Every finding on record at Spencer Post Acute Rehabilitation Center

Based on observation, record review, and staff interview, the facility failed to provide adequate assessment and timely intervention to assure 2 of 3 residents (Resident #1 and #2) received prompt treatment for a change in condition. Resident #1 had urinary tract infection (UTI) symptoms on the weekend of 5/16-17/26 and the facility failed to notify the physician or initiate any other interventions related to the symptoms. Resident #1 had difficulty catching her breath after the evening meal on [DATE] and needed staff to intervene for the resident to clear it. According to the clinical record the resident sat where she could be observed for a half hour and then went to bed. The clinical record lacked documentation the staff monitored her after going to bed. She was later discovered in respiratory distress and transferred to the hospital in critical condition. Resident #1's diagnoses included UTI and pneumonia. Resident #2 admitted to the facility on [DATE]. On [DATE] the nurse going off at 6 p.m. reported to the nurse taking over at 6 p.m. that Resident #2 had nausea and dry heaves. The nurse taking over checked the record and the resident had an order for Zofran and she administered to Resident #2. When the family decided they wanted Resident #2 evaluated in the Emergency Department (ED) and asked for the ambulance to transport, they were told they could not call the ambulance because she was not emergent. The family had to transport the resident in a personal vehicle. Transferring in and out of the vehicle required 3 people and was very taxing on the resident.The facility reported a census of 66 residents. Findings include:1) According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #1 scored 0 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. The resident depended on staff for activities of daily living including, eating, dressing, grooming, transfer and toilet use. Resident #1's diagnoses included Alzheimer's disease, dysphagia, and cognitive communication deficit.The Care Plan revised [DATE] identified Resident #1 on anticoagulant therapy related to a history of venous thrombosis and embolism. Interventions included monitoring/documenting/reporting to the physician as needed signs and symptoms of anticoagulant complications including blood tinged or frank blood in urine.The Progress Notes dated [DATE] at 1:09 p.m. contained a note to monitor for signs and symptoms of bleeding and notify the physician if any of the symptoms were present including passing blood in the urine. The note documented Resident #1 had slight blood-tinged urine off and on during the shift.The Progress Notes dated [DATE] at 6:14 a.m. documented Resident #1 had blood tinged urine, and more lethargic. The resident was incontinent and unable to voice concerns or needs. The note included vital signs, a scant amount of blood in the resident's brief, lethargic, and a slight foul urine odor noted. They requested an order for a urinalysis by straight catheter. A fax dated [DATE] at 6:14 a.m. contained the same information in the Progress Note. The response from the provider read the patient went to the ED for respiratory distress before this was received during clinic hours, no longer applicable, and clinic not open on Sunday so fax not attended to until Monday [DATE] at 8 a.m.The Progress Notes dated [DATE] at 9:31 a.m. documented at start of shift last eve, Resident #1 observed to be struggling to get her breath, with respirations labored and audible congestion noted. Resident #1 encouraged to continue coughing and the resident positioned upright to assist with breathing and clearing fluid she coughed. The resident did cough up and spit out large amount of thick clear/white secretions and able to improve respiratory effort at that time. Vital signs checked. Temperature 98.1, Respirations 20, Blood Pressure 109/59, pulse oximetry 95% on room air at that time. Resident #1 observed closely for roughly 30 min to ensure the resident continued to be stable and breathing without difficulty. No additional issues observed and the resident taken to her room and to bed by 8 p.m. Upon completing rounds on the resident later into last night, at about 10:45 p.m. the resident observed again with labored respirations and struggling to breathe. The resident's color started to change and she became diaphoretic. Resident #1 could no longer clear the heavy respiratory congestion, and at about 11 p.m. 911 called as the resident's condition became concerning. The resident's Responsible Party (RP) contacted to update on the resident's condition and to question if they wanted the resident to be evaluated in the ED or if they wanted to stay and be treated supportively at the facility. Resident #1's RP stated she would like the resident seen. Paramedics arrived and immediately started treating Resident #1, putting measures into place and then transporting her to the ED. Per the paramedic's statement, there was no time or need to contact the provider as they had protocol to follow, and they left the facility with the resident at 11:10. P.m. Call to ED staff with a report. Call received from ED staff several hours later with update the resident would be admitted to the Intensive Care Unit (ICU) with pneumonia, UTI and possible heart attack. Also noted the resident on Bilevel Positive Airway pressure (BIPAP) and that they were contacting family regarding what measures and how aggressive they would be with the resident's treatment and plan of careAn Out of Hospital Patient Care Report (ambulance) dated [DATE] at 10:54 p.m. documented upon on arrival in the hallway they could hear the resident breathing rapidly with rhonchi. Two staff members were present with the resident and sat her in a sitting position. The resident's respiratory rate was above 40 per minute as she gasped short shallow breaths, using accessory muscles to breathe. The resident looked up when they said her name. Her eyes were big and dilated. Skin was pale with core diaphoretic, but extremities cold, cyanotic in color and mottling (irregular red, blue, or purplish patches). Initial oxygen saturation was 78% on room air. The resident's breathing did start to improve with placement of CPAP (Continuous Positive Airway Pressure). Arriving at the facility they went through the double doors and headed to the nurse's station as no one met them. They were directed to Resident #1's room. The RN was on the phone trying to get the Dr's order to place oxygen on the resident. Before they went in to the room they could hear the resident struggling to breathe and inform the RN they would take over care using their protocols. In the room the resident had 2 staff members who had sat her up and tell them she was having trouble breathing. A rapid assessment performed and the resident placed on CPAP and Intravenous (IV) established in the right forearm. Attempt was made to obtain further information but staff was not able to provide besides the resident being a DNR (do not resuscitate). They said she had been fine just a little while ago, but when pushed last known well time was possibly 6 p.m.An Emergency Department Note dated [DATE] at 11:20 p.m. documented the clinical impression of Resident #1 included pneumonia, Urinary Tract Infection (UTI), sepsis, acute hypoxic respiratory failure, and elevated troponin. The resident's condition was critical. The resident went to the emergency department by way of EMS with reports of audible gurgling, respiratory distress and mottled skin. She was given Solumedrol and brought into the ED with CPAP on. Exam included Resident #1 had tachycardia (abnormally fast heart rate), tachypnea (abnormally rapid shallow breathing), course lung sounds, and mottled skin.On [DATE] at 8:40 a.m. Resident #1 sat at the dining room table. She sat hunched over with her head falling forward. Resident #1 opened eyes but did not respond verbally to her name.On [DATE] at 11:31 a.m. Staff A CNA stated Resident #1 was very lethargic and had blood tinged urine that morning. She reported the information to the nurse. She didn't remember helping get a urine sample. She said the blood tinge was off and on.On [DATE] at 12:21 p.m. Staff B Licensed Practical Nurse (LPN) stated it was reported Resident #1 was lethargic and had blood tinged urine. She sent a fax to the provider, anticipating they would receive it and respond the next day. She did not feel it was an urgent matter. She said the resident perked up in the afternoon. She said the resident had no breathing problem her shift.On [DATE] at 1:35 p.m. Staff C Registered Nurse (RN) stated she had done a 6-week contract with the facility and that was her last night. When she got there and they were bringing Resident #1 back from supper she could hear she had difficulty breathing. They got her to cough and bring up some phlegm. She had the resident sit at the nurse's station with her for a while. She said it was not a choking spell, and not something she needed to see a physician for. She told the CNA's not to lay her down right away. She said she checked on her again, and she was breathing easily so she told them she could lay down. She said they had a tornado watch that turned into a tornado warning. The residents remained in their rooms with their curtains closed. She said she also had medications to administer to other residents. She said a nurse who worked as a CNA came and told her Resident #1 was having trouble breathing. Staff C went to the room and the resident was having the same issue she had before. Resident #1 couldn't clear it and she called 911. She didn't have a chance to get oxygen. The ambulance arrived and took over.On [DATE] at 3:09 p.m. Staff D RN said she picked up a shift on [DATE] working as an aide on the 2-10 shift. She said Resident #1 had sinus congestion, like a cold when she saw her early in the shift and she told the day nurse. She said Resident #1 ate supper. She was not aware of any problem following supper. She said they had the weather alerts and a warning that went on until 9:30 p.m. Another CNA asked her how long Resident #1 had been like that and Staff D said she was congested. The CNA said it was way more than that. Staff D went to the room and it was an obvious problem. She elevated the head of the bed and got Staff C, and told her she needed to assess the resident. While Staff C called 911 and made some other calls, Staff D stayed with the resident until the paramedics arrived. They asked her questions she didn't know the answers to. They took over care and started an IV while still there.On [DATE] at 8:31 a.m. the Director of Nursing (DON) stated if an issue arose on the weekend the nurse called the ED with information on the resident and request for an order. The ED got hold of the family practice on call. Then they receive the order or say that it could wait. If they send a fax to the physician on the weekend, it would not be addressed until Monday. She said blood in the urine should not wait until Monday. She said Resident #1 would have trouble clearing secretions.On [DATE] at 9:40 a.m. Resident #1's Physician stated if there was blood in the urine it could probably be a fax to the office. If there were other symptoms like being more lethargic and slight foul urine odor, she preferred they would contact the on-call physician for orders, rather than waiting until Monday if it was on the weekend.She said if a resident was just coughing at a meal, she didn't feel that needed reported. If it affected breathing that should be reported, but it could be a fax if the resident was able to clear it. She thought an assessment would include vital signs and heart and lung check. She thought the fax would be ok if they monitored Resident #1's respiratory status closely that night. 2) The Progress Notes dated [DATE] documented a report from the hospital identified Resident #2 was alert and oriented with aphasia (impaired ability to process, speak, write and understand language). The resident utilized oxygen continuously. The resident was a pivot transfer.The Progress Notes dated [DATE] at 12:14 p.m. documented Resident #2 had dizziness and emesis this a.m. with low blood pressure (BP) 83/48, and severe pain in her back with any movements and while sitting in the recliner, rated 7 (on a scale 0 being no pain and 10 being the worst pain they could imagine). Resident #2 got extremely dizzy when standing. The Progress Notes date [DATE] documented follow up pain scale a 2. At 8:11 p.m. received electronic faxes regarding the note the nurse sent out earlier. Resident #1 would start Zofran 4 mg every 8 hours as needed for nausea and vomiting. The order also contained a pain patch and a gel for pain.The Progress Notes dated [DATE] at 7:39 p.m. documented Resident #2 received Ondansetron (Zofran) 4 mg for nausea. At 7 :41 p.m. Resident #2's family to visit. Per the family member, the nurse called the on-call ED physician to request a visit to the ED for evaluation. The ED nurse said the on-call provider would call the facility with further orders. While discussing with the family, the physician called and said okay for ED visit. Family said they would wait for the Zofran to work and see how she did through the night. A family member would stay the night. At 10:52 p.m. Resident #2 taken to the ED by 2 family members. At 11:07 p.m. received call from the hospital requesting further information. The facility nurse briefed them the resident had nausea an vomiting and Zofran not effective. The family requested Resident #2 go to the ED for evaluation.The Progress Notes dated [DATE] at 2:30 a.m. documented the nurse from the hospital call to conform the last time the Resident #2 received Eliquis, and the facility staff relayed at 8 p.m. The hospital nurse said the resident would stay over night since her hemoglobin was 5 (very low). At 8:09 a.m. Resident #2 admitted to the hospital. At 1:44 a.m. family removed Resident #2's belongings from her room and said she was not doing well and would not return to the facility.On [DATE] at 3:10 p.m. a hospital nurse stated Resident #2 brought to the hospital in a car. She was minimally responsive. It took 3 people to get her out of the car when she arrived. It was difficult and distressing to the resident. Family stated they thought she should be seen and Staff F Registered Nurse (RN) told them they would have to transport her because she wasn't emergent.On [DATE] at 12:37 p.m. Staff E Certified Nursing Assistant (CNA) stated she only worked with Resident #2 1 day ([DATE]). Staff E got Resident #2 up and she said she felt really weak. Resident #2 was getting a shower, and Staff E didn't work with her again that day.On [DATE] at 8:40 a.m. Staff F RN stated she worked 6 p.m. to 10 p.m. where Resident #2 resided (that evening). She said the off going nurse reported Resident #2 was nauseas and had dry heaves. She checked Resident #2's Medication Administration Record (MAR) and saw she had Zofran ordered, so she gave her 1 to see if that would settle (the nausea) down. Staff F talked to the Dr. on the speaker phone with the family there, and they said they would wait to see if the Zofran worked. Staff F said, the family member present said Resident #2 should go to the hospital, so she called the RP and he wanted her to go by ambulance. Staff F said Resident #2 was not appropriate to go by ambulance, her condition was not emergent and she could transfer into a vehicle. She asked the son to take her and he was okay with it.The Clinical record lacked any documentation Resident #2 had nausea or dry heaves on the 6 a.m. to 6 p.m. shift, or interventions to help relieve it.On [DATE] at 9:02 a.m. Resident #2's RP stated he asked about sending her by ambulance and the nurse said they couldn't because it was not an emergency. They went to take her and they had trouble getting her in and out of the vehicle. She was moaning and crying. He said she died 2 days later. He said she shouldn't have had to go out that way.On [DATE] at 9:13 a.m. Resident #2's family member stated they were told she couldn't go by ambulance because it was a non-emergency. The family member said they had to pull her up in the seat and she cried help me. She said 3 people had to get her out when she got to the hospital.On [DATE] at 12:54 p.m. Staff G RN (worked day shift) stated Resident #2 did have nausea and dry heaves [DATE]. She said she did give her a Zofran, then got busy with something else and forgot about it. She could not remember the time she gave it. She thought it might have helped. She could not give specifics (time) if it wasn't documented. On [DATE] at 8:31 a.m. the DON stated Resident #2 was in the facility not even 2 days. She was unsure how things went on Saturday except what she was told or read in the nurse's notes. She did not know the family transported her to the hospital. She said Staff F may not have known she could call for the facility transport on the weekend. She agreed if the family wanted her sent by ambulance they could have called the ambulance. She would expect staff to assess residents who had a new or worsening condition and intervene as appropriate, including notifying the physician for possible orders. The facility policy Notification, Physician or Responsible Party revised 08/2007, documented it was the policy of the facility to promptly notify the resident, his/her attending physician, and/or family/responsible party of changes in the resident's condition and/or status.The facility Resident Assessment and Associated Processes policy documented it was the policy of the facility that residents would be assessed and the findings documented in their clinical health record.

