remained; a bone and wound culture was obtained. Due to the presentation of the wound, the wound was covered with Dakin's (a diluted, antiseptic sodium hypochlorite solution used to clean wounds, prevent infections, and manage odors) soaked gauze, and R3 was sent to the emergency department for further evaluation/treatment/possible admission. The Health Status Note, dated 04/29/26, documented the facility received a call from the wound care clinic, which reported R3 was being transferred to the emergency room for evaluation. The Health Status Note, dated 04/30/26, documented R3 was very shaky and reported being warm. R3 was confused during the conversation about her appointment with the wound care clinic and her visit to the emergency room. The wound care clinic called and ordered the facility to make an appointment with a vascular surgeon in one week for magnetic resonance imaging (MRI-medical imaging used to view soft tissue) with and without contrast, peripherally inserted central catheter (PICC-a thin, flexible tube that is inserted into a vein in the upper arm and threaded into a large vein above the heart) at the hospital for IV vancomycin (antibiotic) and wound care of 1one-quarter percent Dakin's solution to gauze to wound bed, calmoseptine or zinc to peri-wound, cover with ABD pad, wrap with gauze, secure with tape, and change three times a day. The Health Status Note, dated 04/30/26, documented a nurse from the hospital called, and the MRI showed osteomyelitis in the right foot. The hospital had administered two grams of cefepime (antibiotic) and 800 mg of daptomycin (antibiotic) through the port on R3's chest port. A PICC line is not needed. New orders were received for the facility to infuse IV antibiotics. The Medication Discrepancy IDT Review Note, dated 05/05/26, documented on 04/29/26 at 04:30 PM, a nurse from the wound care clinic called and reported R3 was being transferred to the ER. At 08:23 PM, the wound care clinic called the facility to report R3 had Aquacel AG placed in her wound bed. The Aquacel AG had clogged the wound vac, and the right foot wound had deteriorated. On 04/30/26 at 01:05 AM, the hospital called to say R3 was ready to return to the facility; the hospital was waiting for the scan results. A wound culture had been obtained, and a wet-to-dry dressing had been applied. The note documented that the identified nurse, LN G, may not perform wound dressing changes independently and will complete wound care competency validation prior to resuming independent wound care responsibilities. All facility nurses complete wound vac competencies prior to changing wound vac dressings. R3 was unavailable for observation or interview. On 05/27/26 at 12:30 PM, LN G stated there were two different orders, one on the TAR and one on the 24-hour shift sheet. The order on the 24-hour sheet said to take moistened Aquacel AG and place it on the wound bed. She did not double-check with anyone on the correctness of the 24-hour shift sheet. LN H started crying and stated she had been a nurse for 29 years and had never had anything like this happen, and she could not stop thinking about it. On 05/27/26 at 03:00 PM, Administrative Nurse D stated she expected nurses to follow the orders in the TAR and, if there were discrepancies, to double-check the order and clarify. The facility's Negative Pressure Wound Therapy Checklist Policy, dated 02/26/26, documented nurses would review the medical order for the application of the wound vac therapy, including the ordered pressure settings for the device. The facility identified and implemented immediate corrective actions which included: LN G, may not perform wound dressing changes independently and will complete wound care competency validation prior to resuming independent wound care responsibilities. All facility nurses completed wound vac competencies prior to changing wound vac dressings. All corrective actions were completed prior to the onsite survey therefore the deficient practice was deemed past noncompliance at the scope and severity of a G (actual harm, isolated).

Based on observations, interviews, and record review, the facility failed to ensure Resident (R) 2 received the necessary care, consistent with professional standards of practice, to prevent a pressure injury from developing when staff failed to identify and implement preventative measures such as heel offloading or repositioning to address R2's risk for pressure risk related to friction and shear and very limited ability to reposition. This failure resulted in an unstageable pressure injury unstageable (depth of the wound is unknown due to the wound bed being covered by a thick layer of other tissue and pus). Findings included:- R2's Electronic Medical Record (EMR) documented he admitted to the facility on [DATE]. The EMR documented diagnoses of displaced fracture of the base of the neck of the right femur (right hip fracture), artificial right hip joint replacement, heart failure (a condition with low heart output and the body becomes congested with fluid), atrial fibrillation (rapid, irregular heart beat), dementia (a progressive mental disorder characterized by failing memory and confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and major depressive disorder(major mood disorder that causes persistent feelings of sadness). R2's admission Minimum Data Set (MDS), dated 11/09/25, documented he had a Brief Interview for Mental Status (BIMS) score of nine, which indicated moderately impaired cognition. The MDS documented R2 did not have a pressure ulcer on admission. The MDS documented R2 required maximum staff assistance with all activities of daily living (ADLs) except eating. The Functional Abilities Care Area Assessment (CAA), dated 11/09/25, documented R2 had impaired balance and transition during transfers and functional impairment in activity. R2 had generalized weakness and decreased safety awareness. The Pressure Ulcer/Injury CAA, dated 11/09/25, documented R2 had the potential for pressure ulcers due to ADL functional/mobility impairment and incontinence. The CAA documented a licensed nurse would assess R2's skin each week and put in proper interventions in place to prevent skin breakdown. R2's Care Plan, initiated 11/07/25, lacked any focus, goals, or intervention regarding any staff assistance R2 required for ADLs. The care plan lacked any focus, goals, or interventions related to the assessment of R2's skin or the prevention of skin alterations or pressure ulcers until 11/26/25, after development of the deep tissue injury (DTI- purple or maroon localized area of discolored intact skin or blood filled blister due to damage of underlying soft tissue from pressure and/or shear). R2's Care Plan dated 11/26/25 documented R2 had impaired tissue integrity related to pressure and shear forces and noted he had a DTI on his right heel. The plan directed staff to assess his nutritional status and consult the dietician if needed. An intervention dated 11/26/26 directed staff to check R2's dressing each shift and follow his treatment plan as directed by the primary care physician. The plan documented R2 would receive adequate pain control. Interventions dated 11/26/26 documented staff would teach R2 and his representatives about pressure injury prevention and directed staff to offload R2's heels by using Prevalon boot (special pressure-reducing heel protectors). The QA admission SKIN ASSESSMENT, dated 11/04/25 at 02:06 PM, documented R2's skin was warm and dry. He had purple discoloration noted on his bilateral arms, an abrasion noted on the right elbow, and a skin tag noted on the left inner arm. He had no redness noted on his heels or groin. There was slight redness to his inner buttocks, and barrier cream was encouraged. He had a skin tag noted on his mid back. He had a surgical incision to his right hip; the dressing was dry and intact and was supposed to stay in place until his orthopedic (medical specialty focused on bones) appointment. He had trace edema to both lower extremities and had a purple-colored area on his right lower leg from his fall; he had spider veins observed on his ankles. He was missing his right great toenail and the nail next to it. He was also missing his great left toenail. His feet were dry, and lotioning was encouraged. He had age spots noted on his face. The Braden Scale Evaluation, dated 11/04/25, documented R2 was occasionally moist, walked occasionally, had very limited bed mobility, and was only able to make occasional, slight changes in body or extremity position but was unable to make frequent or significant changes independently. The evaluation documented of R2's nutrition was probably inadequate. The N Adv - Braden Scale for Predicting Pressure Ulcer Risk Evaluation dated 11/11/26 documented R2 had no sensory perception impairment, was occasionally moist, and walked occasionally. The assessment noted R2 was very limited in mobility and made occasional slight changes in body or extremity position but was unable to make frequent or significant changes independently. His nutrition was marked as probably inadequate. The assessment noted friction, and shearing was a potential problem. The Braden score was 16, which indicated mild risk (but requires preventative measures). R2's EMR lacked evidence that preventative measures to avoid pressure injuries were implemented. The N Adv - Skin Check note dated 11/20/25 at 05:14 AM documented R2's skin was warm and dry. R2's skin color was within normal limits. His skin turgor (the degree of elasticity of the skin, which shows hydration levels) was normal. No new skin issues identified. The note documented a foot evaluation was completed. R2 had an incision to his right hip that was healing nicely with no redness, swelling, or drainage noted. The N Adv - Braden Scale for Predicting Pressure Ulcer Risk Evaluation dated 11/20/26 at 05:20 AM documented R2's sensory perception was slightly limited. He was occasionally moist and walked occasionally. The assessment noted R2 was very limited in mobility and made occasional slight changes in body or extremity position but was unable to make frequent or significant changes independently. His nutrition was marked as probably inadequate. The assessment noted friction, and shearing was a potential problem. The Braden score was 16 which indicated. R2's EMR lacked evidence that preventative measures to avoid pressure injuries were implemented. The Skin/Wound Note, dated 11/24/25, documented the nurse was notified by nursing staff R2 had a sore on his right heel. R2's heel presented with eschar (dead tissue) and an open blister, which measured 1.5 cm by 1.75 cm. No drainage was noted. The area was cleansed and covered with protective dressing. Staff left a message with R2's responsible part and sent a message to the wound care nurse for further treatment recommendations and staff elevated R2's heels at that time. The Skin Issues Note dated 11/26/26 documented R2 had a new DTI to his right heel acquired in-house. The note documented that the wound was painful and burning. The wound measured 3.66 cm in length by 3.02 cm in width, and 0.1 cm in depth. The wound bed had 60% eschar with light sanguinous (bloody drainage) exudate (a fluid that leaks out of body vessels and tissues). The new interventions included repositioning. The dressing change directions were to cleanse the area with wound cleanser and pat dry, apply skin prep to the peri-wound tissue, apply betadine to the wound bed, apply a foam dressing, change every three days and as needed. Under additional care, the note directed to apply Prevalon boots while in bed. Staff faxed the skin update to R2's primary care physician. The Skin/Wound Note, dated 12/10/25, documented R2 continued with the DTI of his right heel related to pressure and shear forces while in bed. The wound bed measured 2.67 cm by 3.54 cm by 0.1 cm. The wound bed had 80% eschar, and the surrounding tissue had erythema (redness or inflammation of the skin). Continued the previous dressing change. The note documented that R2 often took off Prevalon boots while in bed. Skin update was faxed to R2's primary care physician. The Skin Issue Note, dated 12/16/25, documented R2's right heel DTI measured 2.81 cm by 3.6 cm by 0.1 cm. The wound bed had 90% eschar with light sanguinous exudate. Called R2's primary care physician regarding wound care referral. The Skin Issue Note, dated 12/23/25, documented R2's right heel DTI measured 1.99 cm by 2.53 cm by 0.1 cm. The note lacked any other wound documentation. The Discharge Summary, dated 12/31/25, documented R2 was to be discharged to his previous assisted living home with home health services. R2 had multiple falls while at the facility. R2 had an ulcerated area on his right heel. Cleansed and border dressing changed every three days and as needed. On 05/27/26 at 12:30 PM, Licensed Nurse (LN) G said she remembered R2 but could not remember if there had been any interventions in place to prevent pressure ulcer development. LN G stated that new admissions who are at risk should have pressure ulcer prevention interventions added and implemented. On 05/27/26 at 03:00 PM, Administrative Nurse D stated she remembered R2, but she did not remember that R2 had a DTI. Administrative Nurse D agreed preventative measures should have been put in place to try to prevent R2 from obtaining a DTI on his right heel. The facility's Skin Integrity Pressure Ulcer/Injury Prevention Policy, revised 03/20/26, documented all residents are considered to have a potential risk for the development of pressure ulcers. Nursing staff will evaluate skin integrity, implement preventative measures as indicated, and treat skin breakdown. The primary care provider's admission orders will authorize approval to begin using established skin and wound treatment guidelines. Dressing changes are performed by a licensed nurse.

The facility identified a census of 53 residents. Based on record review and interview, the facility failed to ensure nursing staff possessed current licensure as required. This deficient practice placed all the residents in the facility at risk for not attaining or maintaining the highest practicable physical, mental, and psychosocial well-being.Findings included:- The Kansas Nurse Aide Registry, printed on [DATE], documented Certified Medication Aide (CMA) R license expired on [DATE] and CMA S license expired on [DATE].The Facility's Working Schedule for the month of [DATE] documented CMA R worked six days in the facility and passed medications to residents after CMA R's license had expired. CMA R was suspended and taken off the schedule until her license was reinstated.The Facility's Working Schedule for the month of [DATE] documented CMA S worked two days in the facility and passed medications to residents after CMA S's license had expired. CMA S was suspended and taken off the schedule until her license was reinstated.On [DATE] at 10:00 AM, Human Resources Staff V stated she was responsible for sending out the dates of the nursing staff's license expiration to Administrative Nurse D, and they were both responsible for reviewing the license expirations to ensure staff were notified in plenty of time to renew their licensure. Human Resources Staff V stated this time, CMA R and CMA S fell through the cracks, and neither she nor Administrative Nurse D had caught the license expirations for CMA R and CMA S.On [DATE] at 10:15 AM, Administrative Nurse D stated they had devised and new procedure for monitoring staff licensure. All staff licensure expiration dates were placed on a spreadsheet, and Human Resources Staff V, the facility scheduler, and Administrative Nurse D would meet every Tuesday to go over staff licensure expiration dates, and staff would be notified of their licensure expiration date two months before the expiration and then weekly thereafter. If staff did not renew their license, they would be taken off the schedule until their license was renewed. Administrative Nurse D stated she expected all nursing staff to have current licensure to take care of residents in the facility.The facility's Nursing Facility Nursing Service Policy, revised [DATE], documented the goal of nursing service is to provide each resident admitted to the health care center with the appropriate level of care to attain his/her optimum level of functioning. Nursing service is staffed, organized, and equipped to provide nursing care on a 24-hour-a-day basis. The health care center is licensed and certified in accordance with state and federal regulations governing long-term care.The facility identified the above deficient practices and implemented immediate corrective actions, which were all completed on [DATE] and included: CMA R and CMA S were suspended upon discovery of the expired certification. The facility implemented a tracking spreadsheet to alert administration staff when certifications were set to expire.

The facility identified a census of 53 residents. Based on record review and interview, the facility failed to ensure adequate administrative oversight when the facility failed to monitor and ensure all nursing staff practicing in the facility maintained active licenses as required to provide the residents residing in the facility with the care they needed to attain or maintain the highest practicable physical, mental, and psychosocial well-being. This deficient practice placed the residents residing in the facility at risk for a lack of quality nursing care.Findings included:- The Kansas Nurse Aide Registry, printed on [DATE], documented Certified Medication Aide (CMA) R license expired on [DATE] and CMA S license expired on [DATE].The Facility's Working Schedule for the month of [DATE] documented CMA R worked six days in the facility and passed medications to residents after CMA R's license had expired. CMA R was suspended and taken off the schedule until her license was reinstated.The Facility's Working Schedule for the month of [DATE] documented CMA S worked two days in the facility and passed medications to residents after CMA S's license had expired. CMA S was suspended and taken off the schedule until her license was reinstated.On [DATE] at 10:00 AM, Human Resources Staff V stated she was responsible for sending out the nursing staff's dates of licensure expiration to Administrative Nurse D, and they were both responsible for reviewing the licensure expirations to ensure staff were notified in plenty of time to renew their licensure. Human Resources Staff V stated this time, CMA R and CMA S fell through the cracks, and neither she nor Administrative Nurse D had caught the license expirations for CMA R and CMA S.On [DATE] at 10:15 AM, Administrative Nurse D stated they had devised and new procedure for monitoring staff licensure. All staff licensure expiration dates were placed on a spreadsheet, and Human Resources Staff V, the facility scheduler, and Administrative Nurse D would meet every Tuesday to go over staff licensure expiration dates, and staff would be notified of their licensure expiration date two months before the expiration and then weekly thereafter. If staff did not renew their license, they would be taken off the schedule until their license was renewed. Administrative Nurse D stated she expected all nursing staff to have current licensure to take care of residents in the facility.The facility's Nursing Facility Nursing Service Policy, revised [DATE], documented the goal of nursing service is to provide each resident admitted to the health care center with the appropriate level of care to attain his/her optimum level of functioning. Nursing service is staffed, organized, and equipped to provide nursing care on a 24-hour-a-day basis. The health care center is licensed and certified in accordance with state and federal regulations governing long-term care.The facility identified the above deficient practices and implemented immediate corrective actions, which were all completed on [DATE] and included: CMA R and CMA S were suspended upon discovery of the expired certification. The facility implemented a tracking spreadsheet to alert administration staff when certifications were set to expire.

The facility had a census of 56 residents. The sample included 15 residents. Based on observation, record review, and interview, the facility failed to store, prepare, distribute, and serve food under sanitary conditions for the 56 residents in the facility, who receive their food from the kitchen. This deficient practice placed the residents at risk for foodborne illness. Findings included: - On 06/24/25 at 07:45 AM, during the initial tour of the kitchen, the handles and door surfaces of the four-door refrigerator were sticky and had dried food substances on them. The ceiling tile above the food preparation table had dried, red in color, food splatter. On 06/25/25 at 10:15 AM, the char broiler (a type of cooking appliance, typically used in commercial kitchens, that uses dry heat to cook food over a grill or grate) had blackish greasy buildup and dried food stuck to the grill. Dietary BB stated they did not use the char broiler but used the outside grill. The knobs of the char broiler were greasy and had food substances dried on them. Further observation revealed the small microwave had food splatter inside of it and an old dried-up hot dog on a plate. The large microwave also had a lot of food spatter and food debris inside it. The outside of the fryer had a significant amount of grease down the front of it and onto the floor, and the grease in the fryer was black in color. In the corner of the kitchen by the oven sat a five-gallon bucket with old grease, reddish orange in color, and no lid. The window behind the trash can had a greasy splatter halfway down the window. The flour, sugar, oatmeal, and cornmeal bins had trash and food debris behind and underneath them. On 06/25/25 at 10:30 AM, Dietary BB stated the kitchen was cleaned every shift and verified the above findings. The facility's Sanitation & Infection Control policy, dated 01/24, documented that the director of Dining Services had the responsibility to develop and maintain clean, sanitary work areas, storage areas, and equipment for the handling of supplies by state and local health department standards. The Director of Dining Services would prepare written standards and work procedures for daily operations. Procedures for the preparation and serving of food to minimize contamination by microorganisms or by chemicals that may result in food poisoning.

- R30's Electronic Medical Record (EMR) documented diagnoses of diabetes mellitus (DM - when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), bacteremia (presence of bacteria in the blood), and acute pyelonephritis (infection of the kidneys). R30's EMR documented she was discharged to a hospital on [DATE] to 03/17/25 and again on 04/30/25 to 05/07/25. Upon request, the facility lacked documentation the Long-Term Care Ombudsman (LTCO) had been notified of the discharges from the facility. On 06/25/25 at 02:30 PM, Social Services Staff X verified she had not notified the LTCO of the March 2025 and April 2025 discharges to a hospital. She stated she only notified the ombudsman of the monthly admissions and discharges to home or another facility. The facility's Transfer/Discharge Notice policy, dated 02/03/25, stated the facility would notify the resident or their responsible party of all discharges or transfers 30 days prior to the transfer unless the resident's medical condition warrants immediate transfer. Notice would be sent to the LTCO. - R54's Medical Record revealed the resident was admitted to the facility 05/21/25 with diagnoses of acute kidney failure (a condition characterized by a relatively sudden onset of symptoms that are usually severe), hypertension (HTN - elevated blood pressure, atherosclerosis heart disease (ASHD a build up of fats, cholesterol and other substance on the artery wall causing the arteries to narrow, blocking blood flow), anemia (an inadequate number of healthy red blood cells to carry adequate oxygen to body tissues), and muscle weakness. The admission Minimum Data Set (MDS), dated 03/27/25, documented R54 had significant cognitive impairment. The MDS documented the resident was dependent upon staff for toilet use, shower and bathe self, required maximum staff assistance with personal hygiene, moderate staff assistance with eating, and oral hygiene. The MDS documented the resident expected to be discharged to the community. R54's Activity of Daily Living (ADL) Care Area Assessment (CAA), dated 04/09/25, documented the resident was a new admit to the facility and was admitted to the hospital after a fall at an assisted living facility and was on the floor at the assisted living for a day before admitted to the hospital. The CAA documented the resident requires staff assistance to complete her ADLs due to weakness and had a diagnosis of COVID-19. R54's Care Plan dated 03/21/25, documented the resident had a decline in endurance due to a recent diagnosis of COVID-19 (highly contagious respiratory virus). The care plan documented staff would assist the resident with turning and repositioning at least every two hours, more often as needed, or requested to prevent skin breakdown. The Nurse's Note, dated 04/10/25 at 09:46 AM, documented R54 was discharged from the facility to a skilled nursing facility out of town. Review of the resident's Medical Record lacked a discharge summary, which included a recapitulation of the resident's stay. On 06/26/25 at 10:00 AM, Administrative Nurse D verified the resident's medical record lacked a discharge summary with a recapitulation of the resident's stay. The facility's Transfer/Discharge Notice policy, dated 09/13/21, documented the facility would provide and document sufficient preparation and orientation to residents to ensure safe and orderly transfer and discharge from the community. The orientation would be provided in a form and manner that the residents can understand. The policy documented upon transfer/discharge from the facility community, the Notice of Discharge Transfer from a nursing community form would be completed by the designated community personnel. A copy would be kept in the chart, and a copy given or sent to the resident or responsible party. The staff would document in the medical record transfer/discharge notification in the interdisciplinary notes. The facility had a census of 56 residents. The sample included 15 residents, with five reviewed for hospitalization and one reviewed for unplanned discharge. Based on observation, record review, and interview, the facility failed to notify the Office of the Long-Term Care Ombudsman (LTCO - a public official who works to resolve resident issues in nursing facilities) for three sampled residents, Resident (R) 6, R19, R30, and failed to complete a recapitulation (a concise summary of the resident's stay and course of treatment in the facility) of R54's stay. This placed the residents at risk for impaired rights and at risk for receiving inadequate care. Findings included: - The electronic Medical Record (EMR) for R6 documented diagnoses of respiratory failure (a serious medical condition that occurs when the respiratory system cannot adequately provide oxygen to the bloodstream), hypertension (high blood pressure), vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). The Annual Minimum Data Set (MDS), dated [DATE], documented severely impaired cognition. R6 required partial staff assistance for toileting hygiene, transfers, ambulation, and substantial assistance for dressing. The Significant Change MDS, dated 06/11/25, documented R6 had severely impaired cognition. R6 was dependent upon staff for toileting hygiene, showers, and lower body dressing. R6 required substantial staff assistance for upper body dressing, mobility, transfers, and toileting. R6's Care Plan, dated 06/05/25, initiated on 08/22/24, directed staff to administer medications as ordered, monitor for lethargy, confusion, and adverse drug reactions, and shortness of breath. R6's Progress Note, dated 05/22/25 at 07:40 PM, documented R6 was admitted to the hospital for aspiration pneumonia (an inflammatory condition of the lungs caused by inhaling foreign material or vomit). R6's clinical record lacked evidence that the Ombudsman was notified of the hospital transfer. R6's Progress Note, dated 05/28/25 at 12:11 PM, documented R6 returned from the hospital. On 06/24/25 at 03:5 PM, R6 sat in her recliner, feet down, eyes closed. On 06/25/25 at 11:45 AM, Social Service X stated she had not notified the Ombudsman of the hospital transfer and had not been aware that she needed to do that when a resident went to the hospital. On 06/26/25 at 12:30 PM, Administrative Nurse D stated the ombudsman should be notified when a resident was transferred to the hospital and stated Social Service X did send a list of hospital transfers to the Ombudsman that morning. The facility's Transfer/Discharge policy, dated 10/01/96, documented, the community would provide and document sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the community. This orientation would be provided in a form and manner that the resident could understand. The resident/responsible party would be notified in writing of all discharges or transfers thirty (30) days before the transfer, unless the resident's medical condition warrants immediate transfer. A notice of the transfer was sent to the State Ombudsman. - The Electronic Medical Record (EMR) for R19 documented diagnoses of hypertensive chronic kidney disease (a long-term condition characterized by the gradual and progressive loss of kidney function over time) stage four, dementia (a progressive mental disorder characterized by failing memory and confusion), chronic obstructive pulmonary disease (COPD - a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), and atrial fibrillation (rapid, irregular heartbeat). The Annual Minimum Data Set (MDS), dated [DATE], documented R19 had moderately impaired cognition. R19 required partial staff assistance with transfers, ambulation, personal hygiene, dressing, and toileting. R 19 was frequently incontinent of bladder and always continent of bowel. The Quarterly MDS, dated 04/16/25, documented R19 had moderately impaired cognition. R19 required partial staff assistance for toileting hygiene, transfers, ambulation, and dressing. R19 was frequently incontinent of bladder and occasionally incontinent of bowel. R19's Care Plan, dated 05/08/25, initiated on 08/28/24, directed staff to administer medications as ordered and monitor for diarrhea, cramping, and vomiting. The care plan directed staff to notify the physician as needed. R19's progress Note, dated 03/17/25 at 11:32 AM, documented R19 told the nurse that he felt like he was going to pass out and reported nausea. R19 was pale and cool to the touch. R19 was admitted to the hospital for diarrhea and hypotension. R6's clinical record lacked evidence that the Ombudsman was notified of the hospital transfer. R19's Progress Note dated 03/19/25 at 02:06 PM documented R19 was readmitted into the facility. On 06/24/25 at 03:45 PM, R19 sat in his recliner and watched television. On 06/25/25 at 11:45 AM, Social Service X stated she had not notified the Ombudsman of the hospital transfer and had not been aware that she needed to do that when a resident went to the hospital. On 06/26/25 at 12:30 PM, Administrative Nurse D stated the ombudsman should be notified when a resident was transferred to the hospital and stated Social Service X did send a list of hospital transfers to the Ombudsman that morning. The facility's Transfer/Discharge policy, dated 10/01/96, documented, the community would provide and document sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the community. This orientation would be provided in a form and manner that the resident could understand. The resident/responsible party would be notified in writing of all discharges or transfers thirty (30) days before the transfer, unless the resident's medical condition warrants immediate transfer. A notice of the transfer was sent to the State Ombudsman.

The facility had a census of 56 residents. The sample included 14 residents. Based on observation, interview, and record review, the facility failed to label Resident (R)158 and R37s' insulin (a hormone that lowers the level of glucose in the blood) flex pens when initially opened for use and when expired. This deficient practice placed the affected residents at risk for ineffective medications. Findings included: - On [DATE] at 08:05 AM, observation of R158's medication cabinet located on the wall in his room revealed R158's Tresiba (long-acting insulin) flex pen was not labeled with an opened date or an expired date. On [DATE] at 08:15 AM, License Nurse H verified that the nurses should label and date the insulin flex pens with the date opened. On [DATE] at 10:00 AM, Administrative Nurse D verified that the nurse should label and date the insulin flex pens with the date opened. Medlineplus.gov directs that open, unrefrigerated Tresiba can be used within 56 days; after that time, they must be discarded. The facility's Medication Storage policy, dated [DATE], documented medications and biologicals are stored safely, securely, and properly following the manufacturer's recommendations or those of the supplier. Medications are accessible only to licensed nurses, pharmacy personnel, or staff members lawfully authorized to administer medications. Medications are labeled for individual residents and stored separately from floor stock medications when not in the medication cart.- On [DATE] at 08:00 AM, observation in R37's room medication cabinet, one - On [DATE] at 08:00 AM, observation in R37's room medication cabinet, one Insulin Glargine (long-acting) insulin pen lacked an open and discard date. On [DATE] at 08:05 AM, Licensed Nurse (LN) G verified the above findings and stated staff should place an open date on insulin pens when they open a new one. On [DATE] at 12:30 PM, Administrative Nurse D stated she expected staff to place an open date on an insulin pen when they open a new one. The facility's Medication Storage policy, reviewed [DATE], documented that medications and biologicals are stored safely, securely, and properly following manufacturers' recommendations or those of the supplier. Medications are accessible only to licensed nurses, pharmacy personnel, or staff members lawfully authorized to administer medications. Medications are labeled for individual residents and stored separately from floor stock medications when not in the medication cart.

The facility had a census of 56 residents. The sample included 15 residents. Based on observation, interview, and record review, the facility failed to ensure staff used Enhanced Barrier Precautions (EBP) when providing care with close contact to residents with an open wound or an indwelling device. This deficient practice placed all residents at risk for infection. Findings included: - Resident (R) 40's Electronic Medical Record documented diagnoses of Parkinson's Disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), and obesity (excessive body fat). The admission Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. The MDS documented R40 required moderate staff assistance for toileting, dressing, and mobility. R40 had no skin issues. The Pressure Ulcer Care Area Assessment (CAA), dated 06/04/25, documented R40 had shearing (the separation of skin layers caused by friction or trauma) to his bottom and an open area to his right lower leg. The Skin Care Plan, dated 05/29/25, documented R40 had an actual impairment to his skin integrity of the bottom related to shearing to bottom. The care plan updates initiated 06/01/2025 directed staff to remove the old dressing, cleanse the area to the left buttock with wound cleanser, and pat dry. Apply Aquacel Ag, cover with a foam dressing, change every three days, and as needed (PRN). Provide a pressure-relieving cushion to protect the skin while up in a chair, pressure relieving mattress to protect the skin while in bed, and Prostat (ready-to-drink concentrated liquid protein) daily for wound healing, 30 cubic centimeters (cc) daily. Resident (R) 40 was admitted to the facility on [DATE] with an area of shearing to his left buttock, which measured 3.58 centimeters (cm) by 3.27 cm. The treatment included cleansing the left buttock area with wound cleanser and patting dry, applying Aquacel Ag (hydrofiber dressing with ionic silver to manage and prevent wound infections), cover with a foam dressing, and change every three days and as needed (PRN). The Skin/Wound Assessment Note, dated 06/20/25, documented R40 continued with areas to his left buttocks with slight serosanguineous (thin watery fluid that is a mix of serous fluid and blood) drainage. On 06/24/25 at 03:50 PM, observation revealed R40 in his recliner. Licensed Nurse (LN) J brought wound dressing supplies to his room, washed his hands, and gloved. LN J and Certified Nurse Aide (CNA) M did not don a gown for EBP precautions. LN J and CNA M assisted R40 to stand with a gait belt and walker, and they toileted him. After providing incontinent care, they assisted him to bed. LN J cleansed the open wound approximately 1 cm by 0.3 cm on his left buttock. LN J applied a 1 x 1 inch square of Aquacel AG dressing to the open area, then a large foam Aquacel dressing to cover both buttocks. On 06/25/25 at 10:39 AM, CNA M and CNA N assisted R40 to the toilet without first donning EBP gowns. LN I came in to change the buttocks dressing without an EBP gown and left to get gowns. Administrative Nurse D came back with her and stated that since the resident had reported the issue on his buttocks to be a skin tear from a scratch, she did not feel that it met the criteria for EBP. On 06/25/25 at 12:39 PM, CNA N and CMA S attempted to assist 40 from his recliner to his wheelchair without wearing EBP gowns. When he was unable to stand well, they placed him back in the recliner. A 1 x 2-inch sign on his door frame stated EBP, and there was a small cart just outside his room with EBP supplies. Staff did not wear EBP for the transfers. On 06/25/25 at 10:10 AM, Administrative Nurse D verified that staff should don an EBP gown and gloves for wound care of an open wound. The facility's Infection Control policy, dated 02/03/2025, stated Enhanced Barrier Precautions (EBP) would be used in conjunction with standard precautions and expand the use of PPE to include donning of gown and gloves during high contact resident care activities that provide opportunities for transfer of infections to staff hands or clothing. EBP was indicated for residents with wounds or indwelling medical devices, even if not known to be infected. Wounds generally included chronic wounds (not skin breaks or tears covered by a Band-Aid or similar dressing. - R159's Electronic Medical Record (EMR) recorded diagnoses of hypertension (HTN- elevated blood pressure), urinary tract infection (UTI- an infection in any part of the urinary system), and gout (inflammation of the joints). R159's EMR documented, the resident was admitted to the facility on [DATE] R159's Care Plan dated 06/20/25, documented the resident had an indwelling urinary catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid). R159's EMR lacked a Physician Order for the Foley catheter. On 06/24/25 at 12:00 PM, observation revealed R159 at the dining room table in a wheelchair, continued observation revealed R159 had capri pants on with a urinary drainage leg bag secured to her right calf, half full of yellow urine. Observation revealed eight residents in the dining room and three staff members with residents, staff, and visitors walking down the Grand Central Station Hall open to the dining room. On 06/24/25 at 12:40 PM, observation revealed two physical therapy staff assisting the resident from the bed to the wheelchair. Continued observation revealed that therapy did not don gloves or a gown during the resident transfer. On 06/25/25 at 09:00 AM, Administrative Nurse D verified the staff should wear Personal Protective Equipment (PPE) for Enhanced Barrier Protection (EBP) when providing cares for R16. They verified they had the PPE equipment outside of the resident's room but lacked a sign to designate who should wear PPE and when. Administrative Nurse D verified they would go and do some education with the staff in regard to the EBP and wearing PPE for the resident's care. Administrative Nurse D verified she would post the necessary signage in the resident's room regarding the use of the PPE for a resident on EBP. The facility's Infection Control policy, dated 05/15/24, documented the facility would facilitate safe care of all residents and staff with gown or suspected communicable disease by establishing and maintaining an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The Infection Preventionist, Director of Nursing, is responsible for overseeing the Infection Control program, including but not limited to surveillance of infections and tracking and trending infections in the community. The facility will have Enhanced Barrier Precautions (EBP), which refers to an infection control intervention designed to reduce transmission of multi-resistant organisms that employs targeted gown and gloves used during high contact resident care activities. EBP are used in conjunction with standard precautions and expand the use of PPE to include donning of gowns and gloves during high contact resident care activities that provide an opportunity for transfer of MDROs to staff hands and clothing. EBP was indicated for residents with any of the following: Infection or colonized with a CDC-targeted MDRO, and Contact Precautions do not otherwise apply; or wounds and/or indwelling medical devices, even if the resident is not known to be infected or colonized with an MDRO. Indwelling medical device examples include central lines, urinary catheters, and feeding tubes. Enhanced Barrier Precautions include gloves and gowns to be worn when entering the room, and to wash hands with antimicrobial soap or alcohol-based gel before entering and after leaving the room. Trash and linens will be double bagged at the resident's door, and linens will be double bagged into a color-coded bag. The person on the outside of the door must wear a gown, gloves, and a mask.