Based on clinical record reviews, staff interviews and policy review, the facility failed to put effective interventions in place and provide adequate nursing supervision to prevent accident and injuries from falls for 1 of 1 residents reviewed (Resident #2). Resident #2 had a risk for falls with a history of repeated falls. Resident #2 had his thirteenth fall on 3/15/25 in a three-month period of time. Findings include: Resident #2's Minimum Data Set (MDS) dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 2, indicating severe impaired cognition. The MDS listed Resident #2 as substantial/maximal assistance with rolling left and right, sit to lie, toilet transfer, supervision for toileting and chair/bed to chair transfer. The MDS described Resident #2 as frequently incontinent of urine. Resident #2's MDS included diagnoses of Parkinson's disease, cerebrovascular accident, diabetes mellitus, and renal insufficiency. The Facility Incident Reports (IR) documented revealed Resident #2 fell on [DATE], 12/27/25, 12/2925, 12/31/25, 1/2/26, 1/6/26, 1/7/26, 2/4/26, 2/25/26, 3/8/26, 3/12/26, 3/13/26 and 3/15/26. The Care Plan with a target date of 10/2/2025 revealed Resident #2 was at risk for falls related to history of falls and decreased safety awareness. The interventions directed the following:12/23/25 Room free from clutter,12/27/25 No current intervention listed,12/29/25 Resident placement closer to nurses station to monitor when resident is ready to get up, so staff is able to assist before resident attempts to self-transfer,12/31/25 Hospice consult,1/2/26 Continue to be out by nurses station for increased supervision,1/6/26 Resident to be seen on facility rounds by provider on 1/7/26, 2/4/26 Transferred to his wheelchair and brought to the recliner near the nurses station for close monitoring,2/25/26 Resident was trying to help another resident and fell. Staff to be mindful when Resident #2 is sitting in the common area with other residents who need assistance.3/9/26 Resident #2 to be toileted before lunch,3/12/26 Will reach out to hospice and see if they can provide more activity throughout the day to help with supervision.3/13/26 Resident #2 to be toileted prior to supper,3/15/26 Urinalysis obtained and started on antibiotic. An Incident Report (IR) dated 1/2/26 at 5:00 p.m. identified an unwitnessed fall in his room. The IR indicated Resident #2 was found in his room on the floor. The IR stated the staff heard yelling coming from Resident #2's room and saw him picking himself up off the bathroom floor. The IR indicated Resident #2 had self transferred to the toilet without a walker or assistance. Resident #2 was trying to go to the bathroom without assistance or utilizing the call light. Immediate action taken to reeducated Resident #2 on the use of the call light and asking for assistance. Resident #2 is oriented to self only. Continue to encourage staff to keep Resident #2 near the nurses station for increased supervision. The notes on the IR indicated Resident #2 was oriented to self only, dementia progression, short recall and impulsiveness. An IR dated 1/7/26 at 7:50 pm identified an unwitnessed fall in the common area. The IR indicated the nurse heard someone yelling and went up to the lounge area to see what happened. Resident #2 was found lying on his left side on the floor, Resident #2 was unable to give a description of what happened. Resident #2 received two abrasions to the left elbow. This nurse and certified nurses assistant (CNA) assisted Resident #2 back to his feet and then put him in the recliner. Staff kept Resident #2 within a visual view after this incident. The IR indicated Resident #2 was seen on nursing home rounds and started on antibiotics, lasix (water pill) and a 2 liter fluid restriction. An IR dated 2/25/26 at 8:05 pm identified an unwitnessed fall in the common area. The IR indicated Resident #2 was sitting in recliner in the common area and another resident asked for help, Resident #2 stood up to help the other resident and he lost his balance and fell landing on his right side. Resident #2 received a skin tear to the right elbow. Intervention for staff to be mindful when Resident #2 is sitting in the common area with other residents who need assistance. Interview on 3/26/26 at 12:58 pm with Staff D, LPN, Staff D stated we had Resident #2 out in the living room a lot for increased supervision. Staff D stated the expectations for Resident #2 was to have visual supervision. Staff D stated she doesn't remember where the other staff were at during this time. An IR dated 3/8/26 at 12:15 pm identified an unwitnessed fall in the common area. The IR indicated this nurse was sitting at the nurse's station on the phone when she turned her head and saw Resident #2 was in mid-fall out of the left side of his recliner. Intervention Resident #2 to be toileted prior to lunch. Interview on 3/26/26 at 1:11 pm with Staff E, LPN stated that she was on the phone talking to another family member and she turned her head and that is when she saw him in mid fall out of his recliner. Staff E stated he self transfers constantly, he wants to go home, bathroom or to bed. Staff E stated we put him in the wheelchair and he will propel himself around, sometimes he is okay with that. The expectation now is to keep at least one staff member out there, before it was just to make sure he was out in the living room area. Staff E stated he wouldn't be out there very long without someone. We would have other staff out there and if he tried to get up, they would call us for help. An IR dated 3/15/26 at 7:45 am identified an unwitnessed fall in the rehab gym. The IR indicated this nurse returned from administering medications to another resident down the hall to find Resident #2 was not in the dining area but his wheelchair was. Resident #2 was found in the therapy room on his knees and leaning on the therapy bed with his arms. (like in a praying position). The therapy gym is connected to the dining room by 3 short hallways. Interview on 3/26/26 at 1:29 pm with Staff C, Licensed Practical Nurse (LPN), revealed Resident #2 was at the dining room table in his wheelchair. She stated when she returned from another resident's room he wasn't in the wheelchair. She stated they found him in the therapy gym. Review of the facility's policy named Fall Management System revised 10/2020 revealed the facility is committed to promoting resident autonomy by providing an environment that remains as free of accident hazards as possible. Each resident is assisted in attaining or maintaining their highest practicable level of function through providing the resident adequate supervision, assistive devices and functional programs as appropriate to prevent accidents. It is the policy of this facility to provide each resident with appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurs. On admission / re-admission to the facility each resident is assessed using the Fall Risk Evaluation to determine his/her risk for sustaining a fall.Residents with a Fall Risk Evaluation score of 10 or above are considered high risk and will have an individualized care plan developed that includes measurable objectives and timeframes. The care plan interventions will be developed to prevent falls and will consider the particular elements of the assessment that put the resident at risk.When a resident sustains a fall, a physical assessment will be completed by a licensed nurse, with results documented in the Nursing Progress Notes. The Attending Physician and family/ responsible party shall be notified of the fall and the resident status. The Interdisciplinary Team (IDT) will review the circumstances surrounding the fall and implement actions to reduce the incidence of additional falls and minimize potential injury. IDT review of the fall incident will include but not limited to determining probable causal factors, environmental factors, resident medical condition, resident behavioral manifestations, and medical or assistive devices that may contribute to the fall. The IDT will also review fall patterns for residents with multiple/repeat falls. Results of the IDT review will be documented in the resident's Clinical Record.Resident's existing care plan will be updated. The care plan interventions will address those elements determined by investigation as probable causal factors that contributed to the fall. Residents will be reassessed for fall risk with any significant change in resident's condition or the development of behavioral symptoms that increases the resident's risk for falls; as well as with a comprehensive MDS and quarterly thereafter. Interview on 3/26/26 at 10:30 am with the DON stated the expectation is that staff were to have visual supervision on Resident #2, and they are to read the resident's kardex's and careplan for updated interventions/communication when they are on shift.