The facility had a census of 56 residents. The sample included 15 residents, with six reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to monitor physician-ordered blood pressures for one resident, Resident (R) 19, which placed the resident at risk for adverse effects related to medication and physical decline. Findings included: - The Electronic Medical Record (EMR) for R19 documented diagnoses of hypertensive chronic kidney disease (a long-term condition characterized by the gradual and progressive loss of kidney function over time) stage four, dementia (a progressive mental disorder characterized by failing memory and confusion), chronic obstructive pulmonary disease (COPD - a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), and atrial fibrillation (rapid, irregular heartbeat). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R19 had moderately impaired cognition. R19 required partial staff assistance for toileting hygiene, transfers, ambulation, and dressing. R19 received antipsychotic (a class of medication used to treat major mental conditions that cause a break from reality), antidepressant (a class of medication used to treat mood disorders), diuretic (a medication to promote the formation and secretion of urine), and opioid (a class of controlled drugs used to treat pain) medications daily. R19's Care Plan, dated 05/08/25, initiated on 09/03/24, documented R19 received medications with a Black Box Warning (BBW - the highest safety-related warning that medications can have assigned by the Food and Drug Administration). The care plan directed staff to monitor R19's pulse (a rhythmical throbbing of the arteries as blood is propelled through them, typically as felt in the wrists or neck) and blood pressure (the amount of force your blood uses to get through your arteries). The Physician's Order, dated 03/26/25, directed staff to administer metoprolol (an antihypertensive medication), 25 milligrams (mg), by mouth, twice per day. Call the physician if Systolic Blood Pressure (SBP - the top number, the force your heart exerts on the walls of your arteries each time it beats) was less than 90 millimeters of mercury (mmHg). The Blood Pressure Record for May 2025 documented 55 out of 62 opportunities; R19's blood pressure was not obtained as ordered by the physician. The Blood Pressure Record for June 2025 documented 38 out of 50 opportunities; R19's blood pressure was not obtained as ordered by the physician. On 06/25/25 at 07:50 AM, Certified Medication Aide (CMA) T administered R19's medications without issue. CMA T stated R19's blood pressure had been obtained by Licensed Nurse (LN) G, and it was within the parameters. On 06/26/25 at 10:30 AM, LN G stated she would obtain the blood pressure first thing in the morning and would document the information into the computer later in the day. LN G verified that there were days when blood pressures for R19 were not documented in the computer, so she was not sure if the blood pressure was taken. On 06/26/25 at 08:15 AM, Administrative Nurse D stated staff were supposed to obtain the blood pressure twice per day. Administrative Nurse D stated she would fix the order in the Medication Administration Record (MAR) to have a space for staff to enter the blood pressure reading before medication administration. The facility's Medication Administration policy, dated 03/15/22, documented, medications are administered as prescribed by good nursing principles and practices and only by a person legally authorized to do so. It was the responsibility of the nursing professional to be aware of the clinical rationale for the medication, classification, action, correct dosage, and side effects of medication before administration and to monitor to determine if there is progress toward goals and/or emergence of adverse consequences. A primary care provider (PCP) order that included dosage route, frequency, duration, and other required considerations was required for the administration of medication.

The facility had a census of 56 residents. The sample included 14 residents, with one reviewed for dignity. Based on observation, record review, and interview, the facility failed to provide dignity and quality of life for Resident (R) 159, by having an uncovered urinary collection leg bag visible to guests and other residents. This placed the residents at risk for embarrassment and an undignified living environment. Findings included: - R159's Electronic Medical Record (EMR) recorded diagnoses of hypertension (HTN - elevated blood pressure), urinary tract infection (UTI - an infection in any part of the urinary system), and gout (inflammation of the joints.) R159's EMR documented, the resident was admitted to the facility on [DATE]. R159's Care Plan dated 06/20/25, documented the resident had an indwelling urinary catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid). R159's EMR lacked a Physician Order for the Foley catheter. On 06/24/25 at 12:00 PM, observation revealed R 159 at the dining room table in a wheelchair. Continued observation revealed R159 had capri pants on with a urinary drainage leg bag secured to her right calf-half full of yellow urine. Observation revealed eight residents in the dining room and three staff members with residents, staff, and visitors walking down the Grand Central Station Hall, open to the dining room. On 06/24/25 at 01:00 PM, Administrative Nurse D stated the resident's urinary catheter bag should always be covered. The facility's Catheter Care-Urinary Foley policy, dated 02/03/25, documented catheter care would be performed appropriately by qualified nursing staff to prevent complications caused by the presence of an indwelling urethral catheter. The staff would provide privacy and explain the procedure to the resident, and if applicable, teach the resident his or her role in caring for the catheter. The staff would identify bags and collection units with the resident's name. The policy documented the collection bag must be stationed below the level of the bladder, off the floor to prevent infection, and covered to preserve the dignity of the resident.

The facility identified a census of 56 residents with three residents reviewed for abuse and neglect. Based on record review, observation, and interview, the facility failed to ensure Resident (R) 1, R2, and R3 remained free from abuse. On 12/17/24 at 05:00 AM, Licensed Nurse (LN) G and Certified Nurse Aide (CNA) N received a report from R1 that CNA M had shoved her hard into the wall when turning to change her and slapped her buttocks. During the night shift, LN G removed CNA M from another hall, due to the mistreatment of R2 and R3. R2 stated CNA M would not listen to her about a transfer and hurt her arm during the transfer, which caused her to have tremors. R3 stated that CNA M came into his room, throwing and slamming things around, and would not provide him assistance to the bathroom. This deficient practice placed R1, R2, and R3 at risk for negative psychosocial impact including fear, anxiety, and neglect. Findings included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) disorder, psychosis (any major mental disorder characterized by a gross impairment in reality perception), and obsessive-compulsive disorder (anxiety disorder characterized by recurrent and persistent thoughts, ideas and feelings of obsessions severe to cause marked distress, consume considerable time or significantly interfere with the resident's occupational, social or interpersonal functioning). The Annual Minimum Data Set (MDS) dated [DATE], documented R1 had a Brief Interview for Mental Status score of 12, which indicated moderately impaired cognition. The MDS documented R1 required moderate to substantial staff assistance for all activities of daily living (ADL), was frequently incontinent of urine and occasionally incontinent of bowel, and lacked documentation of behaviors. The Functional Abilities Care Area Assessment (CAA), dated 11/25/24 documented R1 required assistance with all ADLs, except eating. The CAA documented R1 could make her needs known. The Urinary Incontinence CAA, dated 11/25/24, documented R1 was frequently incontinent of bladder and required assistance to the toilet, required check and change at night, and needed assistance with peri care and moisture barrier protectant. The Care Plan documented R1 could be interviewed and could respond verbally (08/26/24). The care plan documented R1 required assistance with toileting, bathing, ambulation, transfers, locomotion, and transfers (08/26/24). The care plan included R1 used incontinence products and staff needed to ensure the incontinence products were on appropriately and changed when soiled (08/26/24). R2's EMR documented R2 had diagnoses of chronic pain, chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), presence of artificial right knee joint, presence of artificial left knee joint, and osteoporosis (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk). The Admission MDS, dated [DATE], documented R2 had a BIMS score of 13 which indicated intact cognition. The MDS documented R2 required moderate to maximum assistance with her ADLs. The MDS lacked any documentation of behaviors. The Functional Abilities CAA, dated 11/25/24, documented R2 had weakness and was unable to care for herself. R2 required assistance with ADLs. The Care Plan documented R2 had depression related to a new move to health care from her independent apartment and directed staff to encourage and provide R2 with opportunities for exercise, and physical activity. R2 preferred to remain in her room with her legs elevated in her recliner and watch TV. (11/25/24) The care plan lacked any documentation or directives regarding R2's ADLs or preferences. R3's EMR documented R3 had diagnoses of acute kidney failure (inability of the kidneys to excrete wastes, concentrate urine, and conserve electrolytes), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), and atrial fibrillation (fast, irregular heartbeat). The Admission MDS, dated [DATE], documented R3 had a BIMS score of 13 which indicated intact cognition. The MDS documented R3 required substantial staff assistance for his ADLs. The MDS lacked any documentation of behaviors. The Care Plan directed staff R3 required one to two staff assistance for his ADLs. The care plan documented R3 was a short-term placement and planned on returning home after his stay. (11/26/24) The EMR for R1, R2, and R3 lacked any progress notes regarding the incident on 12/17/24. The Facility Incident Report, dated 12/31/24 (14 days after the incident), documented on 12/17/24 at approximately 05:00 AM, R1 reported to LN G that CNA M had hit her bottom while assisting R1 with incontinent care in bed through the night. R1 stated CNA M just pushed me hard against the wall as she swatted me wanting me to turn. Please don't say anything to her. LN G reported she performed an immediate skin examination and did not find any type of redness or bruising. LN G reported the situation to Administrative Nurse D. Administrative Nurse D examined R1 after her shower and revealed no visible signs of being hit or swatted. R1 did have a chem strip completed and was noted to have symptoms of a urinary tract infection. CNA M was immediately removed from the schedule and informed she was suspended. Administrative Nurse D conducted interviews with eight other residents. Six of those residents reported no concerns. Two residents reported concerns. The first reported concern, from R2, stated CNA M had come in to assist her to the toilet. R2 tried to explain to CNA M how she would like to be transferred, and R1 reported CNA M tried to pull her hard from the left side, while stating I am not going to sacrifice my back, during the transfer. R2 reported CNA M pulled from the wrong side and caused her to have knee pain and spasms. R2 reported CNA M was being mean to her and raised her voice. R2 voiced that she did not want CNA M to provide care to her in the future. The second concern was from R3. R3 reported he had the opportunity to be cared for by CNA M on two separate occasions. On one occasion, CNA M came into his room, did not turn the lights on, demonstrated erratic behavior, slammed things around in his room, and did not appear right. R3 reported he asked CNA M if he could help her with anything and CNA M was flippant with him. CNA M then refused to provide R3 assistance to the bathroom because he didn't need to go to the bathroom. R3 tried to explain to CNA M he no longer had a catheter and CNA M again refused and walked out of the room leaving R3 to transfer himself to the bathroom. R3 stated when CNA M came back to his room, R3 told CNA M to get out of his room and not come back. R3 stated he did not want CNA M to provide care to him. CNA M's Witness Statement, dated 12/17/24, documented R1 turned on her call light at about 05:45 AM. CNA M went to R1's room and gathered supplies to change R1's brief. CNA M stated she changed R1's brief and provided peri care. R1 then told CNA M she wanted to get up for the day. CNA M stated she informed R1 that she would need help to transfer R1 and she would need to wait. CNA M stated R1 was upset CNA M could not get her up by herself or get someone right away to help with the transfer. CNA M stated she informed R1 she would get help and walked out the door, partially shutting the door, as R1 wanted to remain uncovered to get up for the day. LN G's Notarized Witness Statement, dated 12/30/24 (13 days after the incident), documented on 12/17/24 LN G had removed CNA M off of the hall CNA M had been assigned, due to R2's complaint regarding CNA M hurting her arm during a transfer. Knowing several residents did not want CNA M in their rooms, LN G stated she decided to move CNA M to another hall. On 12/17/24 at 05:00 AM, LN G entered R1's room to administer her 05:00 AM medication. R1 told LN G That girl hit me. R1 stated the girl [CNA M] was trying to get her up and rolled R1 over, and was pushing on R1's hip quite hard. R1 stated she told CNA M to leave and CNA M said, Fine, and hit R1. LN G asked R1 where CNA M had hit her and R1 stated My butt. LN G reported the incident to Administrative Nurse D. CNA N's Notarized Witness Statement, dated 12/31/24 (14 days after the incident), documented R1 was yelling for help. CNA N went into R1's room and R1 was uncovered with her brief halfway pulled on and her bottom still not cleaned. CNA N asked R1 what she could do to help, and R1 stated, Look how I was left. R1 proceeded to tell CNA N she had not had a good morning so far and the aide that was helping her had been rough and had hit her on the bottom. CNA N stated she helped R1 get dressed and comfortable and then reported the situation to the nurse. During an observation on 01/15/24 at 10:30 AM, R1 sat in her wheelchair in her bathroom. R1 was going to wash her hands after participating in the activity. R1 was dressed and groomed neatly. R2 was unavailable for observation due to hospitalization . During an observation on 01/15/24 at 11:00 AM, R3 walked out of his bathroom with his walker, went to his lift recliner, and sat down. R3 was neatly dressed and groomed. During an interview on 01/15/24 at 10:30 AM, R1 stated she remembered CNA M hitting her bottom very well. R1 became teary-eyed and stated she had feared CNA M when the incident happened. R1 stated she had been told CNA M would never take care of her again. R1 stated she never had anyone treat her so poorly in her life. R1 stated she had not had any other problems with staff. During an interview on 01/15/24 at 10:45 AM, CNA N stated she was the one to initially find R1 the morning of 12/17/24. CNA N stated when she walked into R1's room R1 was completely uncovered with her brief half off and her buttocks covered in BM. CNA N stated R1 was visibly upset and told her CNA M had smacked her butt and just left her like this. CNA N stated R1 did not want to get CNA M in trouble and CNA N assured R1 she should not have been treated that way. CNA N stated she had received re-education regarding abuse and neglect. During an interview on 01/15/24 at 11:00 AM, R3 stated CNA M had really upset him. R3 stated he felt unsafe with CNA M in his room and that is why he asked her to leave and not come back. R3 stated he thought CNA M was on something because her behavior was so erratic. R3 stated people like CNA M should not be in healthcare taking care of people because he was able to stand up for himself, but others might not be able to do the same. On 01/15/24 at 11:30 AM, Administrative Nurse D stated during the investigation, and with three residents revealing CNA M had treated them badly in some way or another, there was no disputing the incidents had occurred. Administrative Nurse D stated she expected all staff working at the facility to understand and follow the ANE [Abuse, Neglect, and Exploitation] policy and treat residents with dignity and respect. Administrative Nurse D stated she happened to come in early that morning and LN G informed her of what was reported. Administrative Nurse D stated she went directly to the shower, where R1 was, and examined her skin and did not find any marks or bruises. Administrative Nurse D stated she then went to the service corridor to wait for CNA M to come back in the facility from taking trash out and then Administrative Nurse D accompanied CNA M to her office and had her fill out witness statements, suspended her pending investigation, and after the investigation terminated CNA M. The facility's ANE: Abuse Prevention, Intervention, Reporting, and Investigation - Staff Treatment of Residents Policy, revised 10/11/21, documented that Residents had the right to be free from verbal sexual, and mental abuse, corporal punishment, exploitation, and involuntary seclusion. It is the responsibility of the employees to promptly report to the community management any occurrence or suspected occurrence of neglect or resident abuse from other residents, staff, family, or visitors including injuries of unknown source and theft or misappropriation of resident property. Staff are mandated reporters and must comply with state and federal regulations regarding reporting suspected occurrences of neglect or resident abuse or unauthorized photographs or video recordings. All reports of ANE are promptly and thoroughly investigated by community management. Employees will receive training regarding abuse, neglect, protection of resident privacy, and misappropriation of resident property at initial orientation and at least annually. Prevention measures will be in place which provide residents, families, and staff related to reporting and handling concerns and grievances. Prevention will include identifying, correcting, and/or intervening in situations in which abuse and neglect are likely to occur. The resident will be protected from harm during the investigation. On 01/14/25 at 01:30 PM, Administrative Staff A and Administrative Nurse D were provided a copy of the IJ template and notified of the facility failure to ensure R1, R2, and R3 remained free from abuse from CNA M, which placed the residents in immediate jeopardy. The facility identified and implemented the following corrective measures provided education to all staff regarding Abuse, Neglect, and Exploitation on 12/17/24. Head-to-toe assessment completed on R1 without any signs of redness or bruising noted. All three residents were placed on monitoring for signs of psychosocial concerns. Interviews were completed with all other alert and oriented residents regarding any concerns with safety in the facility. The surveyor verified the implemented corrective actions on 01/15/25 at 01:00 PM. Due to the facility's corrective actions completed prior to the surveyor's arrival onsite, the deficient practice was deemed past non-compliance at a J scope and severity following removal of the immediacy.

The facility identified a census of 58 residents with three residents reviewed for accidents and hazards. Based on record review, observation, and interview, the facility failed to identify risk for burns and provide adequate supervision to prevent accidental hot liquid burns for Resident (R) 1 and R2. On 10/07/24 at approximately 12:30 PM, R1 ate lunch in the dining room. R1 required staff assistance with eating and drinking. R1 took the plastic wrap off the coffee on his tray, lifted it towards his mouth, and lost control of the coffee cup, spilling hot coffee on his right thigh. R1 sustained a second-degree burn (potentially painful burn that affects the first and second layers of the skin) to his right thigh. On 12/03/24 at approximately 05:30 PM, Student Certified Nurse's Aide (CNA) GG took R2's supper tray to R2's room and placed the tray on the bedside table. Student CNA GG attempted to adjust the height of the bedside table and instead pressed the latch that tilted the bedside table, causing hot tomato soup and hot coffee to land on R2's left thigh causing a burn to R2's left thigh. These deficient practices placed R1 and R2 at risk for injury, pain, and delayed healing. Findings included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses of hemiplegia (paralysis of one side of the body) and hemiparesis (muscular weakness of one half of the body) after cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain) affecting his non-dominant left side, calcific tendonitis (a painful condition that occurs when calcium deposits build up in the tendons, usually in the shoulder and causes inflammation, pain and limited range of motion in the joint) of his right shoulder, and rheumatoid arthritis (chronic inflammatory disease that affected joints and other organ systems). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R1 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated moderately impaired cognition. The MDS documented R1 required substantial assistance from staff for dressing, toileting, bathing, and bed mobility. R1 was dependent on staff for all transfers. R1 required moderate staff assistance for eating, oral care, and personal hygiene. The MDS incorrectly documented R1 did not have any first or second-degree burns. The Activity of Daily Living (ADL) Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 09/06/24, documented R1 had a diagnosis of hemiplegia and calcific tendonitis of his right shoulder. The CAA documented R1 required partial to substantial assistance with his activities of daily living (ADLs). The Nutritional Status CAA, dated 09/06/24, documented R1 was on a mechanical soft, nectar-thickened liquid diet. R1's intakes had decreased. Staff attempted to give R1 thin liquids and R1 coughed and choked. The CAA documented R1 required assistance with eating. R1's Care Plan documented R1 had a self-care deficit and required assistance with ADLs such as repositioning, toileting, bathing, transfer, and locomotion (09/09/24). The care plan documented R1 was on a regular diet with thin liquids and high protein (10/01/24). After the hot liquid spill, R1's Care Plan was updated, and it documented R1 preferred to use a lid on his coffee due to R1's decrease in hand dexterity (10/07/24). The care plan directed staff to ensure a lid was present on R1's hot liquids at all times due to poor hand dexterity (10/07/24). The care plan documented R1 had a blister on his right groin area (10/07/24). The care plan directed staff to cleanse the blister to R1's inner thigh with wound cleanser, apply Aquacel (anti-bacterial dressing) to the wound bed, cover it with a foam dressing, and change the dressing every other day and as needed until healed (10/23/24). The Nursing Note, dated 08/12/24, documented R1 readmitted to the facility after suffering a hemorrhagic stroke. R1 required extensive assistance from two staff with a gait belt for transfers and toileting. R1 was on a regular diet with nectar-thickened liquids. R1 was unable to have conversations but was able to answer yes or no. R1 had generalized weakness, bilaterally. The Nursing Note, dated 08/12/24 documented R1 required a mechanical soft diet with nectar-thickened liquids due to having difficulty taking medication with regular water and pocketing food at dinner. The Social Service Note, dated 08/13/24, documented R1 readmitted yesterday from the hospital post-hemorrhagic stroke. R1 was unable to converse but could say yes or no. R1 required assistance with meals. Staff had to crush R1's medications due to swallowing issues. The Nursing Note, dated 08/13/24, documented R1 required help in the dining room and needed assistance with meals. R1 was unable to complete full sentences. R1 was able to follow verbal cues. The Nursing Note, dated 08/13/24, documented R1 ate 50% of his meals that shift. The CNA stated R1 was talking gibberish while the CNA assisted him with his meal. R1 was not having difficulty eating a mechanical soft diet with nectar-thickened liquids. The Nursing Note, dated 08/14/24, documented R1 was being monitored post-hemorrhagic stroke. R1 had been up for meals and was fed all meals by staff. R1 refused to help with feeding or drinking. The Nursing Note, dated 08/21/24, documented R1 ate his meal in his room with assistance from staff. R1 appeared to be coughing often while eating. R1 ate 25% of his meal. The Nursing Note, dated 08/24/24, documented R1 came out of his room for meals. R1 needed some assistance with eating. The Health Status Note, dated 10/07/24, documented R1 spilled coffee in his lap at lunch. Staff cleaned R1 and noted there was mild redness on his thighs. R1 had no complaints of pain or discomfort. The Skin Alteration/Injury Report, dated 10/07/24, documented dietary staff in the dining room notified Licensed Nurse (LN) LN G around 12:45 PM, during lunch, R1 spilled coffee in his lap. R1 had finished eating and was taken to his room where his clothes were removed, and he was placed in bed. R1's skin was cleansed, patted dry, barrier cream was applied, and then the area was left open to air. There was mild redness present on R1's right inner thigh before the end of the shift. R1 had no comment on the incident but did deny pain. The Skin/Wound Noted, dated 10/08/24, documented R1 had a blistered area on his right upper thigh close to the groin. Measurements of the blistered area were 11.7 centimeters (cm) by 2.7 cm. Staff applied Skin-Prep (liquid skin protectant) and covered it with a foam dressing. The Health Status Note, dated 10/08/24, documented staff notified R1's primary care physician's nurse of the blister to R1's right inner thigh related to his spilling coffee the previous day at lunch. The current plan was to apply Skin-prep every shift and may apply a foam dressing for protection. The nurse stated she would let R1's primary care physician know and would call if he had any other recommendations. The Health Status Note, dated 10/09/24, documented therapy was contacted and asked if they could work with R1 on dexterity such as holding cups at meals related to his issue of spilling coffee earlier that week. The Skin/Wound Note, dated 10/13/24, documented the blister to R1's right inner thigh was assessed and noted the previous foam dressing was soiled. The previous dressing was removed and a small amount of serous (clear) drainage was noted. No odor or signs or symptoms of infections were noted. The lower part of the blister no longer had skin covering it and was open. The open area measured 4.2 cm by 1.5 cm. There was still a closed area to the upper part of the blister and Skin-prep was applied to the closed area. The open area was cleansed, patted dry, triple antibiotic ointment applied, and covered with a foam dressing. The Health Status Note, dated 10/14/24, documented a fax was sent to R1's primary care physician that the blister on R1's right thigh had opened, and staff were waiting on new orders. The Health Status Note, dated 10/15/24, documented R1 continued to receive outpatient speech therapy. R1 used lids on his cups but did not like the lids. The Health Status Note, dated 10/16/24, documented orders were received to continue the current treatment of applying triple antibiotic ointment to the open area on R1's thigh, Skin-prep the intact area, and cover with a foam dressing. R1's October 2024 Treatment Administration Record (TAR), documented an order for facility staff to apply Skin-prep (liquid skin protectant) to R1's right inner thigh blister every shift. Let dry. May apply foam dressing for protection. Staff were to monitor for signs and symptoms of infection and discontinue the treatments when healed. The start date was 10/08/24. The October 2024 TAR, documented a new order directing facility staff to cleanse R1's right inner thigh wound with wound cleanser, apply Aquacel to small area with drainage, apply a foam dressing, and change the dressing every other day and as needed until healed. The start date was 10/25/24. R1's Hot Liquids Assessment, (not completed until after the event on 10/18/24), documented R1 drank hot liquids, had a burn or a hot liquid spill in the last year, R1 had a neurological disease that affected his functioning, had a loss of hand or arm function, and R1 had weakness in his dominant hand or arm. The Hot Liquid risk score for R1 was sixteen, which indicated R1 was a high risk for hot liquids. The Facility Incident Report, dated 10/30/24, documented on the afternoon of 10/07/24 at approximately 12:45 PM, R1 was seated in his wheelchair at his table when the dietary staff assisted him with a cup of coffee. The cup was a standard cup that had a plastic wrap on top of the cup. R1 removed the plastic wrap and proceeded to take a sip. Dietary staff observed R1 lose his grip on the handle and spill the entire cup of coffee on his lap. Dietary staff immediately assisted R1 by attempting to absorb the liquid and requested a nurse. LN G immediately responded to the situation. LN G requested that R1 remove his clothing, which he declined, and the resident requested to stay in the dining room to finish his noon meal. Upon R1 finishing the meal, LN G assisted him back to his room, removed his pants, and noted a red area on the right inner thigh. R1 denied any pain at that time of the assessment. LN G updated R1's responsible party and R1's primary care physician about the incident. During the early morning hours of 10/08/24, the night shift nurse noted R1 had a fluid-filled blister to his right inner thigh/groin area. The area measured 11.7 cm by 2.7 cm. Staff cleansed the area with normal saline, applied Skin-prep, and covered it with a foam dressing to keep the fluid-filled blister intact. R1 was served coffee as usual from a carafe that had been prepared at least thirty minutes earlier. The coffee was not assessed for temperature at the time of the event because there was none [coffee] available. The coffee machine from the hospitality bar machine was checked later and the temperature was 138.7 degrees Fahrenheit (F). Coffee obtained from the kitchen measured 178.7 degrees F. The staff could not determine where the coffee filling the carafe was obtained. R1 insisted on continuing his meal following the spill which most likely contributed to the severity of the burn. R1 was provided a lidded coffee cup. Dietary staff were to check the temperature of the coffee carafe to ensure the temperature was below 140 degrees F. The staff received instructions and the care plan was updated. The facility incident report lacked witness statements. The November 2024 TAR, documented the continued order directing facility staff to cleanse R1's right inner thigh wound with wound cleanser, apply Aquacel to small area with drainage, apply a foam dressing, and change the dressing every other day and as needed until healed. R1's December 2024 TAR, documented the continued order directing facility staff to cleanse R1's right inner thigh wound with wound cleanser, apply Aquacel to small area with drainage, apply a foam dressing, and change the dressing every other day and as needed until healed. On 12/10/24 at 10:00 AM, observation revealed R1 sat in his wheelchair dressed for the day. R1 had his tray table beside him with a filled water pitcher on it. On 12/11/24 at 11:00 AM, observation revealed R1 lay in bed with his pants off. LN H and Administrative Nurse D performed R1's dressing change to his right inner thigh. The wound to R1's right inner thigh was approximately 3 cm by 0.5 cm and covered with eschar (dead tissue) with redness around the peri-wound (skin around the wound). R1 tolerated the treatment well. On 12/10/24 at 10:00 AM, R1 stated he did not remember spilling his coffee on his lap. R1 stated lids were used on his coffee cups. R1 could not answer when asked if his wound caused him pain he just stared straight ahead. On 12/10/24 at 10:30 AM, LN H stated that R1's burn to his right inner thigh was completely healed and the facility continued to perform the dressing change for prophylaxis. LN H stated she would not perform R1's dressing change until after he returned from his appointment. On 12/10/24 at 11:00 AM, LN H found the surveyor and stated she told the surveyor the wrong information about R1's right inner thigh wound, and the wound was not healed. LN H said she could perform the dressing change at that time before R1 went to his appointment. On 12/10/24 at 11:30 AM, CNA M stated R1 required assistance from staff for eating his meals at all times because of his continued weakness since his stroke. CNA M stated R1 required a lid on his coffee cup at all times. On 12/10/24 at 09:45 AM, Administrative Nurse D stated the coffee temperature that was served to R1 had not been checked before the coffee was served. Administrative Nurse D verified R1 required assistance with meals at times. The facility's Hot Beverage Service in Senior Dining, documented that coffee or hot beverages may be brewed in the dining rooms and offered to each resident with their meals. Licensed areas must serve hot beverages at no greater than 140 degrees F. Record the time that the coffee or hot beverage was brewed using the log provided. The temperature of the coffee or hot beverage should be taken using a clean and sanitized digital instant-read thermometer. Following the reading the thermometer should be wiped using alcohol wipes provided. If the temperature is above the required temperatures, allow it to cool for a while longer and check the temperature again. Record the temperature when the coffee or hot beverage has reached the appropriate temperature using the log provided. Once the temperature is appropriate based on the above guidelines, the coffee or hot beverage can be served. The facility failed to identify risk and implement appropriate interventions and assistance with eating to prevent a hot liquid spill and further failed to assess the temperature of hot liquids prior to serving to ensure safe temperatures which resulted in a second-degree burn for R1. This deficient practice also placed R1 at risk for pain and prolonged healing. - R2's Electronic Medical Record (EMR) documented R2 had diagnoses of peripheral vascular disease (PVD- slow and progressive circulation disorder causing narrowing, blockage, or spasms in a blood vessel), hypertension (high blood pressure), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R2 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS documented R2 required moderate staff assistance for bathing, bathing, dressing, and bed mobility. R2 was dependent on staff for all transfers and putting and taking off her footwear. The MDS documented R2 was independent for eating. The MDS documented R2 had no skin impairment. R2's Care Area Assessments (CAA), dated 12/18/23, lacked analysis. R2's Care Plan documented R2 ate in her room for all meals and was able to feed herself once the tray was delivered (08/22/24). R2 required assistance from one staff for bathing dressing and toileting, one to two staff for bed mobility, and assistance from two staff for transfers (08/22/24). The care plan documented R2 enjoyed tomato soup and liked to eat it several times a week (09/06/24). R2's Care Plan was updated after the incident and directed staff R2's primary care physician prescribed Silvadene (a topical antibiotic used in partial thickness and full thickness wounds to prevent infection) to treat the burn injuries to R2's left thigh. The plan directed staff to administer the ointment as prescribed and notify R2's primary care physician of any concerns. The care plan directed staff to monitor R2's burn injury sites to her left thigh every shift until healed (12/04/24). The Skin/Wound Note, dated 12/03/24, documented CNA N called Licensed Nurse (LN) I into R2's room during supper. CNA N stated that Student CNA GG had accidentally knocked over R2's table that had her coffee and tomato soup on it. The coffee and soup spilled on R2's legs, mostly landing on her left thigh. The area appeared red and had no blistering. CNA N, who had witnessed this, stated Student CNA GG took R2's supper into her room and was readjusting the height on her table. Instead of adjusting the height, Student CNA GG accidentally tilted the table, causing the tomato soup and coffee to spill. R2 stated, I have no idea what happened, it all happened so fast. It hurt so bad it brought tears to my eyes. I know it was an accident, so I hope she is not in trouble. Staff removed R2's clothing and cleaned the coffee and soup. LN I applied a cold washcloth and a towel-wrapped ice pack to the site. LN I completed a skin assessment and obtained vital signs. R2's vital signs were within normal limits for her. After the skin assessment was completed, R2 was dressed in clean, dry clothes. LN I notified the on-call nurse of what happened. Approximately an hour later, LN I and CMA R assisted R2 to the bathroom to reassess her left thigh. The area appeared to be less red and still had not blistered. LN I advised R2 to keep her pants off and R2 refused. LN I provided R2 education that the heat from her burn could be trapped by keeping the pants on and the pants rubbing against her skin could cause further irritation. Student CNA HH's Witness Statement, dated 12/03/24, documented Student CNA HH walked by R2's room and saw a cup of soup get spilled on R2's lap as the table tipped over toward her. R2 was in a lot of pain. The CNAs in the room at the time poured water over R2's legs. A family member of R2 asked for help so a charge nurse was called. The nurse went into R2's room and provided care. Student CNA GG's Witness Statement, dated 12/03/24, documented Student CNA GG gave R2 dinner. There were two mugs with liquids in them on the tray. Student CNA GG moved the tray closer to R2. The side lever was pushed to adjust the tray. The tray was stable. A few minutes later the tray tilted, and the mugs spilled off the tray. The mug with soup spilled on R2. R2's responsible party poured cold water on her lap immediately. Staff lifted R2 up and her wet pants were pulled down. The nurse was informed immediately and went into R2's room. The tray table was very unstable and wobbled when maneuvered. CNA N's Witness Statement, dated 12/03/24, documented Student CNA GG brought R2 tomato soup and coffee and went to adjust the height of the table but grabbed the wrong thing and tilted the table towards R2. The tomato soup and coffee spilled on R2's left upper thigh. The skin appeared red with no blisters on it. CNA N stated they removed R2's clothes to get the hot soup and coffee off her, dried her leg, and gave her a cool rag and ice pack. Staff then put dry clothes on R2. The staff took that tray out and brought in another tray that did not tilt. The Progress Note, dated 12/04/24, documented R2's left thigh was checked related to the coffee spill on 12/03/24. The note documented two raised welts and two red areas to R2's inner and top of the thigh. The sites were measured by Administrative Nurse D that morning. The Communication with Physician Note, dated 12/04/24, documented that staff placed a call to R2's primary care physician about getting an appointment for R2 to have her leg looked at related to a soup burn she received on 12/03/24 and asked to have a physician's assistant come in-house to see R2. The Skin Wound Note, dated 12/04/24, documented a skin assessment was completed to R2's left thigh post hot liquid spill. The note documented two reddened areas that were non-blanchable, and non-blistered. Site A measured 4 centimeters (cm) by 1.4 cm and site B measured 3.6 cm by 1.5 cm. There was no depth noted. The peri-wound (skin around the wound) was light pink without warmth. Staff updated R2's primary care physician and responsible party. The Communication with Physician Note, dated 12/04/24, documented R2's primary care physician wanted to see R2 via virtual medical appointment in the afternoon related to the burn site on her left thigh. The Health Status Note, dated 12/04/24, documented R2 had a virtual medical appointment with her primary care physician related to the burn on R2's left thigh. R2 received a new order for Silvadene external cream topically to the left thigh twice a day for ten days. The Administration Note, dated 12/05/24, documented the red area remained. R2 voiced no pain at the site during the assessment. R2 wore pants with no difficulties or irritation voiced. The Skin/Wound Note, dated 12/06/24, documented R2's old bedside table had been removed from R2's room and replaced with one that did not tilt related to the soup spill. R2's responsible party told the nurse she was putting the old bedside table back in R2's room because R2 did not like the new table and preferred her old table. The nurse educated R2's responsible party on the risks of having the old table with the tilt ability. R2's responsible party stated, She has had this one for a long time and it was never an issue. The nurse taped a sign over the tilt mechanism that stated, Do not adjust. The Facility Incident Report, dated 12/10/24, documented on 12/03/24 at 05:30 PM, LN I was called to R2's room by CNA N. CNA N stated Student CNA GG had taken R2's supper to her room and was readjusting the height on her bedside table. Instead of adjusting the height, Student CNA GG adjusted the tilt of the table accidentally causing R2's bedside table to tilt and spilled R2's coffee and tomato soup onto R2's legs; most of the spill landed on R2's left thigh. CNA N and Student CNA GG immediately assisted R2 in removing her pants, cleaned the liquids, and applied cool compresses to the site. The areas appeared red and had no blistering upon initial observation. Cool compresses remained in place through the evening over the next two hours. Assessments remained unchanged. After the skin assessment was completed, R2 was dressed in clean, dry clothes. At 06:19 PM, LN I and Certified Medication Aide (CMA) R assisted R2 to the bathroom and the areas appeared to be less red and had still not blistered. LN I advised R2 to keep her pants off to decrease discomfort and the potential for injury. R2 refused to allow her pants to be off and was redressed in her pants upon her request. On 12/04/24 at 07:30 AM, the exam revealed R2 had two reddened areas on her left thigh that were non-blanchable and non-blistered. The first site measured 4 cm by 1.4 cm. The second site measured 3.6 cm by 1.5 cm. The peri-wound was light pink with no warmth. R2 did not report pain in the areas. R2's primary care provider updated and ordered Silvadene cream twice a day and measured weekly until healed. R2 had no complaints and resumed her usual routine. On 12/10/24 at 10:15 AM, observation revealed R2 sat in her wheelchair, which was pushed up to her tray table and she was reading the paper. R2's tray table had a note over one of the levers that stated, Do Not Adjust. R2 pulled down the left side of her pants to show her burn sites. Observation revealed R2 had two burn sites that were dark pink on her left upper thigh. The first area measured approximately 4 cm by 0.6 cm and the second area measured approximately 4 cm by 0.7 cm. On 12/10/24 at 09:30 AM, Administrative Nurse D stated the facility had CNA students training on the day the accident happened. Administrative Nurse D stated Student CNA GG accidentally engaged the tilt function of R2's tray table and the soup and coffee had spilled on R2. Administrative Nurse D revealed Student CNA GG had warmed up R2's soup and coffee in the microwave in the dining room and had not assessed the temperature of the hot liquids for an appropriate temperature prior to serving. Administrative Nurse D stated all the microwaves in the three dining rooms had been removed and that from now on if any food or drink items needed to be warmed, the items would be taken to the kitchen for kitchen staff to warm the items and check temperature to make sure they were the appropriate temperature. Administrative Nurse D stated nursing staff had been educated regarding the new procedure. On 12/10/24 at 10:15 AM, R2 stated that when the student spilled the coffee and soup on her it hurt so bad. R2 stated she screamed in pain. R2 stated she knew it was an accident and the student did not mean for it to happen. R2 stated her left thigh hurt so bad that she had not been able to get a good night's sleep since the accident happened until last night and she was finally able to sleep. R2 stated they had taken her old tray table out of her room, but she did not like the new tray table, so her daughter went and got the old tray table back. R2 stated this tray table had a ledge around it that prevented her things from falling off her table. On 12/10/24 at 10:40 AM, LN J stated R2's left thigh burn sites were still red and the Silvadene was scheduled to be continued to be applied twice a day until 12/14/24. LN J stated she had not performed R2's treatment with Silvadene yet because she had been at a hair appointment. LN J said R2 had not reported any pain at her burn sites. The facility's Hot Beverage Service in Senior Dining, documented that coffee or hot beverages may be brewed in the dining rooms and offered to each resident with their meals. Licensed areas must serve hot beverages at no greater than 140 degrees F. Record the time that the coffee or hot beverage was brewed using the log provided. The temperature of the coffee or hot beverage should be taken using a clean and sanitized digital instant-read thermometer. Following the reading the thermometer should be wiped using alcohol wipes provided. If the temperature is above the required temperatures, allow it to cool for a while longer and check the temperature again. Record the temperature when the coffee or hot beverage has reached the appropriate temperature using the log provided. Once the temperature is appropriate based on the above guidelines, the coffee or hot beverage can be served. The facility failed to provide adequate supervision and failed to assess the temperature of hot liquids prior to serving to ensure safe temperatures to prevent R2 from sustaining a hot liquid burn. This deficient practice resulted in a burn which caused excruciating pain which impacted R2's ability to sleep and placed R2 at risk for ongoing pain and impaired psychosocial wellbeing. The facility completed corrective actions to correct the deficit practice, which were completed by 12/06/24. The actions included assessing R1's safety with hot liquids and updating his care plan accordingly to ensure he always received a lid on hot beverages. Dietary staff would assess the temperature of the coffee carafes to ensure temperatures were in the appropriate range. The microwaves were removed from the dining rooms and staff must take all food and beverages to the dietary staff for reheating so temperatures can be assessed and ensured in the appropriate range. R2's tray table was switched out then later returned at her request and marked for increased staff awareness regarding the tilt function. Staff received education on the new processes and accident prevention. Since all corrective actions were completed before the onsite survey, the deficient practice was deemed past noncompliance and remained at G to represent the actual harm to R1 and the psychosocial harm to R2.