Based on clinical record review, interviews, and facility policy, the facility failed to ensure bed hold notice was signed by residents and or the resident's responsible person when residents transferred out of the facility for 4 of 4 residents reviewed (Residents #2, #4, #5 and #9). The facility reported a census of 67 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #4 documented reentry to the facility on 2/20/25 for a short term hospital stay. Review of the Clinical Census report for Resident #4 revealed the following information:a. 11/25/24- hospital leaveb. 12/3/24- activec. 2/9/25- hospital d. 2/11/25- active Review of the Progress Notes for Resident #4 revealed the following:a. 12/12/24 at 2:55 PM, Resident admitted to the hospital on [DATE] for a fracture. b. 2/9/25 at 1:30 PM, Resident admitted to the hospital for emesis and repeated hospitalizations. Review of Resident #4’s chart on 8/13/25 at 9:19 AM showed the facility lacked a bed hold form for 11/25/24 and 2/9/25. In an interview on 8/13/25 at 1:52 PM, the Director of Nursing (DON) reported she would look for bed hold forms for 11/25/24 and 2/9/25. The DON reported that she expected staff to complete bed hold forms prior to residents leaving the building. No bed hold forms submitted. 2) According to the MDS assessment dated [DATE] Resident #2 scored 3 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. The resident's diagnoses included a stroke and aphasia (a language disorder affecting the ability to communicate). The Progress Notes dated 6/24/25 at 7:09 a.m. documented the resident had Urinary Tract Infection (UTI) symptoms. At 11:26 a.m. a phone call from the clinic reported the Urinalysis (UA) was positive for infection. The white blood count at 19.8 (elevated). Sent to the emergency room (ER) for further evaluation, with possible admission, would call back later. At 1:18 p.m. called the ER for an update on the resident. The ER nurse stated the resident would admit to the hospital for a UTI. The resident's clinical record lacked documentation the facility notified the resident/representative of the bed hold policy. On 8/13/25 at 5:20 p.m. the DON stated the bed hold would be scanned in to the Miscellaneous tab if they had one. The Miscellaneous tab revealed no file indicating a bed hold. 3. The MDS assessment dated [DATE] for Resident #5 documented diagnoses of hypertension, depression and acute respiratory failure with hypoxia. The MDS showed the BIMS score of 10, indicating moderate cognitive impairment. Review of Resident #5’s Census tab revealed the following information: 3/14/25- stop billing 4/3/25- active Review of Progress Notes revealed the following: On 3/14/25 at 2:50 p.m., verbal order received to send resident to the emergency room (ER) for evaluation. On 3/14/25 at 5:41 p.m., resident admitted to the local hospital. On 4/3/25 at 4:11 p.m., resident returned to facility via transport from hospital. Review of the medical chart lacked a bed hold for resident during hospitalization. Interview on 8/13/25 at 10:30 a.m., with the Assistant Director of Nursing (ADON) revealed there was no bed hold completed for Resident #5 during hospitalization on 3/14/25. 4. The MDS assessment dated [DATE] for Resident #9 documented diagnoses of anemia, cancer and malnutrition. The MDS showed the BIMS score of 15, indicating no cognitive impairment. Review of Resident #9’s Census tab revealed the following information: 8/1/25- stop billing 8/5/25- active Review of Progress Notes revealed the following: On 8/1/25 at 7:14 p.m., resident sent to local ER for evaluation. On 8/1/25 at 10:00 p.m., resident hospitalized with right hip fracture. On 8/5/25 at 12:21 p.m., resident back to facility via facility transport. Review of the medical chart lacked a bed hold for resident during hospitalization. Interview on 8/13/25 at 10:30 a.m., with the Assistant Director of Nursing (ADON) revealed there was no bed hold completed for Resident #9 during hospitalization on 8/1/25. Review of facility provided policy titled Bed Hold with a revision date of 5/21/21 revealed it is the policy of this facility to inform the resident, or the resident’s representative, in writing, of the right to exercise the bed hold provision, upon admission and before transfer to a general acute care hospital or before the resident goes on therapeutic leave. A copy of this notification shall become a part of the resident’s health record at the time of transfer. Interview on 8/12/25 at 1:27 p.m., with Medical Records revealed when a bed hold is completed it is uploaded into the residents charts and if they are not there they were not applicable or they didn’t get them done. Interview on 8/13/25 at 10:30 a.m., with the ADON revealed the bed holds for Resident #5 and #9 were not completed and they should have been done when the resident was transferred out of the facility.