The facility had a census of 57 residents. The sample included 15 residents. Based on observation, record review, and interview the facility failed to prepare food in accordance with professional standards for food service safety when staff used contaminated gloves to transfer food items from one container to another while preparing the four residents pureed diets, failed to use gloves when cutting and handling food items, and failed to ensure clean and sanitary food prep areas. This placed the residents at risk for foodborne illness. Findings included: - On 10/25/.23 at 10:15 AM, observation revealed, during preparation of the pureed diets, Dietary Staff (DS) BB washed hands, applied gloves, then touched the food prep counter (with food particles and clear liquid on it). DS BB then used her contaminated gloved right hand to transfer cooked, cubed carrots from a container to the blender container. Further observation revealed DS BB, with the same contaminated gloves, retrieved a four ounce scoop from the hanging utensil device, and placed it on the same food prep counter. After pureeing the carrots, DS BB picked up the scoop from the counter and used it to place the carrots onto four divided plates. Further observation revealed DS BB retrieved a spatula from a kitchen drawer, with the same contaminated gloves, placed it on the same contaminated food prep table, and used it to transfer pureed bread sticks, one at a time onto the four divided plates. Further observation revealed DS CC, working at the food prep table across from DS BB, handled and sliced ham with ungloved hands, then touched the counter, retrieved onions and sliced the onions with his contaminated ungloved hands. On 10/25/23 at 10:30 AM, DS BB verified the above observation regarding her actions and stated she should not have used her gloved hand to transfer food items from one container to another and probably should place the spatula and scoop on a plate. On 10/25/23 at 11:15 AM, Dietary Manager (DM) DD stated staff should not transfer food items with their gloved hands, they should use a utensil and should not place utensils on the counter should place them on a plate. DM DD verified DS CC touched the ham and onions with ungloved hands and stated DS CC should have used gloves. The facility's Use of Gloves Policy, revised 09/23, documented gloves must be worn when touching ready-to eat foods that would not be heated or processed further. Gloves should be changed when they become soiled or torn, when changing from one task to another, or after two hours of continuous use. The facility's Food Handling Principles Policy, revised 09/23, documented employees would be trained in safe food service techniques and personal hygiene on an annual basis or more often as needed. The facility kitchen staff failed to prepare food in accordance with professional standards for food service safety. This placed the 57 residents who received their meals from the facility kitchen at risk for foodborne illness. - On 10/25/23 at 10:30AM observation in the kitchen revealed the following: The wall behind the back of the oven hood had numerous different size streaks of brown substance running below. The oven hood front had brown substance, approximately two feet (ft) by 12 inches (in), located above the deep fat fryer. The seam between the back of the oven hood had approximately six ft with missing caulk. The sugar, flour, breadcrumbs, and oatmeal bins had numerous areas of different size blackish gray substance all around the outside of them. The trash cans had numerous areas of different size blackish gray substance on the outside of them. The two deep fat fryers had numerous different size streaks of blackish brown substance on the sides of them. The black counter toaster had numerous dried food particles on the top of it. On 10/25/23 at 11:00 am, DM DD verified the above findings and stated the dietary department had been short staffed and he had worked four 12- hour days in a row so staff had not cleaned the kitchen. The facility's Cleaning and Sanitizing of Work Surfaces Policy, revised 09/23, documented a cleaning schedule is completed and posted to ensure routine cleaning was completed weekly. Larger pieces of equipment and area are scheduled on a biweekly and monthly basis. The facility kitchen staff failed to prepare food in accordance with professional standards for food service safety. This placed the 57 residents who received their food from the facility kitchen at risk for foodborne illness.

The facility had a census of 57 residents. The sample included 15 residents. Based on observation, record review and interview, the facility failed to maintain a Quality Assessment and Assurance (QAA) Committee that met quarterly and had the required membership in attendance when the Medical Director (or designee) did not attend one quarterly meeting. This placed the residents at risk for decreased quality of care. Findings included: - The facility provided the signed QAA Committee attendance roster for 10/26/22, 01/18/23, 04/19/23, and 07/26/23. Review of the 01/18/23 roster revealed the Medical Director (or designee) did not attend. On 10/30/23 at 03:10 PM, Administrative Nurse F verified the Medical Director had not been present for the QAA meeting. The facility's Quality Assurance Performance Plan policy, dated 09/01/23, documented the Administration of [NAME] Presbyterian Manor develops and leads our program with input from staff at all levels, family members, community members and resident's themselves. It was formed a QAPI Steering Committee that meets quarterly composed of leaders from administration, leaders from the various service areas, Medical Director and Consultants. The facility failed to maintain a QAA Committee that met quarterly and had the required membership in attendance. This placed the residents at risk for decreased quality of care.

The facility had a census of 57 resident. The sample included 15 residents. Based on observation, record review, and interview, the facility failed to ensure licensed nursing staff had appropriate competencies and skill set to provide nursing related services to assure resident safety and to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This placed Resident (R) 40 at risk of injury during transfers and ongoing wound assessments and all residents at risk for decreased quality of care. Findings included: - The Facility assessment dated [DATE], documented the Interdisciplinary Team assessment was made considering the team members skill sets in regard to residents' acuity. Equipment along with specific staff education will be provided to meet a resident's need. Involvement of the Medical Director will be in place regarding the admission/continuing care assessment and discussion. On 10/30/23 at 11:05 AM, Administrative Nurse D provided three nursing staff competencies. One of the three did not have the competencies required. Administrative Nurse D reported the facility recognized this issue in 05/2023 and developed a form to complete the required task in 06/2023 but had not yet completed competencies for all the nursing staff. The facility's Staff Competency policy, dated 10/11/21, documented all staff will receive education and training applicable to their position and job description. Check lists, Relias courses and competency testing will be used to ensure staff are appropriately trained for position. The facility failed to ensure licensed staff had appropriate competencies and skill sets to provide nursing related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This placed all residents at risk for decreased quality of care. 32360 - The Electronic Medical Record (EMR) for R40 documented diagnoses of Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness), weakness, edema (swelling resulting from an excessive accumulation of fluid in the body tissues), hemiplegia (paralysis of one side of the body), other symptoms and signs with cognitive functions and awareness. The Admission Minimum Data Set (MDS), dated [DATE], documented R40 had intact cognition and required supervision and one staff assistance for transfers, ambulation, dressing, and toileting. The MDS further documented R40 had unsteady balance, no functional impairment, and had no skin issues. The Significant MDS, dated [DATE], documented R40 had severely impaired cognition and required extensive assistance of two staff for bed mobility, transfers, toileting, extensive assistance of one staff for dressing, ambulation in room, and personal hygiene. The MDS further documented R40 had unsteady balance, no functional impairment, and had no skin issues. R40's Care Plan dated 10/09/23, initiated on 06/06/23, directed staff to assist R40 with set up assistance with transferring, repositioning, toileting, and ambulation. The Fall Investigation, dated 10/19/23 at 12:25 AM, documented upon entering R40's bathroom, he was observed on the floor with his back towards the toiled seat. R40 stated a spider ran across his foot and he tried to get up and kill it, lost his balance, and fell , The staff assisted R40 off the floor, assessed him for injury, and transferred him into his recliner. The investigation documented staff were educated to offer/assist resident to use the bathroom between 12:00 AM and 4:00 AM, and a work order was placed to have resident's room checked for any spiders. The Skin Evaluation Record, dated 10/19/23 at 12:54 PM, documented a skin tear to R40's mid back which measured six centimeters (cm) x 2.5 cm and noted a treatment to cleanse the skin tear with normal saline or wound cleanser, pat dry, apply triple antibiotic ointment (TAO) if needed, cover with a dressing, and monitor skin every shift for infection until healed. On 10/26/23 at 12:54 PM, observation revealed a large skin tear in the middle of R40's back. The dressing came off and drainage from the wound seeped onto the back of R40's shirt. Further observation revealed Licensed Nurse (LN) G washed her hands, donned clean gloves, took gauze and cleansed the wound with normal saline, changed her gloves and placed a foam dressing on the wound. LN G stated she was the nurse that found the skin tear on the resident's back. LN G stated she thought R40 sustained the skin tear as a result of staff's use of a gait belt when staff transferred R40. LN G stated she planned to contact R40's physician to get the TAO discontinued as it was causing the skin tear to be too moist and delay healing. On 10/26/23 at 01:00 PM, Administrative Nurse F stated the skin tear happened after R40 fell . Three staff members used a gait belt to get R40 off the floor. The nurse on duty at the time did not see the wound as it did not bleed, and she had already completed a skin assessment prior to getting R40 off the floor. Administrative Nurse F further stated education was provided with all three staff on proper gait belt use after the incident, and to make sure the gait belt was secured properly, not too tight but not too lose as where it may move and cause injury. Administrative Nurse F said a heavy-duty gait belt with side handles had been ordered to use for R40's transfers. On 10/30/23 at 02:00 PM, Administrative Nurse D stated she had ordered a different gait belt for R40, and it would be more appropriate to use when he falls. Administrative Nurse D verified she had not visualized the wound to R40's back from the gait belt. The facility's Lifting and transferring resident policy, dated 10/25/23, documented, the facility would provide a safe work environment for resident care areas by providing and requiring the use of safety materials, equipment, and training designated to prevent injury. Nurse's assess and determine lifting and transfer requirements and the procedure used for each resident, all residents must be lifted or transferred according to the determined procedure. The facility failed to ensure staff possessed the required skill and knowledge to safely apply and use a gait belt for an assisted transfer. As a result, R40 sustained a large skin tear on his back. This also placed the resident at risk for further injuries or complications related to improper transfers and/or use of gait belt.

The facility had a census of 57 residents. Based on observation, record review, and interview the facility kitchen staff failed to provide food prepared by methods that conserve nutritive value, flavor and appearance, when dietary staff failed to follow a recipe while preparing four residents' pureed diets. This placed the affected residents at risk for impaired nutrition. Findings included: - On 10/25/23 at 10:15 AM, Dietary Staff (DS) BB, with Dietary Manager (DM) DD overlooking, stated the facility had four residents with pureed diets, and one received double portions. DS BB placed five square pieces of lasagna in a blender container, blended to a consistency of pudding, then placed unmeasured portions of lasgna onto four divided plates using a spatula. Observation revealed DS BB took the blender container and lid to the three-sink area, rinsed the blender, and placed the blender and lid through each section of the sink. DS BB returned to the prep table, placed unmeasured cubes of cooked carrots into the blender, blended to consistency of pudding, and placed onto the divided plate in a different section then lasagna. DS BB then used the same procedure to wash the blender and lid. DS BB placed a bread stick into the blender, added unmeasured amount of chicken broth, blended to consistency of pudding, and placed onto one of the divided plates; DS BB continued with the same procedure for the next four bread sticks. On 10/25/23 at 10:45AM, DS BB verified she had not followed a recipe and stated she was taught to go by the food consistency. On 10/25/23 at 11:15 AM, DS DD stated staff should follow a recipe when preparing residents pureed diet. The facility's Dysphagia (swallowing difficulty) and Puree (cooked food that is a smooth, creamy substance or thick liquid suspension) Creations Policy, undated, documented each employee associated with dietary, nursing and auxiliary staff needs to understand methods to improve the quality of life to which each resident was entitled, especially the resident with dysphagia. Producing sensory-appealing entrees can yield positive outcomes, such as improved quality of life, increased meal satisfaction and improved health status, for the resident with dysphagia. The facility kitchen staff failed to follow a recipe when preparing four residents' pureed diet. This placed the affected residents at risk for impaired nutrition.

The facility had a census of 57 residents. The sample included 15 residents. Based on observation, record review, and interview, the facility failed to provide Resident (R)31 or his representative with written information regarding the facility bed hold policy when R31 was transferred to the hospital. This placed R31 at risk for not being permitted to return and resume residence in the nursing facility. Findings included: - R31's Electronic Medical Record (EMR) documented the resident had diagnoses of urinary tract infection (UTI-an infection in any part of the urinary system). R31's Quarterly Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview of Mental Status (BIMS) of 15, which indicated intact cognition. The MDS documented R31 required extensive staff assistance with bed mobility, transfers, dressing and toilet use. R31 required staff supervision with locomotion on and off unit, personal hygiene, and eating. R31's Care Plan, revised 10/03/23, documented R31 had an indwelling urinary catheter (tube inserted into the bladder to drain urine) and instructed staff to monitor his fluid intake and urine output per physician orders, provide catheter care every shift and as needed (PRN). The care plan instructed staff to change R31's catheter every 30 days and PRN, empty it every shift and PRN, ensure R31's catheter tubing and bag did not touch the floor or become elevated above his bladder and to ensure R31's catheter was appropriately positioned during transfer to prevent any obstruction. R31's Progress Notes, dated 05/31/23 at 09:34PM, documented R31 was transferred to the hospital. Review of R31's clinical record lacked evidence the resident or representative was provided the facility bed hold policy. On 10/24/23 at 11:44 AM, observation revealed R31 rested in bed on his left side; staff entered the room and repositioned him on his back. On 10/26/23 at 10:50 AM, Licensed Nurse (LN) FF verified R31 or his representative was not provided a bed hold policy when he was transferred to the hospital on 05/31/24 and stated the facility did not provide the bed hold policy to residents who received Medicaid when they are transferred to the hospital. On 10/30/23 at 11:51 AM, Administrative Nurse D stated nursing staff were responsible for providing residents the bed hold policy when they were transferred to the hospital. Administrative Nurse D stated R31 should have received the bed hold notice even if he received Medicaid services. The facility's Bed/Unit-Hold Policy, revised 05/28/2019, documented upon admission or transfer, the resident and family member or legal representative or surrogate would review and be informed that the facility would hold a bed/unit for residents on medical or non-medical leave, as requested and agreed upon. Staff should verify Medicaid and private insurer's bed/unit-hold coverage. The facility failed to provide R31 or his representative with the bed hold policy when he was transferred to the hospital. This placed the resident at risk for not being permitted to return and resume residence in the nursing facility.