Based on observation, Medication Administration Record (MAR), policy review, and staff interview the facility failed to provide appropriate infection prevention practices when providing care to a resident with a catheter, with wound care, and a resident with an enteral tube, that was on Enhanced Barrier Precautions (EBP) for 5 of 7 reviewed (Resident #4, #7, #9, #14 and #38). The facility reported a census of 67 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #4 documented a Brief Interview for Mental Status (BIMS) of 5 indicating severe cognitive impairment. The MDS documented Resident #5 had a diagnosis of type 2 diabetes mellitus without complications. Review of Resident #4’s MAR documented a Physician’s Order for insulin Lispro injection per sliding scale if blood glucose was 140-180 2 units. 2. The MDS dated [DATE] for Resident #14 documented a BIMS of 5 indicating severe cognitive impairment. The MDS documented Resident #5 had a diagnosis of type 2 diabetes mellitus without complications. Review of Resident #14’s MAR documented a Physician’s Order for blood sugar checks one time a day at 7:00 AM. 3. The MDS dated [DATE] for Resident #38 documented a BIMS of 6 indicating severe cognitive impairment. A continuous observation on 8/13/25 at 7:12 AM morning blood glucose checks and insulin administration revealed Staff B, Registered Nurse (RN) did not complete hand hygiene, applied gloves, knocked on Resident #4’s door, entered the residents room, barrier placed on bedside table, cleansed left index finger with alcohol wipe, utilized a lancet to obtain blood sample from left index finger, blood glucose of 153 reported. Staff B exited room, removed gloves, unlocked medication cart, placed blood glucose supplies on the medication cart, returned to Resident #4’s room, covered Resident #4 with a blanket, left Resident #4’s room walked down the hall to Resident #38’s room, knocked on the door, entered Resident #38’s room. Staff B exited Resident #38’s room, returned to the medication cart, moved the medication cart down the hall to Resident #14's room. Staff B applied gloves, knocked on Resident #14’s door, placed a barrier on the Resident #14s bedside table, cleansed the right index finger with an alcohol wipe, lancet utilized to obtain blood sample, blood glucose of 171 reported. Staff B exited room, blood glucose supplies placed on medication cart, removed gloves, pushed medication cart to the nurse station, sat down at the computer, typed on the computer. Same blood glucose machine used on both residents without being cleansed. Staff B returned to medication cart, removed heavy sani-cloth removed from medication cart, utilized sani-cloth to wipe glucose monitor, glucose monitor placed on sani cloth, obtained hand sanitizer from nurse station, placed hand sanitizer on the medication cart, utilized hand sanitizer to complete hand hygiene, Staff B removed Resident #4's insulin Lispro and insulin Glargine from medication cart, Staff B dialed 2 units on the insulin Lispro pen for sliding scale, Staff B dialed 32 units of insulin glargine. Staff B did not prime 2 units from either insulin pen. Staff B walked down the hall, knocked on Resident #4’s door, explained the procedure, cleansed the area on left abdomen with an alcohol wipe, insulin Lispro administered in Resident #4’s left abdomen, area on left abdomen cleansed with alcohol wipe, insulin Glargine administered in Resident #4’s left abdomen. Staff B returned to the medication cart, Staff B removed gloves, placed insulin in the medication cart, pushed the medication cart down the hall to next residents room, Staff B knocked on the door and entered the residents room. On 8/13/25 at 9:10 AM Staff B, RN stated she never primed the needle tips for insulin pens. Staff B stated she had never been told to prime the needle for the insulin pen. Staff B acknowledged that every resident shared one glucose monitor at the facility. Staff B stated she was nervous and forgot to cleanse the monitor the first couple times. Staff B stated she utilized the sani-cloth to cleanse the glucose machine. Staff B explained she wiped it down and allowed it to dry. Staff B stated she was unaware if the machine was required to be wet for any amount of time. Staff B acknowledged the machines were not wet for 2 minutes per the instructions on the Super Sani-wipes. On 8/13/25 at 11:12 AM the Director of Nursing (DON) stated hand hygiene should have been completed prior to application of gloves and after removal of gloves. The DON stated her expectation was the blood glucose machine would be cleansed according to the manufactures requirements and between residents. The DON stated the facility’s expectation was the rubber septum of insulin pens prior to application of the needle tip. Review of document dated 4/18/25 titled, Hand Hygiene documented hand hygiene should be utilized before and after direct contact with residents, before preparing or handling medications, after contact with a resident’s intact skin, after contact with bloody or bodily fluids and after removing gloves. Review of document reviewed 6/25 titled, Infection Control Policy / Procedure with subject Glucometer, Cleaning and Decontamination of documented the facility’s policy was to follow recommendation from the CDC or manufacturer’s guidelines. Review of Assure Platinum Blood Glucose Monitoring System User Instruction Manual documented cleaning and disinfection could be completed by using a commercially available EPA-registered disinfectant detergent or germicide wipe. To wipe, remove from the container and follow product label instructions to disinfect the meter. Review of directions for use of Super Sani-Cloth Germicidal Disposable Wipe documented to unfold wipe and thoroughly wet surface. Allow the surface to remain wet for 2 minutes. Let air dry. 4. The Clinical Physician Orders for Resident #7 showed an order on 5/15/25 to:a. Cleanse buttocks with wound cleanser and 4x4'sb. Dampen collagen with normal saline before inserting into wound c. Place a small piece of calcium alginate on topd. Cover with a 4x4 silicone bordered dressing, changing daily and PRN for dislodgment, drainage, or if it gets soiled. Observation on 8/13/2025 at 10:11 AM of Resident #7 showed Staff E and Staff F Certified Nursing Assistants, (CNA) completed peri care, catheter care then removed the pressure ulcer dressing to the coccyx area, and completed peri care. After care Staff B, Registered Nurse (RN) entered the room to complete the dressing change to the coccyx. Upon arrival to the room the nurse reported she wasn't sure if the pressure ulcer had healed. The nurse washed hands, donned gloves and cleansed the area. The nurse failed to don Personal Protective Equipment (PPE) per Enhanced Barrier Precaution (EBP) protocol. In an interview on 8/13/2025 at 1:52 PM, the Director of Nursing (DON), reported the nurse should follow EBP precautions when completing cares for a resident with a catheter or pressure ulcer. The DON reported the nurse to be knowledgeable in infection control practices. The DON stated, I don’t know why she didn’t. 5. The MDS assessment dated [DATE] for Resident #9 documented diagnoses of anemia, cancer and malnutrition. The MDS showed the BIMS score of 15, indicating no cognitive impairment. Observation on 8/11/2025 at 11:37 a.m., resident noted to be hooked up to feeding tube and sitting up in bed sleeping with an EBP sign on the door into the residents room. Observation on 8/13/2025 at 2:46 p.m., with Staff B, RN entered residents room to administer medications via feeding tube and to hook up his feeding. Staff B entered the residents room and did not apply any personal protective equipment (PPE) upon entering the residents room. Staff B administered medications into the feeding tube with no PPE. At 3:00 p.m., Staff B exited the room after removing gloves and washing her hand to return a basket to her medication cart. At 3:02 p.m., Staff B returned to the room and did not apply any PPE. Staff B checked tube placement and exited the room to take a phone call. Staff B reentered the room at 3:08 p.m., and did not apply PPE prior to listening to the residents lungs and hooking up the residents tube feeding. During interview on 8/13/2025 at 3:34 p.m., Staff B was asked if she was aware of what EBP was? Staff B paused and stated yes she was aware of what EBP was and she should have used it in the room but she had forgotten about the feeding tube. Staff B looked in Resident #9’s room and revealed the room contained PPE for the staff to wear during cares. Review of the Centers for Disease Control website titled Frequently Asked Questions about Enhanced Barrier Precautions in Nursing Homes dated June 28, 2004 visited on 8/14/25 revealed the following information: Enhanced Barrier Precautions are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). The studies that informed EBP, including defining which care activities most commonly result in transfer of MDROs to staff hands and clothing, were conducted in adult nursing home populations. Assuming Contact Precautions do not otherwise apply, Enhanced Barrier Precautions are recommended for residents with any of the following: 1) infection or colonization with a MDRO or 2) a wound or indwelling medical device, even if the resident is not known to be infected or colonized with a MDRO. Enhanced Barrier Precautions are recommended for residents with indwelling medical devices or wounds, who do not otherwise meet the criteria for Contact Precautions, even if they have no history of MDRO colonization or infection and regardless of whether others in the facility are known to have MDRO colonization. This is because devices and wounds are risk factors that place these residents at higher risk for carrying or acquiring a MDRO and many residents colonized with a MDRO are asymptomatic or not presently known to be colonized. Interview on 8/13/2025 at 3:32 p.m., with the ADON revealed she expected staff to be wearing PPE when they were coming into contact with body fluids. When asked if she would expect the staff to wear PPE during a tube feeding the ADON verified the staff should be wearing PPE when providing care to a resident with a tube feeding. Interview on 8/13/2025 at 4:02 p.m., with the DON revealed the staff and nurses should be wearing PPE when providing care to Resident #9 as he has a feeding tube. During the interview with the DON she revealed Staff B used to be the infection control nurse for the building and she knows that she should have been wearing PPE during the medication administration and working with the tube feeding. The DON verified Staff B should have been wearing PPE.

Based on resident and staff interviews, and policy review, the facility failed to have ready and reasonable access to personal funds upon request for 1 of 17 residents reviewed (Resident #10). The facility reported a census of 67. Findings Include:In an interview on 8/11/2025 12:55 PM, Resident #10 reported that if she wanted personal funds during the weekend, she had to plan to get money from the office on Friday.In an interview on 8/12/2025 at 9:25 AM, Resident #10 reported she could not remember when or which staff she asked for personal funds. Resident #10 stated, when I asked they told me that I had to wait for the office manager to be here.In an interview on 8/14/2025 at 8:38 AM, Staff C, Certified Medication Assistant/Certified Nurse Assistant (CMA/CNA) reported if a resident requested personal funds she would go to the Business Officer Manager (BOM). When asked what she would do during non-business hours, Staff C stated, I would probably try to call the head of Human Resources. When asked if a locked cash box or any other way to get funds for a resident during non-business hours, Staff C stated, no. In an interview on 8/14/2025 at 8:58 AM, Staff D, Licensed Practical Nurse, (LPN) reported if a resident requested funds after hours they would have to call whoever was on call. Staff D reported having no access to available funds for residents. Staff D reported she worked at the facility for five years and never knew there to be funds readily available. In an interview on 8/14/2025 at 9:02 AM, the Business Office Manager, BOM reported she would be on call if residents needed funds. When asked if the facility provided readily available funds for residents, the BOM reported approximately a year ago the facility had a lock box but the process needed to be updated. When informed staff interviews failed to show knowledge of a lock box, the BOM replied, the process needs to be updated. In an interview on 8/14/2025 at 9:02 AM, the Director of Nursing (DON) reported no knowledge of personal funds on site for residents. When told the BOM reported having a locked box about approximately one year ago the DON replied, I'll look into it. When asked if the facility should have funds readily available for residents upon request, the DON stated, of course, for dinner with family, or whatever they want.In an interview on 8/14/2025 at 10:56 PM, the Administrator reported the facility failed to have a policy related to personal funds. In an interview on 8/14/2025 at 1:56 PM, BOM showed an envelope with cash and reported funds now available for residents. The BOM explained the facility would work on a plan for the location and staff access to funds.

Based on clinical record review and staff interview the facility failed to identify non-pharmacological interventions and targeted behaviors on the care plan related to high risk medications in 2 out of 5 sampled residents reviewed (Resident #4 and #21). The facility reported a census of 67 residents.Findings include: 1.The Minimum Data Set (MDS) assessment dated [DATE] for Resident #4 documented diagnoses of stroke, aphasia, and anxiety. The MDS showed the Brief Interview for Mental Status (BIMS) score of 5, which indicated severe cognitive impairment. The Clinical Physician Orders for Resident #4 showed the following orders: Seroquel Oral Tablet 25 milligram (MG) at bedtime with a start date of 4/3/25 Olanzapine Oral Tablet 10 mg daily with a start date of 7/3/25 Oxycodone Oral Tablet 5 MG every eight hours as needed for pain with a start date of 2/11/25. The Care Plan identified Resident #4: Prescribed antipsychotic medication related to anxiety and depression. The Care Plan lacked targeted behaviors to monitor. Prescribed psychotropic medication related to anxiety and depression. The Care Plan lacked targeted behaviors to monitor. Prescribed opioid for chronic pain. The Care Plan lacked non-pharmacological interventions to use prior to opioid medication usage. In an interview on 8/13/2025 at 1:52 PM, the Director of Nursing, (DON) reported the care plan should include non-pharmacological interventions to use prior to opioid medication usage and targeted behaviors to monitor for with the usage antipsychotic and psychotropic medications. The Unnecessary Drugs policy last revised 11/12/15 identified: POLICY: It is the policy of this facility that each resident’s drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used:In excessive dose (including duplicate therapy); orFor excessive duration; orWithout adequate monitoring; orWithout adequate indications for its use; [NAME] the presence of adverse consequences which indicate the dose should be reduces or discontinued; orAny combinations of the reasons above. PURPOSE: The purpose of this requirement is that, each resident’s entire drug/medication regimen be managed and monitored to promote or maintain the resident’s highest practicable mental, psychical, and psychosocial well-being. PROCEDURES: Resident receives only those medications, in doses and for the duration clinically indicated to treat the resident’s assessed condition(s). Non-pharmacological interventions are considered and used when indicated, instead of, or in addition to, medicationBehavioral interventionsExercisePrevention of constipationPain managementSleep hygieneIndividualized toileting scheduleAddressing food preferences The potential contribution of the medication regimen to an unanticipated decline or newly emerging or worsening symptom is recognized and evaluated, and the regimen is modified when appropriate. Incorporate appropriate medication related goals and parameters for monitoring the resident’s condition into the comprehensive care plan. 2) According to the MDS assessment dated [DATE] Resident #21 scored 3 on the BIMS indicating severe cognitive impairment. The resident's diagnoses included senile degeneration of the brain. The MDS did not indicate the resident took antidepressant medication. The Care Plan revised 1/2/25 identified the resident on antidepressant medication use related to insomnia. The interventions included giving antidepressant medications ordered by the physician. Monitor/document side effects and effectiveness. The August 2025 Medication Administration Record (MAR) showed the resident received Trazadone 50 MG bedtime daily for Insomnia initiated 10/1/24. The clinical record lacked documentation of a Gradual Dose Reduction (GDR) of the Trazadone. On 8/13/25 at 12:05 p.m. the Pharmacy Consultant confirmed the resident should have had a GDR. She stated she sent out a letter for a GDR in May, and again in June. She said she wondered if the Dr. addressed it in a Progress Note in June. She had the Director of Nursing (DON) looking for it. On 8/13/25 at 3:38 p.m. the DON stated they had not found any completed GDR's for the resident's Trazadone. On 8/14/25 at 12:51 p.m. a sister facility's DON showed the facility policy for psychotropic meds, that did not specifically address GDR's. He said he did not find one that did.

Based on observations, clinical record review and staff interview the facility failed to revise and update care plans to include a new order for oxygen usage on the comprehensive care plan for 1 of 17 residents reviewed (Resident #9). The facility reported a census of 67 residents. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #9 documented diagnoses of anemia, cancer and malnutrition. The MDS showed the Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. Observation on 8/11/2025 at 11:36 AM currently wearing oxygen sitting up in bed. Observation on 8/12/2025 at 12:27 PM currently sleeping in bed with oxygen concentrator on via nasal cannula and running. Review of August Medication Administration Record (MAR) lacked orders for oxygen usage. Review of current Physician Orders lacked an order for oxygen usage. Review of the Care Plan dated 8/12/25 lacked information regarding oxygen usage. Interview on 8/13/2025 at 10:30 a.m., with the Assistant Director of Nursing (ADON) revealed the resident has an oxygen order from his current hospital discharge. The ADON revealed the order should have been added to the orders when he came back from the hospital. Interview on 8/13/2025 at 1:34 p.m., with the Director of Nursing (DON) revealed the hospital discharge order had been noted and should have been put on the orders. The order should have been on the chart and it should have been added to the care plan for the staff. Review of the facility provided policy titled Care Planning with a reviewed date of 9/2020 revealed it is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. The Care Plan will be revised as needed, and interventions will be implemented. The resident's comprehensive plan of care will be reviewed and/or revised by the IDT after each assessment and updated as appropriate. The Care Plan will be revised as needed for order changes or Resident changes in condition, and interventions will be implemented as appropriate.

Based on clinical record review, resident and staff interviews and facility policy review the facility failed to have a physicians order to administer medications prior to administering medications to 1 of 1 residents reviewed (Resident #70). The facility reported a census of 67 residents. Findings include:Resident #70's active diagnosis list included type 2 diabetes mellitus with hyperglycemia and hypertension.The MDS had not been completed for a Brief Interview for Mental Status (BIMS). Interview on 8/11/2025 at 12:38 p.m., with Resident #70 revealed she had a concern with her medications and the facility not having them. She further explained that on 8/9/25 she had to call the local pharmacy to get her Mounjaro (tirzepatide(diabetic medication)) delivered to the facility as they did not have it. Review of hospital discharge records revealed an order for tirzepatide every 7 days with the word hold written next to it. Review of the Order Summary Report signed by the physician on 8/5/25 lacked an order for Mounjaro. Review of current orders revealed an order for Mounjaro with an order date of 8/9/25 at 7:40 p.m., entered by Staff J, Licensed Practical Nurse (LPN). Review of the current Progress Notes lacked orders for Mounjaro medication orders on 8/9/25. Review of the Order Summary Report signed by the physician on 8/11/25 revealed an order for Mounjaro with an order date and start date of 8/9/25. Interview on 8/13/25 at 10:35 a.m., with the Assistant Director of Nursing (ADON) revealed the hospital records were her orders and the facility wrote hold on the orders and faxed that to the pharmacy so they would not send it as the resident told her she would provide the medication so she would not get charged for the medication again. Interview on 8/13/25 at 10:56 a.m., with Resident #70 further revealed that when she was admitted the facility told her she needed to provide her own Mounjaro medication. She was unsure why but she said she had to call on 8/4/25 to get it filled at the local pharmacy. She stated the pharmacy had to order it and when she called them again on 8/9/25 the pharmacy delivered it to the facility. She further revealed the evening of 8/9/25 she had to ask the nurse for the medication. The nurse told her the facility didn't have the order and a little while later she came back with it. Resident #70 explained the nurse didn't know how to use the pen so the resident told her to give it to her and she would do her own injection. Resident #70 verified she gave herself the injection that evening. Interview on 8/13/2025 at 11:06 a.m., with Staff H, Pharmacist revealed the pharmacy received an order for Resident #70 for Mounjaro on 8/4/25 and the pharmacy had to order the medication. She believed the medication was there on 8/7/25. Staff H revealed Resident #70 called the pharmacy on 8/9/25 upset that her medication had not been delivered to the facility. Staff H explained the pharmacy does not usually deliver medications on the weekends but did deliver the medication to the facility on 8/9/25 due to the resident being upset and not having any medication. Interview on 8/13/2025 at 11:46 a.m., with Staff I, Pharmacist. Staff I verified they received the order but did not have anything telling them they needed to hold it. Staff I stated if a medication is over $500 than they call the facility and ask if they are to send it and they send a form for the facility to fill out and return. Staff I revealed staff at the pharmacy had called the facility and they were told absolutely do not send the medication. Staff at the pharmacy did not have the staff member from the facility that said not to send the medication. The form was faxed to the facility but was never returned. Interview on 8/13/2025 with the Director of Nursing (DON) revealed they are unsure of where the order for the medication came from and the facility was actively trying to contact the nurse that entered the order on 8/9/25. The DON verified she had wrote hold on the admission orders as she was trying to verify when the medication was last given and when the resident was to resume the medication. The DON verified the facility admission orders lacked an order for Mounjaro. The DON further revealed the facility had not received the form from the pharmacy that she was aware of and she was unaware the resident called and ordered the medication from the local pharmacy and had the medication delivered to the building. The DON verified she was unaware of the happenings on 8/9/25. Interview on 8/14/2025 at 9:15 a.m., with Staff J, LPN revealed she worked the night of 8/9/25. Staff J verified Resident #70 had a box of Monjauro at the facility and she did not know how it got to the facility but the resident had asked for her medication. Staff J revealed she could not find the order for the medication and she called the pharmacy and the pharmacy said they would fax it to the facility. Staff J verified the pharmacy did not fax the order to the facility that evening. She never saw a physical order prior to giving the medication. Staff J further revealed she wasn't quite sure how to use the medication pen and the resident administered her own medication. Staff J explained she took the information off of the box the medication came in to enter the order into the MAR. Staff J further explained the resident had a doctor appointment on Monday and she was off on Monday but knew the doctor would sign off the order then as it would have been on her order summary report. Review of the facility provided policy titled Administration of Medication with a reviewed date of 10/2021 revealed Medications must be administered in accordance with the written orders of the attending physician.Interview on 8/14/2025 at 10:10 a.m., with the DON revealed the nurse should have never given the medication without an order from the physician and the nurse should have called her if she didn't know how to give the injection.

Based on observation, record review, and staff interview, the facility failed to ensure residents with significant weight loss were immediately identified, and assessed for nutritional needs for 1 of 2 resident's reviewed (Resident #21). The facility reported a census of 67 residents. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #21 scored 3 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. The resident's diagnoses included senile degeneration of the brain, cancer, and atrial fibrillation. The resident weighed 125#, and had a weight loss of 5% in 1 month or 10% in 6 months.The Care Plan initiated 7/30/25 identified the resident would tolerate her diet as ordered. The goal with a target date of 11/4/25, read the resident would maintain weight and nutritional balance through the review date. Interventions included diet to be followed as prescribed, monitoring food and fluid intakes daily and recording, monitoring weight as directed, and supplements as ordered. The Weights and Vitals record documented on 7/4/25, the resident weighed 126.5#. On 8/5/25, the resident weighed 118#, a -6.72% Loss. On 8/13/25 at 10:03 a.m. the resident received breakfast around 9:15 a.m. Staff did set up putting jelly on toast. The resident picked up toast and started eating while chatting. Staff added brown sugar to the resident's hot cereal. The resident started eating. A cup of supplement sat nearly empty. On 8/13/25 at 3:38 p.m. the Director of Nursing (DON) thought the weight could not be right. The Nurse Consultant (NC) said a reweight should have been obtained that day or the next day, and if the weight was correct they should have assessed and intervened. On 8/14/25 at 8:56 a.m. Staff D, Licensed Practical Nurse (LPN) brought a sticky note citing the resident weighed 118# this morning. The Weights and Vitals record documented a weight of 118# on 8/14/25 at 8:46 a.m. The facility Nutrition Policy reviewed 7/2024 documented it was the policy of this facility to ensure that all residents maintained acceptable parameters of nutritional status, such as body weight and protein levels, unless the resident's clinical condition demonstrated it was not possible. Any resident weight that varied from the previous reporting period by 5% in 30 days, 7.5% in 90 days and 10% in 180 days would be evaluated by the Interdisciplinary Team to determine the cause of weight loss/gain, intervention required and need for further recommendations and/or referral.