The facility had a census of 57 residents. The sample included 15 residents. Based on observations, record review, and interview, the facility failed to develop a comprehensive care plan for Resident (R) 40 which addressed his edema and related needs. This placed the resident at risk for impaired care due to uncommunicated care needs. Findings included: - The Electronic Medical Record (EMR) for R40 documented diagnoses of Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness), weakness, edema (swelling resulting from an excessive accumulation of fluid in the body tissues), hemiplegia (paralysis of one side of the body), other symptoms and signs with cognitive functions and awareness. The Admission Minimum Data Set (MDS), dated [DATE], documented R40 had intact cognition and required supervision and one staff assistance for transfers, ambulation, dressing, and toileting. The MDS further documented R40 had unsteady balance, no functional impairment, and had no skin issues. The Significant MDS, dated [DATE], documented R40 had severely impaired cognition and required extensive assistance of two staff for bed mobility, transfers, toileting, extensive assistance of one staff for dressing, ambulation in room, and personal hygiene. The MDS further documented R40 had unsteady balance, no functional impairment, and had no skin issues. R40's Care Plan lacked documentation of his diagnosis of edema and interventions to prevent edema. R40's Physician Order, dated 01/06/23, directed staff to administer spironolactone (a diuretic medication), 50 milligrams (mg), by mouth, twice per day, for the diagnosis of edema. R40's Physician Order, dated 04/28/23, directed staff to apply compression stockings (designed to apply pressure to your lower legs, helping to maintain blood flow and reduce discomfort and swelling), for knee-high edema, on in the morning and off in the evening. On 10/24/23 at 01:01 PM, observation revealed R40 sat in a recliner in the living room pod. R40 did not have compression socks on. Further observation revealed nursing students placed a pillow under his legs. On 10/25/23 at 10:00 AM, observation revealed R40 sat in his wheelchair, and did not have his compression socks on. On 10/26/23 at 07:36 AM, observation revealed R40 sat in a recliner in the living room pod with his feet elevated. R40 had no compression socks on, and his ankles appeared edematous. On 10/30/23 at 09:36 AM, observation revealed R40 sat in a recliner in the living room pod with his feet elevated. He had no compression socks on, and his ankles appeared edematous. On 10/26/23 at 12:06 PM, Administrative Nurse E verified that there was not a care plan related to R40's edema and stated it was everyone's responsibility to put interventions on the care plan. Administrative Nurse E further stated she looked through nurse's notes and talked to staff before the care plan meetings to see if there was anything new to put on the care plan. On 10/30/23 at 02:00 PM, Administrative Nurse D stated the care plan should reflect the resident and his edema related cares should be on the care plan. The facility's Care Plan policy, dated 07/28/22, documented a person-centered plan of care as developed for each resident by the interdisciplinary team, through assessments within the established timeframes, according to state and federal regulations. Each discipline would be responsible for identifying problems, management of avoidable declines in functioning, and establishing goals for the person-centered plan of care. Problems & goals would focus on building upon resident strengths, their needs, and personal, as well as cultural preferences identified in the admission assessment. The facility failed to develop a plan of care for R40's edema. This placed the resident at risk for impaired care due to uncommunicated care needs.

The facility had a census of 57 resident. The sample included 15 residents. Based on observation, record review, and interview, the facility failed to revise Residents (R) 38's care plan to include fluid restriction quantities, which placed R38 at risk of complication related to hydration status, dialysis (procedure where impurities or wastes were removed from the blood) treatment and history of urinary tract infections (UTI-an infection in any part of the urinary system) due to uncommunicated care needs. Findings included: - The Electronic Medical Record (EMR) for R38 documented diagnosis of acute kidney failure, end stage renal failure (ESRD-a terminal disease of the kidneys), hydronephrosis (excess urine accumulation in the kidney that causes swelling), multiple sclerosis (MS- progressive disease of the nerve fibers of the brain and spinal cord), history of UTI's, bacteremia (presence of bacteria in the blood), acidosis (excess acid in the body fluids), neuromuscular dysfunction of bladder (dysfunction of the urinary bladder caused by a lesion of the nervous system), irritable bowel syndrome (IBS- abnormally increased motility of the small and large intestines), history of venous thrombosis (clot that developed within a blood vessel) and embolism (an obstruction in a blood vessel due to a blood clot or other foreign matter that gets stuck while traveling through the blood stream), and abdominal pain. The Significant Change Minimum Data Set (MDS), dated [DATE], documented R38 had intact cognition, was independent with eating, required partial/moderate assistance with toileting hygiene, bathing self, upper and lower body dressing, to roll left to right, sit to lying, lying to sitting on side of bed, sit to stand, chair/bed transfer, and toilet transfers. The Activity of Daily Living Care Area Assessment (CAA), dated 09/19/23, documented R38 went to dialysis three times a week and family member transported the resident. The Nutritional Status Care Area Assessment (CAA), dated 09/19/23, documented R38 received a therapeutic renal diet with a 1500 milliliter (ml) fluid restriction; R38 received hemodialysis three times a week which would cause weight fluctuation. R38's Care Plan, dated 09/28/23, documented R38 went to dialysis on Monday, Wednesday, and Fridays. The care plan directed staff to monitor shunt thrill (a fine vibration felt which reflects the blood flow by a dialysis resident's shunt) and bruit (blowing or swishing sound heard when blood flows through a shunt)every shift and report concerns to dialysis; educate resident and family to any restrictions related to dialysis such as diet/fluids, and continue a 1500 ml fluid restriction. The care plan lacked direction to staff as to dietary and nursing department specification on interdisciplinary communication of fluid intake. R38's Physician Order dated 09/22/23, directed staff to provide a regular diet and 1500 ml fluid restriction in 24 hours. R38's EMR lacked evidence staff monitored and recorded fluid intake until 10/09/23. R38's EMR further lacked documentation of fluid intake for the day shift two out of 14 opportunities; evening shift lacked documentation for eight of 14 opportunities, and night shift lacked 11 of 14 opportunities. On 10/26/23 at 11:11 AM, observation revealed R38 sat in her recliner with a family member present. R38 was alert, watched TV with her feet elevated and covered with a blanket. R38 reported she took paperwork with her to the dialysis center on treatment days and returned with the paper which she gave to staff. R38 verified the facility had not weighed her consistently before or after dialysis treatment but stated the dialysis center did weight her. R38 reported she had a 1500 ml in 24-hour fluid restriction and had to ask for fluids. R38 stated she expected nursing staff were monitoring the amounts she consumed. On 10/26/23 at 12:52 PM, Consultant GG stated the nursing staff provided the resident fluid and tracked the fluid intake. Certified Nurse Aide (CNA) O stated she was instructed to provide R38 a medium glass of fluids with meals, which consisted of 360 mls. On 10/30/23 at 09:37 AM CNA P reported R38 was on a fluid restriction but did not know the amount of the restriction. On 10/30/23 at 09:48 AM Licensed Nurse (LN) J reported R38 received dialysis treatments three times a week. LN J verified R38 should have vital signs and weight before and after dialysis treatment and had physician order for a 1500 ml fluid restriction. LN J reported an intake and output record was kept in the resident's room so staff could record the intakes, and it was the nurse's responsibility to keep track of this information. LN J verified the lack of documented fluid intakes, weights, and completion of the Dialysis Communication Form. On 10/30/23 at 12:57 PM Administrative Staff D stated the Dialysis Communication Form should be completed and accessible for staff to review in the EMR or left on the unit for the nursing staff if they should need to review information collected. Administrative Nurse D verified she expected nursing staff to complete the communication form before and after treatment, weight, take vital signs and monitor R38's fluid intake. The facility's Hydration/Fluid Maintenance policy, dated 09/17/21, documented to identify residents admitted to the community with risk factors which can lead to dehydration. Determine through assessment of clinical conditions if sufficient fluid intake is being offered to the resident. Develop an appropriate preventative plan of care. Risk factors for the resident becoming dehydrated are fluid loss and increased fluid needs, fluid restriction secondary to renal dialysis, functional impairments, residents who forgets to drink or forgets how to drink, and refusal of fluids. The general procedure of using daily fluid need guidelines, determine if resident needs input monitoring, perform MDS/CAA process and develop plan of care, incorporate hydration plan based on the needs of the resident. The facility failed to revise R38's care plan to include fluid restriction quantities between nursing and dietary departments, which placed R38 at risk of complications due to uncommunicated care needs.

The facility had a census of 45 residents. The sample included three residents reviewed for accidents. Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent accidents for one of three sampled residents, Resident (R) 1, who fell out of the sit to stand mechanical lift (assists from sitting to standing position) resulting in a left humerus (left upper arm bone) fracture (broken bone). Finding included: - The Physician order [REDACTED]. R1's Quarterly Minimum Data Set (MDS), dated [DATE] documented the resident was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 13. The MDS documented the resident had no falls since previous assessment, required extensive physical assistance from two or more staff for transfers, balance not steady, only able to stabilize with staff assistance, and used a wheelchair for mobility. The revised Falls Care Plan, dated 06/01/20, directed staff to use a sit to stand lift with two staff for transfers. The Physician Order, dated 06/04/20, documented the resident could bear weight as tolerated. The Physical Therapy (PT) Therapist Progress and Discharge Summary, dated 06/26/20, documented therapy treated R1 for a [DIAGNOSES REDACTED]. R1 showed improvement in use of sit to stand lift transfers with staff. R1's Fall Risk Assessment Tool, dated 08/23/20, documented a score of 13 (moderate fall risk). R1's Fall Risk Assessment Tool, dated 11/09/20, documented a score of 12 (moderate fall risk). The Progress Note, dated 11/09/20 at 10:05 PM, documented staff notified Licensed Nurse (LN) G that nursing staff lowered R1 to the floor out of the sit to stand lift. LN G assessed the resident, obtained vital signs which were within normal limits for the resident, noted the left shoulder to be dislocated, and R1 complained of pain rating it 7 out of 10 on a 0-10 pain scale. Staff used the full body lift and assisted R1 off the floor. LN G notified the primary care physician who gave orders to send R1 to the hospital emergency room for evaluation and treatment. At 09:50 PM R1 left the building with emergency medical staff. The Hospital Discharge Summary, dated 11/10/20, documented R1 had a left proximal (closer to the body) humerus fracture. The Certified Nurse Aide (CNA)/Certified Medication Aide (CMA) Skills Checklist- Transferring the Resident Using the Stat Assist Mechanical Lift, dated 11/05/20, documented CNA M completed the skill satisfactory. On 11/23/20 at 10:06 AM, observation revealed the resident lying in bed watching television, with purple bruising noted from her shoulder to mid forearm. On 11/19/20 at 02:19 PM, CNA M stated she worked at the facility through a staffing agency. On 11/09/20 around 09:15 PM, she gave R1 a shower. CNA M asked another staff member to help transfer R1 from the shower chair to the wheelchair, but the staff member stated she did not have time to assist. CNA M raised the sit to stand lift into the standing position and observed R1 slipped half-way out of the lift, so CNA M went behind R1 to try to stop R1 from slipping. R1's left arm was caught in the sling of the lift, so CNA M removed the sling as carefully as she could while she supported R1, assisted R1 to the ground, then yelled out the shower door for assistance. On 11/23/20 at 09:54 AM, R1 stated CNA M independently showered R1 in the shower room, when CNA M tried to transfer R1 from the shower chair to her wheelchair R1 fell out of the sit to stand lift and hurt her arm. On 11/23/20 at 10:59 AM, LN H stated before R1 went to the hospital she required two staff and the sit to stand to transfer, she currently transferred with the full body lift. LN H stated the facility staff were responsible to train and work with agency staff to ensure safe transfers. On 11/23/20 at 12:28 PM, LN G stated on 11/09/20 around 09:15 PM she was informed R1 was on the floor of the shower room. She assessed the resident and found the resident's left shoulder was bulging out, so she called the resident's physician who ordered to send R1 to the emergency room . After R1 left the building, LN G did not educate or train the CNAs on proper use of the sit to stand lift. LN G stated she was told the sit to stand lift was considered the second person and she allowed staff to transfer residents with one staff member and the sit to stand. LN G stated she did not know the facility's policy for the sit to stand lift. On 11/23/20 at 12:56 PM, CNA N stated R1 required two staff for the sit to stand lift. CNA N stated she was trained to use two staff when transferring a resident using the sit to stand lift. On 11/23/20 at 1:01 PM, Administrative Nurse D stated the facility did not have a specific written policy on how many staff members were needed to use the sit to stand lift, staff were trained to use two staff members, and CNA M should not have transferred R1 with the sit to stand lift by herself. The facility's revised Lifting & Transferring Residents policy, revised 05/02/10, documented all lifts performed with a mechanical lift must be performed with two staff members present. The facility failed to transfer R1 with assistance of two staff while using a sit to stand lift. R1 fell out of the sit to stand mechanical lift and sustained a left humerus fracture.