Based on observations, clinical chart review and staff interview the facility failed to implement policies and procedures regarding the technical aspect of feeding tubes by pushing enteral medication with a syringe into enteral tube for 1 of 1 residents (Resident #9). The facility reported a census of 67 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #9 documented diagnoses of anemia, cancer and malnutrition. The MDS showed the Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. Observation on 8/13/2025 at 2:33 p.m., with Staff B, Registered Nurse (RN) setting up Resident #9's medications. Staff B explained resident is able to take medications by mouth but he sometimes will get gaggy and vomit at times so they do all crushable medications through this tube. At 2:46 p.m. Staff B entered residents room to administer medications. Staff B set up each medication on the bedside table in the medication cup and added water to the crushed medications. Staff B then placed another medication cup next to each one of the medications and filled it with water. Staff B revealed she uses water after each medication. Staff B applied gloves and took a screw on the syringe and placed it into the medication cup and tried to mix the medication and water in the cup and drew the mixture into the syringe. Staff then screwed the syringe onto the tube and pushed the medication through the tubing swiftly and unscrewed the syringe and drew up the water that was in the cup and screwed the syringe back onto the tube and pushed the water into the tubing. The nurse did not check for residual or placement prior to administering the medications or water. The nurse repeated this until all medications were administered. During the administration the resident coughed and an orange like substance came out of the tubing which at this time the resident clamped the tube closed. The nurse did reopen after she was unable to push water through the tubing. After the medications were administered there was white power left in one medication cup that was then placed into the trash. Staff B took the syringe to the bathroom and rinsed the syringe. Prior to rinsing the syringe there was a white substance noted to be on the outside of the syringe and after rinsing there was a white substance noted to be on the inside of the syringe as well when placed into the graduate. At 3:02 p.m., the nurse reentered the room to date the bag the liquid was in hanging on the pole. At this time Staff B stated that she would check for residual but she just gave medications so she is just going to check placement of the tube. At 3:07 p.m., Staff B exited the room to take a phone call and at 3:08 Staff B reentered the room and applied gloves and checked the residents lung sounds. Staff B then primed the tubing and opened the end of the tubing and with the syringe pushed 60 cc of water into the tube. Staff B revealed the resident gets 60 cc of water before and after his feedings. Interview on 8/13/25 at 3:32 p.m., with the Assistant Director of Nursing (ADON) revealed when medications are being placed through the feeding tubes they need to be pushed over a couple minutes as the stomach cannot handle too much at one time and then the resident will regurgitate what was put into their stomachs. The ADON revealed she would not expect the nurse to be pushing the medications quickly. Review of the facility provided policy titled Tube Feeding with a revised date of 9/2019 revealed it is the policy of this facility to assure safe practice in providing tube feedings and to check tube for correct placement every shift or every medication administration by auscultation and spiration. If not in place hold feeding and meds, and notify physician for orders. Interview on 8/13/25 at 4:02 p.m., with the Director of Nursing (DON) revealed she is not sure why Staff B gave the medications through the feeding tub as he is able to take his medications orally. The DON verified she should not have pushed the medications swiftly into the residents stomach she should not have left any medication residual in the cup or syringe after giving the medications. The DON further revealed Staff B should have checked placement of the tube prior to administering medications and not after.

Based on record review and staff interview, the facility failed to ensure that residents who required dialysis received services, consistent with professional standards of practice by communication with the dialysis center for 1 resident on dialysis (Resident #3). The facility reported a census of 67 residents. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #21 scored 3 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. The resident's diagnoses included end stage renal disease, and end chronic obstructive pulmonary (lung) disease. The resident received dialysis. The Care Plan revised 6/19/25 identified the resident needed dialysis Monday/Wednesday/Friday with chair time of 8:30 a.m. A Notebook with the resident's name on it contained pre and post (dialysis) Vital Signs (VS) (taken at dialysis center), including blood pressure, temperature, pulse and weight in kilograms.The Notebook lacked VS between 5/2/25 and 5/9/25. On 5/26/25 a note documented to remind the resident of a fluid restriction of 1500 cc per day, she was gaining too much weight. The clinical record lacked documentation the resident had a fluid restriction, or any communication with the physician about a fluid restriction.The Notebook lacked documentation of pre and post VS between 5/30/25 and 6/4/25, between 6/9/25 and 6/13/25, and between 6/13/25 and 7/4/25.The June TAR initiated documentation of the resident going to dialysis starting 6/5/25 and a refusal on 6/16/25.The Notebook lacked VS between 7/14/25 and 7/18/25, between 7/18/25 and 7/25/25, and 1 undated pre and post VS between 7/25/25 and 8/4/25.The Notebook lacked pre and post VS 8/11/25.On 8/13/25 at 4:54 p.m. the Corporate Nurse stated she had looked and could not find VS for the missing dialysis days. She said normally they would send a sheet with the resident's information on it and dialysis would fill it out and return it. Those sheets would be maintained in her record. The facility Dialysis, Pre and Post Care policy reviewed 6/2022 included collecting dialysis run sheets and following up with the provider on recommendations as needed.

Based on observation, Medication Administration Record - Treatment Administration Record (MAR-TAR), Electronic Health Record (EHR) review, and staff interviews the facility failed to provide 2 of 31 medications as ordered resulting in a medication error rate of 6.45. The facility reported a census of 67 residents. Findings include:1. The Minimum Data Set (MDS) dated [DATE] for Resident #4 documented a Brief Interview for Mental Status (BIMS) of 5 indicating severe cognitive impairment. The MDS documented Resident #5 had a diagnosis of type 2 diabetes mellitus without complications.Review of Resident #4's MAR-TAR documented a physician's order for insulin Lispro injection per sliding scale if blood glucose was 140-180 2 units at 7:30 AM and insulin Glargine inject 32 units subcutaneously one time a day at 7:00 AM.Review of Resident #4's EHR titled, Orders documented a physician's order for insulin Lispro injection per sliding scale if blood glucose was 140-180 2 units at 7:30 AM and insulin Glargine inject 32 units subcutaneously one time a day at 7:00 AM.A continuous observation on 8/13/25 at 7:12 AM morning blood glucose checks and insulin administration revealed Staff B, Registered Nurse (RN) removed Resident #4's insulin Lispro and insulin Glargine from medication cart, Staff B dialed 2 units on the insulin Lispro pen for sliding scale, Staff B dialed 32 units of insulin glargine, Staff B did not prime 2 units from either insulin pen, Staff B walked down the hall, knocked on Resident #4's door, explained the procedure, cleansed the area on left abdomen with an alcohol wipe, insulin Lispro administered in Resident #4's left abdomen, area on left abdomen cleansed with alcohol wipe, insulin Glargine administered in Resident #4's left abdomen, Staff B returned to the medication cart, Staff B removed gloves and placed insulin in the medication cart.On 8/13/25 at 9:10 AM Staff B, RN stated she never primed the needle tips for insulin pens. Staff B stated she had never been told to prime the needle for the insulin pen. On 8/13/25 at 11:12 AM the Director of Nursing (DON) stated the facility's expectation was 2 units would be primed after the septum of the insulin pen was cleansed with an alcohol wipe and the needle was screwed on for each of the insulin pens.

Based on observations, staff interviews, Medication Administration Records - Treatment Administration Records (MAR-TAR) and Electronic Health Records (EHR) review the facility failed to ensure the residents were free of significant medication errors to 2 of 6 residents reviewed (Resident #4 and #7). The facility reported a census of 67 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #4 documented a Brief Interview for Mental Status (BIMS) of 5 indicating severe cognitive impairment. The MDS documented Resident #5 had a diagnosis of type 2 diabetes mellitus without complications. Review of Resident #4’s MAR-TAR documented a physician’s order for insulin Lispro injection per sliding scale if blood glucose was 140-180 2 units at 7:30 AM and insulin Glargine inject 32 units subcutaneously one time a day at 7:00 AM. Review of Resident #4’s EHR titled, Orders documented a physician’s order for insulin Lispro injection per sliding scale if blood glucose was 140-180 2 units at 7:30 AM and insulin Glargine inject 32 units subcutaneously one time a day at 7:00 AM. A continuous observation on 8/13/25 at 7:12 AM morning blood glucose checks and insulin administration revealed Staff B, Registered Nurse (RN) removed Resident #4's insulin Lispro and insulin Glargine from medication cart, Staff B dialed 2 units on the insulin Lispro pen for sliding scale, Staff B dialed 32 units of insulin glargine, Staff B did not prime 2 units from either insulin pen to ensure needle tip patency, Staff B walked down the hall, knocked on Resident #4’s door, explained the procedure, cleansed the area on left abdomen with an alcohol wipe, insulin Lispro administered in Resident #4’s left abdomen, area on left abdomen cleansed with alcohol wipe, insulin Glargine administered in Resident #4’s left abdomen, Staff B returned to the medication cart, Staff B removed gloves and placed insulin in the medication cart. On 8/13/25 at 9:10 AM Staff B, RN stated she never primed the needle tips for insulin pens. Staff B stated she had never been educated to prime the needle for the insulin pen. On 8/13/25 at 11:12 AM the Director of Nursing (DON) stated the facility's expectation was 2 units would be primed after the septum of the insulin pen was cleansed with an alcohol wipe and the needle was screwed on to ensure patency. Request for policy / procedure revealed no policy provided for insulin administration with an insulin pen. 2.The Minimum Data Set (MDS) dated [DATE] for Resident #7 documented a Brief Interview for Mental Status (BIMS) of 15 which indicated no cognitive impairment. The MDS documented Resident #9 had a diagnosis of traumatic brain injury, aphasia and bipolar. The Care Plan for Resident #7 showed initiated on 11/29/24 anticonvulsant therapy Levetiracetam related to traumatic subdural hemorrhage without loss of consciousness. The Progress Note dated 6/18/2025 at 1:01 PM for Resident #7 showed Staff B, RN documented the following: Resident's night meds omitted last night 6/17/25. No side effects/adverse effects noted. The resident states she feels fine. Family and Primary Care Provider (PCP) notified. The June 2025 Medication Administration for Resident #7 showed the following bedtime medication incorrectly documented as administered on 6/17/25 by Staff G, RN:Levetiracetam 1 tablet by mouth at bedtime for seizures. In an interview on 8/13/2025 at 10:03 AM, Staff B, RN reported in the morning of 6/18/25 Staff C, Certified Medication Assistant/Certified Nurse Assistant (CMA/CNA) reported she found bedtime medications for Resident #7 still in the medication packs from the night before. Staff B reported she couldn't remember what medications were missed but that she reported it to the Director of Nursing (DON), the physician and family. Staff B recalled the night nurse to be Staff G, Licensed Practical Nurse (LPN). In an interview on 8/13/25 at 3:02 PM, Staff G, LPN reported she recalled that she failed to give bedtime medications to Resident #7 on 6/17/25. When asked if there was a reason why she failed to administer medications, Staff B stated, I just missed giving them. The Medication Administration policy last revised on October 2021 identified:Administration of Medication POLICY:It is the policy of this facility that medications shall be administered as prescribed by the attending physician.PROCEDURES:Only licensed medical and nursing personnel or other lawfully authorized staff members may prepare, administer, and record the administration of medications.Medications must be administered in accordance with the written orders of the attending physician including following parameter orders – pulse, blood pressure, blood sugar, etc. All current drugs and dosage schedules must be recorded on the resident's medication administration record (MAR).Identification of the resident must be made prior to administering medication to the resident. Medications may not be set up in advance and scheduled medications must be administered within one (1) hour before or after their prescribed time. NOTE: Before and/or after meal orders must be administered as ordered.When PRN medications are administered, the nurse must record:Justification/ reason the medication is given The date and time administered;The medication nameAny results achieved from administering the drug and the time such results were observed; andThe signature and title of the person administering the drug.If a medication is withheld, refused, or given other than at the scheduled time, the documentation will be reflected in the clinical record. The seven rights of medication administration are as follows in order to ensure safety and accuracy of administration. Right Resident – Resident is identified prior to medication administration Right Time – Medications are administered within prescribed time frames. Right Medication – Medications are checked against the order before they are given. Right Dose – Medications are administered according to the dose prescribed Right Route – Medications are administered according to the route prescribed Right Documentation – Document administration or refusal of the medication after the administration or attempt and note any concerns Right Diagnosis – Medications are administered according to appropriate indication/diagnosis. In an interview on 8/13/2025 at 1:52 PM, the Director of Nursing (DON), reported she expected medications to be given as ordered and that Levetiracetam should have been given to prevent seizures.