The facility had a census of 55 residents. The sample included 3 residents, who were reviewed for accidents. Based on observation, record review and interview, the facility failed to provide an environment as free as hazards as possible, and provide adequate assistance devices to prevent accidents, for 2 of the 3 sampled residents. Resident #1 spilled hot coffee on himself/herself and received a second degree burn (burn to the first and second layers of skin) and Resident #3, spilled coffee on himself/herself and received a first degree burn (involving the first layer of skin). Findings included: - The 1/10/17 signed physician orders [REDACTED]. Resident #1's quarterly (MDS) Minimum Data Set assessment, dated 2/16/17, documented the resident had a (BIMS) Brief Interview for Mental Status score of 4, which indicated he/she had severely impaired cognition. The MDS documented the resident usually understood and could understands others. The MDS documented the resident required extensive staff assistance for most (ADLs) activities of daily living, limited staff assistance for ambulation, supervision with eating, and used a walker for mobility. The admission (CAA) Care Area Assessment for cognition (dated 12/14/16), documented the resident scored 4 on the BIMS (severely impaired cognition), and he/she was able to verbally express his/her needs and concerns. The CAA for ADLs did not trigger. The 12/8/16 care plan documented the resident had severely impaired cognition, wore bilateral (both sides) hearing aides, was interviewable, able to be verbally respond, or by pointing to answers on a cue card, used a wheelchair for mobility, and required staff assist of 1or 2 for ADLs, including eating. The care plan directed staff to observe for decreased ability in understanding and how to use communication aides. The 2/25/17 updated care plan directed the staff to use coffee cups with a lid when the resident drank coffee in his/her room, and not to warm the coffee in the microwave. The 2/25/17 at 5:46 AM, nurse's note stated a (CNA) certified nurse aide, notified the nurse to come to the resident's room, where he/she had spilled coffee on his/her left mid abdomen. The note documented the burn area measured 4.5 (cm) centimeters by 5.5 cm, pink in color, and staff left the area open to air and would monitor the resident. Staff notified the physician by fax. The 2/25/17 at 12:55 PM, nurse's note documented staff performed a skin check at 8:00 AM, and the area was bright red in appearance, with no blisters, and the resident denied pain. At 10:00 AM, staff completed a skin check and the area was bright red, had no blisters and no pain reported by the resident. The 1:00 PM skin check, revealed the area was dull red in appearance, with fluid filled blisters, and no pain reported by the resident. The note stated staff covered the area with Kerrafoam (highly absorbent, conforming dressing). The 2/27/17 at 11:45 AM, nurse's note stated staff contacted the physician with an update on the resident's burn, and the fluid filled blisters that were present. The 2/27/17 at 1:24 PM, nurse's note stated the physician returned the facility's phone call and directed staff to continue Kerrafoam dressings to the resident's abdominal burn. The 2/28/17 at 1:24 PM, weekly skin assessment documented the blister was open, the wound bed was dry, red in color, and measured 4.0 cm by 1.1 cm. Staff cleansed the wound with normal saline (solution of sodium chloride and water, used to clean skin wounds or skin abrasions) and staff applied a new dressing. The 3/1/17 at 8:14 PM, nurse's note documented staff changed the dressing on the resident's abdomen, and noted yellow/white slough (dead tissue, usually cream or yellow in color), and no signs or symptoms of infection. The note documented staff cleansed the wound with normal saline, applied a new dressing, the resident tolerated the procedure well, and had no complaints of pain. The record revealed no documentation staff notified the physician of the slough on the resident's burn. The 3/3/17 at 10:09 AM, monthly assessment note documented the dressing to the resident's abdomen remained intact, clean, dry, and the resident had no complaints of pain. The note stated the resident continued to have coffee in his/her room and used a coffee mug with a lid. On 3/6/17 at 11:50 AM, observation revealed the resident ambulated into the dining room, with his/her walker, staff assistance of 1, and a gait belt. Further observation revealed staff served the resident coffee (temperature of 156.4 degrees Fahrenheit) in a cup, without a lid. On 3/7/17 at 4:45 AM, observation revealed the temperature of the coffee in the hospitality bar coffee maker was 127 degrees Fahrenheit. On 3/2/17 at 1:15 PM, Nurse A stated the resident received a burn when he/she spilled hot coffee on his/her lap. Nurse A stated the wound was healing, and there were no blistered areas. Nurse A stated the facility had not assessed the resident for hot beverage safety, but if a resident had problems with shaking, weakness, or holding onto a cup, staff would monitor the resident and ask for a speech therapy or occupational therapy evaluation. On 3/6/17 at 9:30 AM, Dietary Service Supervisor F stated he/she checked the temperature of the hospitality bar coffee pot, and the temperature was set on low, which is 165 degrees Fahrenheit when brewed, and 140 degrees Fahrenheit when the coffee dispensed. The dispensed temperature could be lower, if several cups of coffee were dispensed in a short amount of time. On 3/6/17 at 11:00 AM, Nurse Aide B verified on 2/25/17, between 5:00 AM and 6:00 AM, the resident asked him/her for coffee and stated he/she wanted the coffee hotter than what comes out of the coffee pot. Nurse Aide B verified he/she placed the coffee in the microwave oven for approximately 30-40 seconds, then served the coffee to the resident, who was in his/her room, seated in a recliner, with his/her feet on the floor. Nurse Aide B verified the cup with the hot coffee did not have a lid on it, and when the resident took the cup, he/she spilled some of the hot coffee on his/her lap. Nurse Aide B stated he/she immediately removed the resident's shirt, and notified the nurse. On 3/7/17 at 8:15 AM, Administrative Nurse C verified staff should not have used the microwave to heat coffee for the resident, and staff did not follow the facility's policy for precautions for handling hot beverages. Administrative Nurse C stated the facility had not assessed if the resident was at risk for handling hot beverages. Administrative Nurse C stated staff monitored the resident, and determined he/she would not need a lid on his/her coffee cup when in the dining room. The facility's 2016 policy, Precautions for Handling Hot Beverages, stated staff will monitor, serve, and hold hot beverages in a safe manner to prevent potential burns. The temperature for brewing and service hot beverages will be based on the manufacturer recommendations for the beverage equipment utilized in each facility. The policy states, although the recommended settings for proper brewing will vary based on facility equipment, it is recommended the temperature of the equipment be set at the lowest possible temperature for adequate brewing, anticipated to be in the range of 160-170 degrees Fahrenheit. The serving temperature should be approximately 10-15 degrees less than the brewing temperature. Additional precautions may be implemented based on the needs of each resident, and may include assessing and identifying those individuals, who are at high risk for burning themselves with hot beverages, ensuring staff monitors the identified high risk resident during meal times and/or when hot beverages are served. The policy directed staff to utilize special spill proof lids and cups for those identified as high risk for spillage and potential for burning, assist those who request beverages served hotter than the guidelines outlined above, the ability to consume hot beverages independently and safely, educating residents, family, and staff about the risk related to hot beverages. The facility failed to ensure Resident #1 received adequate supervision and specialized equipment to prevent burns, when he/she was served coffee from a coffee pot, which was then heated further in a microwave oven, spilled the hot coffee on himself/herself, and received a 2nd degree burn. - The 1/17/17 signed physicians orders revealed Resident #3 had [DIAGNOSES REDACTED]. Resident #3's annual (MDS) Minimum Data Set assessment, dated 2/16/17, documented the resident had a (BIMS) Brief Interview for Mental status score of 9, which indicated he/she had mild cognitive impairment. The MDS documented the resident required extensive staff assistance for all (ADLs) Activities of Daily Living, except he/she required set up assistance for eating. The MDS indicated the resident used a wheelchair for mobility. The 11/18/16 care plan documented the resident had short and long term memory problems, required frequent arousal at meals as he/she would tend to fall asleep, required staff assist of 1-2 with ADLs, and preferred coffee with his/her meals. The care plan lacked information regarding the resident's risk of handling hot beverages. The 2/3/17 updated care plan directed the staff provide a coffee cup with a lid with meals. The 2/3/17 at 2:21 PM, nurse's note documented at 12:00 PM, staff reported to the nurse, the resident yelled out when he/she spilled coffee on his/her chest. The note documented staff immediately removed the resident from the dining room to remove his/her clothing, while dietary staff obtained the temperature of the coffee. Staff documented the coffee at 123 degrees Fahrenheit. The note documented the resident complained of burning to his/her chest, and staff placed a cool wash cloth on the pink/red area on the resident's chest, and across his/her upper breasts. The note documented the resident returned to the dining room, and continued to complain of burning to the area. The note indicated staff notified the physician of the burn by fax. The 2/6/17 at 10:37 AM (3 days after the burn incident) dietary note documented they received notice the resident had spilled coffee on himself/herself, initiated adaptive equipment of a mug with a lid for hot beverages, and recorded the information on the resident's meal card. The 2/6/17 at 12:15 PM, nurse's note documented staff received instructions to monitor the resident's burn, and no new orders. The note documented no red areas on the resident's chest. On 3/6/17 at 8:10 AM, observation revealed the resident, sat in his/her wheelchair, at the dining room table. Further observation revealed the resident asked staff for coffee, and staff served the resident coffee in a cup with 2 handles and a lid. Observation revealed staff sat next to the resident to assist him/her with the hot cup of coffee. On 3/6/17 at 9:15 AM, Nurse Aide D stated the resident drank coffee with his/her meals and it was served in a cup with handles and a lid for safety. Nurse Aide D stated the resident required staff assistance to eat and drink. On 3/6/17 at 11:50 AM, Nurse E stated he/she assessed the resident after he/she spilled coffee on himself/herself. Nurse E stated the area was pink/red in color, and there were no blisters. Nurse E stated staff serve the resident coffee in a cup, with a lid, and handles, and the resident required staff assistance with meals. On 3/7/16 at 8:10 AM, Administrative Nurse C verified the resident spilled coffee on his/her chest, and there was a pink/red area, with no blisters. Administrative Nurse C verified after the incident, the facility implemented a new low temperature coffee maker, and initiated a cup with a lid for the resident. Administrative Nurse C stated all the dining rooms have cups with lids available for any resident that was at risk for spilling hot beverages on themselves. The facility's 2016 policy, Precautions for Handling Hot Beverages, stated staff will monitor, serve, and hold hot beverages in a safe manner to prevent potential burns. The temperature for brewing and service hot beverages will be based on the manufacturer recommendations for the beverage equipment utilized in each facility. The policy states, although the recommended settings for proper brewing will vary based on facility equipment, it is recommended the temperature of the equipment be set at the lowest possible temperature for adequate brewing, anticipated to be in the range of 160-170 degrees Fahrenheit. The serving temperature should be approximately 10-15 degrees less than the brewing temperature. Additional precautions may be implemented based on the needs of each resident, and may include assessing and identifying those individuals, who are at high risk for burning themselves with hot beverages, ensuring staff monitors the identified high risk resident during meal times and/or when hot beverages are served. The policy directed staff to utilize special spill proof lids and cups for those identified as high risk for spillage and potential for burning, assist those who request beverages served hotter than the guidelines outlined above, the ability to consume hot beverages independently and safely, educating residents, family, and staff about the risk related to hot beverages. The facility failed to assess Resident #3's need for a specialized cup with a lid, and he/she was served hot coffee in an open cup, spilled it on his/her chest, and received a burn.

The facility had a census of 54 residents. The sample included 14 residents, of which 5 were reviewed for unnecessary drugs. Based on observation, record review, and interview the facility failed to thoroughly evaluate and monitor for adverse drug reactions for 1 of 5 sampled residents. Resident #30 received anticoagulant therapy (agent to prevent blood clots), had a change of condition, and staff failed to seek physician intervention for 6 days after the resident continued to have blood in his/her urine. This deficient practice placed the resident in immediate jeopardy. The facility failed to document administration of physician ordered medications for 1 of sampled 5 residents. (#2) Findings included: - Resident #30's quarterly (MDS) Minimum Data Set assessment, dated 3/8/16, indicated the resident cognitively impaired with a (BIMS) Brief Interview for Mental Status score of 5, required supervision with eating, limited assistance with locomotion, and extensive assistance with all other (ADLs) activities of daily living. The MDS indicated the resident received blood thinning medication for 7 of 7 days of the assessment period. The significant change MDS, dated [DATE], indicated the same. The 3/8/16 care plan for medication stated the resident received [MEDICATION NAME] (a blood thinning medication) for a-fibrillation (rapid, irregular heart beat), and was at risk for side effects including digestive or urinary tract bleeding, hematuria (blood in the urine), skin bruising, signs of stroke, shortness of breath, dizziness, [MEDICAL CONDITION] (low blood pressure) and falls. The care plan stated the (INR) International Normalized Ratio (a test used to help diagnose bleeding or clotting disorders, primarily used to monitor [MEDICATION NAME] therapy, documented to maintain an INR in target range. A level of 4.9 or above is considered critical.) The physician would monitor the levels and staff would notify the physician if side effects were noted. The care plan included the black box warning for [MEDICATION NAME]. The 4/13/16 physician's orders [REDACTED]. The 4/24/16 at 4:49 PM, nurse's note indicated the resident's urine amber, red tinged and staff obtained a urine sample. Staff performed a chemical strip urine test (in the facility) which indicated a large amount of blood in the urine and a small amount of leukocytes (white blood cells that help the body fight infections such as UTIs (an infection in any part of the urinary system)). The note stated staff faxed the results of the urine test to the physician, informing him/her the resident had continued with increased restlessness. Staff requested a (UA) urinary analysis (examination of urine). The 4/25/16 physician's orders [REDACTED]. The 4/25/16 UA indicated 3+ blood, negative for [MEDICATION NAME] ([MEDICATION NAME] in urine show a urinary tract infection was present), and negative for leukocytes. The 4/25/16 physician's orders [REDACTED]. Review of the (MAR) Medication Administration Record [REDACTED]. The nurse's notes revealed the following: 4/26/16 at 1:43 PM, blood in the resident's brief this afternoon when toileted. 4/27/16 at 2:33 PM, resident's urine was amber in color. 4/27/16 at 6:09 PM, resident's urine continued amber colored, with a small amount of blood with incontinence care. 4/28/16 at 3:19 PM, resident's urine continued to have blood in it. 4/28/16 at 5:33 PM, continued observation of blood in the resident's urine. The 4/29/16 at 3:03 AM, nurse's note stated some blood in the urine noted upon toileting resident this shift. The nursing note dated, 4/30/16 at 2:19 PM, recorded no improvement in the color of the resident's urine, and a large amount of blood was observed in the urine this morning. The note stated the resident displayed difficulties in balance, gait weakness this morning when walking, and complained of a headache this afternoon, and staff gave the resident the pain medication Tylenol. Review of the medical record lacked documentation the staff notified the physician of the continued observations of blood in the resident's urine, as directed in the plan of care. The medical record lacked further reassessment of the resident for more than 6 hours after staff noted the resident had a large amount of blood in his/her urine on the morning of 4/30/16. The 4/30/16 at 9:05 PM nurse's note stated the resident had no complaints of discomfort, and received antibiotics. Nursing notes lacked further evidence staff assessed the resident. Review of the medical record lacked evidence the staff notified the physician from 4/24/16 until 5/1/16, although the staff continued to observe and document blood in the resident's urine. The 5/1/16 at 2:30 PM, physician's verbal telephone order directed staff to send the resident to the hospital for evaluation and treatment. The 5/1/16 at 2:34 PM nurse's note stated staff sent the resident to the emergency room by ambulance for evaluation and treatment this afternoon. The note stated the resident's (gender specific) genital area bleeding got worse, with bright red color, no clots, and his/her skin was very pale. The note stated the resident had a weak, unsteady gait and had difficulty following directions from staff. The 5/1/15 (ER) emergency room report stated the ER physician assessed the resident at 2:47 PM, for (gender specific) genital bleeding. The ER laboratory testing indicated the (PTT) Partial [MEDICAL CONDITION] Time (a test used primarily to investigate unexplained bleeding or clotting) greater than 200 (normal range is 22.2-37.4), INR high-unreadable, hemoglobin (a complex protein-iron compound in the blood that carries oxygen to the cells from the lungs and carbon [MEDICATION NAME] away from the cells to the lungs) 11.0 (normal range 12-16), and the UA indicated red, cloudy urine without bacteria. The report stated the resident had minimal blood of the (gender specific) genital area, but visible blood on the catheter (tube inserted into the bladder to drain urine) site which likely indicated a urine/bladder source of the bleeding. The ER staff administered Vitamin K (plays a key role in helping the blood clot, preventing excessive bleeding), fresh frozen plasma (liquid portion of human blood that has been frozen), obtained a UA. At 4:16 PM, the acute care hospital admitted the resident with the primary [DIAGNOSES REDACTED]. On 7/18/16 at 11:13 AM, Hospital Laboratory Staff V stated the normal range of an INR with [MEDICATION NAME] use was 1.5-3.5, greater than 4.5 was considered high, greater than 6 indicates critical and greater than 13.9 was unreadable (the laboratory testing does not read INR greater than 13.9). The 5/1/16 hospital history and physical document stated the facility brought the resident to the emergency room with bleeding, and laboratory tests revealed the resident had a critical high, unreadable INR. Hospital staff administered, to the resident, vitamin K (plays a key role in helping the blood clot, preventing excessive bleeding) and (FFP) Fresh Frozen Plasma (refers to the liquid portion of blood that has been frozen and preserved and will be used for blood transfusion to replace blood after an acute loss of blood). The document stated the resident has been taking [MEDICATION NAME], 7.5 mg, daily, since 1/4/16. The 5/3/16 hospital transfer form for readmission to the facility indicated [DIAGNOSES REDACTED]. The hospital discharge orders directed staff to notify the physician with any further bleeding, repeat INR on 5/6/16 and 5/10/16 and send results to the physician. On 7/11/16 at 1:43 PM, observation revealed the resident, seated in the commons area, reminiscing with activity staff. On 7/11/16 at 1:20 PM, Nurse G stated if staff reported blood on a resident's brief, he/she would check to see where it may have come from, and contact the physician for further orders. On 7/11/16 at 2:05 PM, Administrative Nurse A stated staff notified the physician of the blood in the resident's urine when they sent the urinary chemical strip results. Administrative Nurse A stated he/she found the blood while toileting the resident, and stated he/she thought it may have been related to the urinary tract infection, and did not notify the physician. Administrative Nurse A stated staff use standard nursing practices for medication administration and monitoring for effectiveness and side effects. On 7/14/16 at 1:35 PM, Physician R stated if the amount of blood in the resident's urine stayed small, he/she would expect the staff to closely monitor the resident. He/she stated the therapeutic target value for the INR was 2-3. On 7/19/16 at 3:00 PM, Administrative Nurse A verified the facility nursing staff should have notified the physician of the continued bleeding on 4/30/16. According to www.fda.gov, [MEDICATION NAME] had a black box warning of bleeding risk. [MEDICATION NAME] could cause major or fatal bleeding. Bleeding is more likely to occur within the first month. A black box warning issued by the FDA (US Food and drug administration) is a warning of serious or life-threatening risks located on the label of a prescription drug. The facility failed to thoroughly assess and monitor for serious adverse medication reaction of [MEDICATION NAME] for this resident that resulted in bleeding, and required hospitalization and emergency treatment with a transfusion and medication to reverse bleeding. The facility further failed to notify the physician of the blood in the resident's urine for 6 days. This deficient practice placed the resident in immediate jeopardy. The facility abated the immediate jeopardy on 7/20/16, after completion of training of all staff regarding monitoring for the side effects of anticoagulant use, adverse reactions and facility guidelines with parameters regarding physician notification. The deficient practice remained at the scope and severity of a G. - The 6/7/16 physician order [REDACTED].#2 revealed [DIAGNOSES REDACTED]. Resident #2's quarterly (MDS) Minimum Data Set assessment, dated 3/22/16, indicated the resident had a (BIMS) Brief Interview of Mental Status score 3, which indicated the resident had severely impaired cognition. The MDS indicated the resident required assistance of 1-2 staff with (ADLs) Activities of Daily Living, received pain and antidepressant (a drug used to treat depression (feelings of hopelessness, despondency, and dejection) medication. The 3/23/16 care plan instructed staff to administer medications to the resident as ordered by the physician, monitor for effectiveness and side effects (monitor liver function tests, and refer to a Mosby Drug Reference, physician or pharmacist for further information). The care plan instructed staff to notify the physician of significant changes in condition. The care plan indicated the resident preferred his/her medications crushed and in a drink of choice. The 4/15/16 behavioral health visit physician order [REDACTED]. The 6/7/16 physician order [REDACTED]. Review of the resident's 6/10-7/9/16 (MAR) Medication Administration Record [REDACTED] 7/2/16- no documentation staff administered to the resident [MEDICATION NAME], 500 mg, at bedtime. 6/29, 6/30, 7/1, and 7/5/16 - no documentation staff administered [MEDICATION NAME], 250 mg, twice a day to the resident. The 7/6/16 laboratory test indicated the resident's [MEDICATION NAME] level 67.5 (normal 50.0-100.0) On 7/11/16 at 5:30 AM, observation revealed the resident resting in bed, eyes closed, and room door open. On 7/11/16 at 11:20 AM, Nurse B verified the lack of documentation regarding administration of [MEDICATION NAME] on the above dates. On 7/11/16 at 12:10 PM, Administrative Nurse A verified the lack of documentation indicating the resident received the physician ordered [MEDICATION NAME] doses on the above dates. Upon request for a Medication Administration policy, Administrative Nurse A stated the facility follows standard nursing practice regarding administration of medications to the residents. The facility failed to consistently document administration of physician ordered [MEDICATION NAME], 500 mg, at bedtime on several days, which placed Resident #2 at risk for not receiving therapeutic levels of his/her [MEDICAL CONDITION] drug.

The facility had a census of 54 residents. The sample included 14 residents, of which 5 were reviewed for accidents. Based on observation, record review, and interview, the facility failed to provide care and services to prevent falls for 2 of 5 residents. Resident #8 fell during a transfer and sustained a fracture when staff failed to use a gait belt per facility protocol, and Resident #72, who continued to have falls without effective preventative measures implemented. Findings included: - Resident #72's quarterly (MDS) Minimum Data Set assessment, dated 3/17/16, indicated the resident had impaired vision and wears glasses. The MDS indicated the resident had a (BIMS) Brief Interview of Mental Status score of 5, which indicated the resident had severe impaired cognition. The assessment revealed the resident required limited staff assistance with walking in the corridor, locomotion on and off the unit, and extensive staff assistance with bed mobility, transfers, dressing, toileting and personal hygiene. The assessment revealed the resident had unsteady balance, only able to stabilize with staff assistance, used a walker or wheelchair for mobility, occasionally incontinent, and had 2 or more non-injury falls, and 1 minor injury fall. The quarterly MDS, dated [DATE], indicated the resident had impaired vision, wears glasses, and had a (BIMS) of 9, which indicated the resident had moderately impaired cognition. The MDS indicated the resident required limited staff assistance with walking in the corridor, locomotion on and off the unit, and extensive staff assistance with bed mobility, transfers, dressing, toileting and personal hygiene. The MDS indicated the resident frequently incontinent of urine, had unsteady balance, only able to stabilize with staff assistance, used a walker or wheelchair for mobility, and had 2 or more non-injury falls, and 1 minor injury fall. The 12/22/15 care plan instructed staff to assist the resident with walk to dine, ensure adaptive positioning devices were within reach for easy access, and remind the resident to lock his/her wheelchair brakes. The care plan indicated the resident required extensive assistance of 1-2 staff with transfers, and ambulation. The care plan instructed staff to ensure the resident's bed was placed in a position easiest for him/her to access/exit, and further instructed staff to educate the resident regarding risks/benefits of fall prevention/safety measures. The staff educated the resident's family and visitors on the assistance he/she needed regarding (ADLs) Activities of Daily Living in and out of facility. Review of the updates to the resident's care plan after each fall revealed the following: 1/22/16- monitor the resident's vital signs and (neuros) neurological examination (a series of simple questions and tests that provide crucial information about the resident) per facility guidelines. 3/22/16-check the resident vital signs and neuros x 72 hours, and assist to the bathroom before and after meals and (PRN) as needed. 4/15/16- check the resident's vital signs every shift x 24 hours, and continue 15 minute checks on the resident's location. 5/9/16- monitor vital signs every shift, assist the resident with ADLs, reminded the resident to use his/her call light. 6/9/16- monitor vital signs and neuros and check resident's location every 15 minutes x 72 hours. The 6/17/16 care plan instructed staff to walk the resident with his/her walker to meals, keep his/her walker within reach, and remind him/her to lock his/her wheelchair brakes. The care plan indicated the resident required extensive assistance of 1-2 staff with transfers, ambulation and locomotion. The care plan instructed staff to ensure the resident's bed in a positon for easy access for him/her, educate the family on assistance needed if he/she to leaves the building or it they were going to assist with (ADLs) Activities of Daily Living. The care plan instructed staff to assist the resident to the bathroom before and after meals and as needed. The care plan instructed staff to place the resident's touch pad call light within reach. The resident's fall assessments indicated the following scores: (a score of 10 or more indicated at risk for falls and required further assessment by the (ID) Interdisciplinary team) 12/9/15-19 2/24/16-24 3/16/16-34 4/18/16-20 5/9/16-21 6/16/16-25 The 12/21/15 at 6:28 PM nurse's note indicated staff found the resident lying on the floor, on his/her left side in the hall with his/her head in the hall and back against the door frame. The note indicted the resident's walker rested on its side with the resident's left lower leg on it and his/her left elbow beneath his/her torso. The note indicated the resident was not wearing his/her glasses, had a scratch to the left lateral lower leg and staff provided education to the resident regarding use of his/her call light. The note stated the facility instructed staff to check on the resident more often. The 1/3/16 at 9:30 PM nurse's note, indicated an aide had reported the resident attempted to sit on the toilet, his/her knees buckled, the resident dropped to the floor, landed on his/her knees, and did not sustain any injuries. The note indicated staff monitored the resident for 24 hours per witnessed fall protocol for vital signs, pain, and delayed injury changes. The 2/24/16 at 1:30 PM nurse's note, indicated an aide heard the resident yell out for help and found him/her sitting on the floor by his/her bed. The note instructed staff to continue 15 minute checks implemented on 2/19/16. The 3/22/16 at 4:25 AM nurse's note, indicated the resident yelled for help, staff found the resident lying on his/her back on the bedroom floor, and no injuries noted. The note indicated the staff last visualized the resident 30 minutes prior to the incident and staff were instructed to continue 15 minute checks on the resident. The 4/18/16 at 4:16 AM nurse's note, indicated the resident yelled out, an aide responded and found the resident on the floor with his/her knees bent, heels on the floor, and hands resting on his/her bed. The note indicated the resident had ambulated independently to the bathroom and staff were educated regarding call light placement and instructed to leave the bathroom light on. The 5/9/16 at 12:36 PM nurse's note, indicated staff found the resident on the bathroom floor after getting up unassisted, lost balance in the doorway of the bathroom, and acquired a skin tear to his/her right hand. The 6/9/16 at 7:15 PM nurse's note, staff found the resident sitting upright on the bathroom floor with legs toward the door and arms supporting his/her upper body. The note indicated 15 minute checks on the resident were initiated for 72 hours. Review of the 15 minute record sheet revealed no documentation 6/9/16 at 7:17 PM to 6/10/16 at 12:00 PM of the residents location. On 7/6/16 at 5:20 PM, observation revealed the resident independently stood up, started walking toward the dining room, and walked approximately 10 feet before staff saw him/her and assisted him/her in ambulating to the dining room. On 7/7/16 at 4:10 PM, Nurse Aide M stated the resident used a walker and required staff assistance with a gait belt for ambulation. Nurse Aide M stated staff check on the resident every 15 minutes, if he/she is up, place a gait belt on the resident, assist him/her, and educate the resident on using his/her call light to call for assistance. On 7/11/16 at 9:30 AM, Administrative Nurse A stated staff remind the resident to use his/her call light to call for assistance before getting up and the resident will use it for a few days, then needs reminded again. He/she stated 15 minute checks are to be done for 72 hours after a fall. He/she verified Resident #72 had short term memory loss and did not remember to use the call light. The facility's 5/9/16 fall policy stated place new interventions after a fall directed toward a goal of preventing further falls. The facility failed to care plan effective interventions for Resident #72, after he/she had several falls, which placed him/her at risk for further falls. - Resident #8's quarterly (MDS) Minimum Data Set assessment, dated 4/5/16, indicated (BIMS) Brief Interview for Mental Status score of 9, indicating moderately impaired cognition. The assessment indicated the resident required limited assistance with eating, and extensive assistance of 1 staff with all other (ADLs) Activities of Daily Living, including transfers and walking, and he/she had adequate vision with glasses. The resident's balance unsteady and he/she only able to stabilize with help, no (ROM) range of motion impairment, and the resident used a walker or wheelchair for mobility. The assessment indicated the resident had no falls since the prior MDS and received restorative nursing for (AROM) Active Range of Motion services, bed mobility, transfers and walking. The 10/5/15 (CAA) Care Area Assessment summary for falls indicated the resident had impaired balance during transitions and had [DIAGNOSES REDACTED]. The 4/5/16 care plan for ADLs directed staff to ensure the resident used a walker and assist of one staff for ambulation, correct footwear, a wheelchair used for locomotion with assistance of one, and restorative program for AROM, transfer and ambulation. The 7/6/16 update instructed staff to provide 2 person assistance with all transfers. The 4/5/16 care plan for falls instructed staff to ensure the call light in reach and remind the resident to use it. Ensure the resident wears non-skid socks or shoes, remind him/her to lock the wheelchair brakes, and ensure the bed in a position to easily get into and out of. The care plan instructed staff to increase assistance during illness/fatigue, keep brakes on the bed locked, do not leave the resident alone in the bathroom, monitor for seizure activity, dizziness, hypotension, falls, syncope (fainting), or fatigue. The 4/4/16 fall risk assessment score was 12 (10 or more indicates at risk). Review of the medical record revealed no falls in the previous 6 months. The 5/8/16 at 10:58 AM, nurse's note indicated the resident ambulated with assistance of 1 staff, gait belt and walker. The note indicated staff reported the resident gets up frequently in the night to toilet, does not use his/her call light, and at times the resident independently walks in his/her room. The 7/2/16 at 6:47 AM, nurse's note stated the resident yelled help me, my shoulder hurts. The note stated the nurse responded and found the nurse aide assisting the resident from his/her wheelchair to his/her to bed, after toileting/dressing. The note stated during the transfer the resident went limp and staff lowered him/her to the bed. The note stated the nurse observed the resident lying on his/her back with his/her head resting crossway on the bed, and his/her legs over the edge of the bed on the floor. The note stated the nurse aide was attempting to move the resident up in bed and get his/her legs onto the bed, while the resident stated help me, help me. The nurse assisted the nurse aide to body lift the resident into position on the bed. The resident complained of hurting all over. The resident's vital signs (blood pressure, pulse, temperature, and oxygen level) were within normal limits, and his/her skin warm and dry. Approximately 10 minutes later, the resident used the call light to request assistance with toileting, and the nurse transferred the resident with a gait belt to his/her wheelchair and the resident complained of left shoulder pain. The note indicated the resident's shoulder had no redness or bruising, but had some difference in shape, limited range of motion and discomfort with movement, and staff applied an ice pack to his/her shoulder. The nurse administered Tylenol, 650 (mg) milligrams, as needed, for discomfort, informed the facility's (DON) Director of Nursing of complaints and concerns and requested the day shift nurse to notify the physician and family. Review of the nurse's notes revealed no nursing documentation until the following: The 7/2/16 at 4:07 PM, nurse's note indicated the facility attempted to contact the physician 4 times, before calling the hospital at 10:30 AM. The on-call physician called the facility at 10:45 AM and instructed staff to send the resident to (ER) emergency room for evaluation and treatment. The resident left the facility at 11:00 AM. The nurse's note further indicated he/she received report from ER, at 12:30 PM, indicating the resident had a closed clavicle (collarbone) fracture and would need to wear a shoulder immobilizer at all times, except dressing, until a follow up appointment with his/her physician in 10 days. The note indicated the resident returned from the emergency room at 1:30 PM, with a shoulder immobilizer in place. The 7/2/16 emergency department report indicated a closed fracture of the left clavicle after a fall at the facility. The 7/2/16 x-ray report stated a shoulder fracture. The 7/2/16 facility investigation stated, on 7/2/16 at 5:45 AM, a (CNA) Certified Nurse Aide transferred the resident from his/her wheelchair to the bed when the resident went limp. Investigation revealed the CNA did not use a gait belt for the transfer. The facility suspended the CNA pending investigation and planned to provide extra education prior to him/her to returning to work. The therapy department will provide a facility wide education on safe transfers and gait belt use. Review of Nurse Aide H's inservice transcripts revealed the facility had provided education regarding accident prevention and management 2 times, preventing slips, trips and falls one time, resident lifting and transfers 1 time, abuse, neglect and exploitation 3 times, since the prior survey on 4/20/15. On 7/7/16 at 12:32 PM, observation revealed the resident, at the dining table, with staff assisting him/her with the meal, and wearing a sling on his/her left arm. At 12:45 PM, Nurse Aides D and E wheeled the resident to his/her room, used a gait belt and extensive assistance of 2 staff to transfer the resident from his/her wheelchair to the toilet. Further observation revealed the resident used the grab bar on the wall to stand and pivot for the transfer. On 7/11/16 at 5:30 AM, observation revealed the resident in bed, arm/shoulder sling in place, call light in reach, TV on, and the room door open. On 7/11/16 at 1:38 PM, Nurse Aides D and F used a gait belt and extensive assistance to transfer the resident from his/her wheelchair to his/her bed, while the resident stood and pivoted slowly. On 7/7/16 at 12:10 PM, Nurse Aide D stated the resident had not fallen for a long time. He/she stated the resident's knees buckle occasionally but he/she does not fall down. Nurse Aide D stated the resident can walk short distances with a walker, gait belt, and his/her balance was relatively good. On 7/7/16 at 3:35 PM, Nurse Aide H stated he/she had been attempting to transfer the resident from his/her wheelchair to the bed when the resident went limp, and they both fell on to the resident's bed. Nurse Aide H stated, as he/she struggled to get the resident onto the bed, the nurse came in to help. Nurse Aide H stated he/she pulled on the resident's upper torso, while the nurse moved the resident's legs. Nurse Aide H stated he/she could not remember if the resident complained of pain at that time. Nurse Aide H verified staff were to transfer this resident using a gait belt, and he/she had not used the gait belt for the transfer on 7/2/16. On 7/7/16 at 4:09 PM, Nurse I stated he/she heard noises coming from the resident's room and went in to see if he/she needed help. Nurse I stated he/she found the resident lying across the bed and the aide attempting to get the resident into proper position on the bed by pulling him/her up by his/her upper body. Nurse I stated the aide verified he/she had not used a gait belt during the attempted transfer. The nurse stated the resident appeared scared, but did not complain of pain at that time. On 7/11/16 at 10:40 AM, Administrative Nurse A verified an aide transferred the resident on 7/2/16, without using a gait belt, and the resident fell across his/her bed, sustaining a fractured clavicle. He/she stated the aide should have used a gait belt with all transfers for this resident. He/she stated the therapy department had provided an inservice regarding transfers on 6/30/16, which was offered as voluntary attendance and he/she verified Nurse Aide H did not attend. Attempts to interview the physician were unsuccessful. The facility's 11/2015 lifting and transferring residents policy stated nurses will assess and determine lifting and transfer requirements and the procedure used for each resident. All residents must be lifted or transferred according to the determined procedure. Residents who require assistance in transferring are transferred using a gait belt or a lift. All nursing staff members are responsible for knowing the proper procedures for transfers. The facility failed to ensure staff transferred Resident #8 using a gait belt, per facility protocol, which placed the resident at risk for injury, and the resident fell during a transfer and sustained a clavicle fracture.

The facility had a census of 57. The sample included 15 of which 3 were sampled for accident hazards. Based on observation, record review, and interview the facility failed to provide adequate supervision and assistive devices for 2 of the 3 sampled residents. Resident #60 had a fall and sustained a cervical fracture when left alone in the shower room. Resident #53 sustained numerous (13) skin tears on upper/lower extremities without no new interventions put in place. The facility had elevated water temperatures in 2 unlocked bathrooms accessible to cognitively impaired independently mobile residents. Findings included: - Resident # 60's medical record revealed [DIAGNOSES REDACTED]. On 1/11/2010 at 2:06 PM observation revealed the resident lying in their bed in the low position with their eyes closed. Further observation revealed the resident had a plastic cervical brace on their neck. Additional observation revealed the resident had a TABS alarm attached to the head of the bed and to the residents shirt. The 7/28/2010 Fall Risk Assessment Screening indicated the resident scored a 10 and with a score of 10 or greater further assessment is required. The assessment further indicated the resident was at risk to fall due to inability to perform balance test and has had 1-2 falls in the last 3 months which resulted in a fracture of the left humerus. The 12/18/2010 post Fall Risk Assessment indicated the resident scored a 27. The assessment further indicated the resident was at risk for falls due to their intermittent confusion, medication administration with side effect for falls, and the resident had falls and a fracture in the last 6 months. The assessment further revealed the resident was unable to perform the balance test, had problems with walking and standing, used assistive devices and the resident was chair bound. The significant change (MDS) Minimum Data Set 2.0 assessment, dated 8/04/2010, indicated the resident had short term memory impairment and moderately impaired decision making skills. The MDS further indicated the resident was at risk to fall due to their predisposing [DIAGNOSES REDACTED]. The quarterly MDS assessment, dated 10/22/2010, indicated the same information as above and also included the addition the resident had a fracture related to a fall. The resident's balance during transfer and walking was not steady and needed stabilization with human help. The MDS further indicated the resident used a walker or a wheelchair for mobility. The 8/06/2010 care plan directed the staff to provide extensive assistance of 1-2 with activities of daily living such as dressing, repositioning, toileting, bathing and to transfer. Further review indicated the resident used a wheelchair for locomotion with an assist of one. Continued review revealed the staff were to lock the wheelchair brakes, and assist the resident to wear non-skid socks or shoes. The 8/06/2010 care plan further directed the staff to "please do not leave me alone in the restroom". The 12/18/2010 at 3:20 PM, nurse's notes indicated Aide F had assisted the resident via a wheelchair to the spa room, closed the door and left the room to obtain linens for the resident's bath. The nurse's notes indicated Aide F heard the resident cry out for help and he/she returned to find the resident on the spa floor with an injury to their face. Continued observation revealed the nurse performed a neurological screen on the resident and noted the right eye to be more sluggish than the left and the resident complained of dizziness. Further observation revealed a bump above the right eye and bloody drainage from a skin tear on the top of the resident's right hand. The 12/18/2019 at 3:37 PM, nurse's notes indicated the resident had been transported to the hospital emergency room . At 6:30 PM the hospital called with an update that the resident had been admitted with a Cervical Spine fracture. On 1/11/2011 at 2:06 PM observation revealed the resident lying in their bed in the low position with their eyes closed. Further observation revealed the resident had a plastic cervical brace on their neck. Additional observation revealed the resident had a TABS alarm attached to the head of the bed and to the residents shirt. On 1/11/2011 at 2:20 PM, Nurse L verified the resident should not be left unattended in the spa/shower room. Nurse L also verified the staff are to place a TABS alarm on the resident at all times. - This deficient practice also affected resident #53 who had multiple skin tears from October to December 2010 without facility interventions or prevention of the skin tears. - On 1/10/11 at 9:45 AM, during the initial tour, observation revealed two unlocked bathrooms located next to the main nurse's station and the service hall. Observation revealed the water temperatures in the bathrooms were 135 degrees when checked by the surveyor. At that time, the surveyor located Maintenance Staff D to check the temperatures. Maintenance Staff D confirmed the surveyor's 2nd temperature check of 130 degrees. Maintenance Staff D further verified no routine temperature checks were obtained on the two unlocked bathrooms. On 1/10/11 at 10:10 AM, Administrative Nurse W verified the bathrooms were unlocked and accessible to residents. The facility failed to ensure the residents' environment, included physical surroundings to which residents had access, remained as free of accident hazards as possible.