Based on observation, policy, Electronic Health Record (EHR) review and staff interview the facility failed to follow the menu and prepare food to meet the residents nutritional needs for 22 of 26 residents (all residents with a regular diet) reviewed. The facility reported a census of 67 residents.Findings include:A continuous observation on 8/12/25 at 11:40 AM revealed Staff A, Certified Dietary Manager (CDM) served the lunch meal. Staff A completed hand hygiene, completed temperature checks on the food, placed serving utensils in the steam table wells with the food, and began lunch service. Through the entire lunch service a 3 oz scoop was utilized to serve all regular diet peas.On 8/12/25 at 12:30 PM Staff A acknowledged the scoop utilized to serve the regular diets the peas was a 3 oz scoop and should have been a 4 oz scoop. Review of document dated 8/14/25 titled, Diet Type Report documented 22 regular diets served in that building for the lunch meal on 8/12/25.Review of document titled, Week 4 Tuesday Diet Spreadsheets the lunch menu revealed regular diets should have 4oz serving of Peas.On 8/12/25 at 3:21 PM the Administrator stated she would expect the staff utilized the appropriate scoop according to the meal spreadsheet. Review of an undated policy titled, Quality of Care Therapeutic Diets documented Routine therapeutic menus are planned by the corporate office or dietary manager and approved by the registered dietitian; however, unusual or complex therapeutic diets are planned in writing by the registered dietitian. A tray identification system is established to ensure that each resident receives his/her diet as ordered.

Based on resident interview, resident family interviews, staff interview, electronic health records (EHR), document review and policy review the facility failed to maintain medical records on each resident that were complete and accurate by failing to accurately transcribe a physicians order into the EHR for 2 of 8 residents reviewed (Resident #9 and #73). The facility reported a census of 67 residents.Findings include: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #73 did not document a Brief Interview for Mental Status (BIMS) as Resident #73 was admitted on [DATE]. On 8/13/25 at 8:40 AM Staff C, Certified Medication Assistant / Certified Nurse Assistant (CMA/CNA) stated Resident #73’s MAR did not match the bubble pack for the potassium chloride ER tablet. Staff C stated MAR read potassium chloride ER give 20 mEq BID. Staff C stated Resident #73’s bubble pack for potassium chloride documented 20 mEq give 2 tablets daily. Review of Resident #73’s bubble pack for potassium chloride documented potassium chloride ER 20 mEq give 2 tablets daily. Review of Resident #73’s MAR-TAR documented an order for potassium chloride ER with the start date 8/11/25 to give 20mEq by mouth two times a day for supplement at 7:00 AM and 8:00 PM. Review of document dated 8/11/25 titled, Home Medication List for Resident #73 from the hospital documented to stop taking 40 mEq oral twice daily and start taking 40 mEq daily as a new dose. On 8/14/25 10:05 AM the DON acknowledged MAR read Potassium Chloride ER give 20 mEq BID. Review of document revised 5/19 titled, Nursing Clinical with subject Physician Orders documented Verbal orders for drugs and treatments shall be received only by licensed nurses, psychiatric technicians, pharmacists, nurse practitioners, physicians, physicians' assistants (from their supervising physician only), and certified respiratory therapists when the orders relate specifically to respiratory care. Verbal orders must be recorded immediately in the resident's chart by the person receiving the order and must include the date and time of the order. The charge nurse or the director of nursing services shall place the order for all prescribed medications. 2. The MDS assessment dated [DATE] for Resident #9 documented diagnoses of anemia, cancer and malnutrition. The MDS showed the BIMS score of 15, indicating no cognitive impairment. Observation on 8/11/2025 11:36 a.m., of resident wearing oxygen sitting up in bed. Observation on 8/12/2025 12:27 p.m., of resident currently sleeping in bed with oxygen concentrator on via nasal cannula and running. Review of August Medication Administration Record (MAR) and Treatment Administration Record (TAR) lacked orders for oxygen usage. Review of current Physician Orders lacked an order for oxygen usage. Review of the Care Plan dated 8/12/25 lacked information regarding oxygen usage. The facility did not provide a policy of maintaining accurate resident records. Interview on 8/13/2025 at 10:30 a.m., the Assistant Director of Nursing (ADON) revealed the resident has an oxygen order from his current hospital discharge. The ADON revealed the order should have been added to the orders when he came back from the hospital. Interview on 8/13/2025 at 1:34 p.m., with the Director of Nursing (DON) revealed the hospital discharge order had been noted and should have been put on the orders. The order should have been on the chart.

Based on clinical record review, staff interviews, Centers for Disease Control and Prevention (CDC) guidelines and facility policy review, the facility failed to screen for eligibility, offer, provide education and document vaccine consent or refusal for the pneumococcal immunization for 1 of 5 resident reviewed (Resident #8) for immunizations. The facility reported a census of 67 residents. Findings include: Resident #8 Minimum Data Set (MDS) dated [DATE] assessment identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition.Review of the clinical record revealed Resident #8 had received the Pneumococcal Conjugate Vaccine 13-valent (PCV13) on 05/19/20, and Pneumococcal Polysaccharide Vaccine 23-valent (PPSV23) on 10/14/98. The clinical record lacked documentation that Resident #8 was educated, offered a consent for or refusal of the Pneumococcal Conjugate Vaccine PCV20 or PVC21 vaccination. Review of the CDC recommendations dated October 2024 for adults 50 years or older who have received the PCV13 at any age and the PPSV23 less than [AGE] years of age, recommended to give one dose of PCV20 or PVC21 at least 5 years after the PCV13.On 08/14/25 at 3:00 PM, the Director of Nursing (DON) reported she expected vaccinations to be offered per resident preference and education to be given if the resident refused the vaccination. A facility policy titled Immunization, Influenza and Pneumococcal revised 7/2015 documented the facility to offer pneumococcal immunization unless the immunization was medically contraindicated or the resident has already been immunized. In addition, the policy documented before offering the pneumococcal immunization, each resident or the resident's legal representative was to receive education regarding the benefits and potential side effects of the immunization.

Based on Electronic Record Review (EHR), staff interviews, and policy review the facility failed to develop a comprehensive care plan that included problems, goals, or interventions for use of a diuretic or diagnosis of congestive heart failure, develop a comprehensive care plan that was personalized when a resident received hospice care, and did not follow a care plan for 4 of 18 residents reviewed (Resident #3, #20, #43, and #50). The facility reported a census of 53 residents. Finding include: 1. The Minimum Data Set (MDS) dated [DATE] documented Resident #50 entered the facility on 7/3/24. The MDS also documented a Brief Interview for Mental Status (BIMS) of 9 indicating moderate cognitive impairment. The MDS revealed diagnosis of essential (primary) hypertension and localized edema. The MDS documented use of diuretic. Review of Resident #50 ' s Physician Orders documented lasix oral tablet 40 mg (Furosemide), give 40 mg by mouth one time related to localized edema started 8/15/24 and lasix oral tablet 20 mg (Furosemide), give 20 mg by mouth one time a day related to localized edema started 8/10/24. On 8/21/24 at 3:02 PM Staff C MDS Coordinator stated she would expect interventions would be in place if a resident was on a diuretic. Staff C stated would want to see interventions such as lab work as ordered, change in blood pressure, administer medication as ordered, monitor dose medication may require modifications to minimize consequences, and notify doctor PRN with adverse reactions. Staff C acknowledged Resident #50 did not have any focus, goals, or interventions in place related to the use of a diuretic. On 8/21/24 at 3:45 PM the DON stated facility expectation was that Resident #50 would have a care plan with focus goals or interventions related to the use of a diuretic. 47079 2. The Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 9 out of 15 which indicated moderately impaired cognition. On 8/20/24 at 12:07 PM, a Progress Note revealed the resident was transferred to acute care (hospital) on 7/01/24. A Progress Note dated 7/01/24 indicated the resident was non-emergently sent to the emergency room . A Nursing Home to Hospital Transfer Form dated 7/01/24 revealed Resident #20 was transported to the local hospital for a low oxygen saturation. It indicated she received 2 liters per minute (LPM) of oxygen and had a saturation of 93%. A Progress Note dated 7/02/24 revealed the resident was admitted to the hospital for Congestive Heart Failure (CHF) exacerbation. The Baseline Care Plan dated 7/05/24 included exacerbation of CHF. The Care Plan revised 7/10/24 did not include CHF focus nor diagnosis related interventions. 46873 3. The MDS of Resident #43 dated 4/18/24 documented the resident received hospice care while a resident of the facility during the 14 day look back period. The Nursing Note dated 4/18/24 at 1:50 pm documented the resident was admitted to hospice care, specifying the name of the hospice and the primary nurse who would be providing hospice services. The Care Plan of Resident #43 documented a Focus Area of Terminal Prognosis dated 5/8/24. The Focus Area failed to document what terminal prognosis the resident had, what hospice company the resident was receiving services from or any contact information for the hospice. On 8/21/24 at 11:09 am, the MDS Coordinator stated all hospice residents have an individual notebook at the nursing station for all hospice paperwork. She stated the hospice contract, diagnoses and other information is found in these books as well as the Care Plan written by the hospice company. She stated if facility staff need any information regarding hospice this is where they look. She stated she does not include this information on the facility Comprehensive Care Plan because it is in the hospice book. 4. The MDS of Resident #3 identified a BIMS score of 8 which indicated moderate cognitive impairment. The Care Plan of Resident #3 documented a Focus Area of Activities of Daily Living (ADL) Self Care Performance deficit related to disease process dated 7/11/24. The Care Plan directed staff for eating, Resident #3 required 1 staff participation to eat - assist and encourage as needed. The resident was to sit at the Assisted Table in the dining room. On 8/20/24 Resident #3 was observed sitting at the assisted table in the dining room with no staff present at the table. At 8:55 am, staff brought Resident #3 her meal. Resident #3 began to eat her meal. She continued to eat unsupervised until 9:11 am when a staff member sat down across the table to provide feeding assistance to another resident. Resident #3 ate unsupervised for 16 minutes. On 8/20/24 at 11:56 am, Resident #3 was observed sitting at the assisted table waiting for her meal service. At 12:21 pm, Staff B, Certified Nurse Aide (CNA) delivered the resident her meal. She assisted to cut her food up, and provide salt and pepper and butter to the food. She then walked away from the table. On 8/20/24 at 12:33 pm, staff arrived at the assist table to sit and provide feeding assistance for two other residents. Resident #3 ate unsupervised for 12 minutes. On 8/22/24 at 11:30 am, the Administrator stated some residents at the assist table just need supervision and not eating assistance, and can be supervised from anywhere in the dining room, not necessarily at the assist table. She stated if the care plan states staff assistance the resident should receive assistance. The facility policy Comprehensive Person-Centered Care Planning, revision date 3/2022 documented the policy statement: It is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident ' s medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. The IDT team will also develop and implement a baseline care plan for each resident, within 48 hours of admission, that includes minimum healthcare information necessary to properly care for each resident and instructions needed to provide effective and person-centered care that meet professional standards of quality care. The policy documented: Point 4 - The comprehensive care plan will be developed by the IDT within seven (7) days of completion of the Resident Minimum Data Set (MDS) and will include resident ' s needs identified in the comprehensive assessment, any specialized services as a result of PASARR recommendation, and resident ' s goals and desired outcomes, preferences for future discharge and discharge plans.

Based on Electronic Health Records (EHR), policy review, resident interview, and observations the facility failed to provide nursing staff to assure residents safety by not responding to call lights in a timely manner for 5 of 18 residents reviewed (Resident #1, #6, #17, #37, and #106). The facility reported a census of 53 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #1 documented a Brief Interview for Mental Status (BIMS) of 15 indicating no cognitive impairment. Review of EHR documented Resident #1 resided in NN09-2. Observation on 8/20/24 at 1:05 PM of room NN09, Resident #1's room revealed the call light was on. Staff B, Certified Nursing Assistant (CNA) entered Resident #1 ' s room at 1:32 PM and answered the call light. Staff B told Resident #1 to let her find another CNA and would be right back. Staff B returned to Resident #1 ' s room at 1:34 PM with mechanical lift. On 8/20/24 at 1:40 PM Staff B stated Resident #1 ' s call light was on because she wanted to use the toilet. On 8/20/24 at 1:33 PM Resident #1 stated she needed to use the toilet that is why her call light was on. Resident #1 stated she was not incontinent during the time she was waiting for her call light to be answered. 2. The MDS dated [DATE] for Resident #17 documented a Brief Interview for Mental Status (BIMS) of 9 indicating moderate cognitive impairment. Review of EHR documented Resident #17 resided in NN11-2. Observation on 8/20/24 at 1:14 PM of room NN11, Resident #17's room revealed the call light was on. On 8/20/24 at 1:36 PM Staff B entered Resident #17 ' s room and answered the call light. On 8/20/24 at 1:40 PM Staff B stated Resident #17 wanted help to transfer into her bed. Staff B stated the facility's expectation was whoever turns the call light on first would be tended to first. Staff B stated she was not sure what the facility ' s expectation was for answering call lights. Staff B stated she believed answering a call light within five minutes would be reasonable, but she could ask the Administrator. Staff B stated anything over five minutes would be too long. On 8/20/24 at 1:42 AM Resident #17 stated her call light was on because she wanted to be transferred to her bed. 3. The MDS dated [DATE] for Resident #37 documented a Brief Interview for Mental Status (BIMS) of 13 indicating no cognitive impairment. On 8/19/24 at 3:40 PM Resident #37 stated she spoke with the Administrator about how short staffing was at the facility. Resident #37 stated the staff frequently took longer than 15 minutes to answer call lights. Resident #37 stated she has a clock on the wall and knows how long it takes for staff to answer the call light when she would turn it on. 46873 4. The Minimum Data Set (MDS) Assessment of Resident #6 dated 8/9/24 identified a Brief Interview of Mental Status (BIMS) score of 14 which indicated cognition intact. On 8/19/24 at 2:52 pm, Resident #6 reported call lights can be up to 45 minutes long. She additionally reported she is unable to take herself from the dining room back to her room. She stated she gets left in the dining room for long periods of time waiting for staff to take her back to her room. 5. The Minimum Data Set (MDS) Assessment of Resident #106 dated 8/15/24 identified a Brief Interview of Mental Status (BIMS) score of 14 which indicated cognition intact. On 8/19/24 at 2:10 pm, Resident #106 reported it is difficult to get staff to answer call lights. She stated it can be over an hour at times. She stated some staff will come and answer the call light and turn if off and tell her they will be back. But they leave and do not address her needs which the call light was turned on for. She further reported when staff tell her they will be back to help her, they do not return. Resident #106 does not have a clock in her room but has a cell phone and reports she watches the time on her phone when the call light is turned on. On 8/20/24 at 4:36 pm the Administrator stated the facility's expectation is that the call would be answered within 15 minutes. On 8/20/24 at 4:42 pm the Director of Nursing (DON) stated the facility's expectation that the resident's call lights would be answered within 15 minutes. The DON stated she would like to see call lights answered within 5 minutes. The DON stated 30 minutes would be excessive. The facility policy titled Policy/Procedure - Nursing Clinical, Routine Procedures, Call Light/Bell documented a policy statement of It is the policy of this facility to provide the resident of means of communication with nursing staff. Point 1: - Answer the light/bell within a reasonable time frame Point 4: - Respond to the request. If the item is not available or you are unable to assist, explain to the resident and notify the charge nurse for further instructions.

Based on observation and staff interview, the facility failed to post the daily census sheet including the facility resident census and the actual working hours of nurses and nurse aides on duty for the current date. The facility reported a census of 53 residents. Findings include: On 8/21/24 at 10:52 am, the Longhouse portion of the facility, where the census posting is to be posted, had no census posting visible. Staff A, Licensed Practical Nurse (LPN) stated it had not been completed yet for the day. She stated the prior day's posting was probably in the medication room. On 8/21/24 at 10:55 am, Staff A, LPN obtained keys to the medication room and found census sheets dated 8/16/24 - 8/19/24. When asked if a census sheet had been completed for 8/20/24 she stated she was off work that day and did not know if one had been done. A census for 8/21/24 was filled out and hung on a board in the dining room. On 8/22/24 at 11:30 am, the Administrator stated the daily census posting is to be done by the charge nurse for each shift. She stated it should be initiated by the day shift at 6:00 am when the shift begins. She stated the census for the prior day should not be removed until the new one is hung.

Based on observation, staff interview, and policy review, the facility failed to maintain sanitary practices by failing to keep the ice makers clean and by improperly handling food during meal service. The facility reported a census of 53 residents. Findings include: On 8/19/24 at 11:55 AM, a north building kitchen observation revealed black and pink substance on the internal plastic ice cube guard edge. At 12:05 PM, a south building kitchen observation revealed black and pink substance on the internal plastic ice cube guard edge. On 8/20/24 at 8:17 AM, Staff G, Dietary Aide (DA), transported a gallon of milk on a cart from kitchen without the lid on it. At 8:35 AM, the Dietary Manager opened a salt & pepper packet for a resident, sprinkled the salt and pepper on the resident's eggs then put the opened packets on the resident's plate. On 8/21/24 at 11:35 AM, Staff G, cook, put a glove on her left hand and used her right hand to adjust the glove fingers. She then put a glove on her right hand, placed her right hand on a non-food preparation counter, opened a drawer, and grabbed a serving utensil to prepare pureed diets. She walked over to the steam table, picked up the serving tongs, peeled the aluminum foil back from the garlic bread steam pan, picked up three (3) slices of garlic bread, and placed them in the blender. She picked up the garlic bread with her gloved hands and tore the bread into smaller pieces. She did not change gloves or perform hand hygiene between touching the non-food preparation counter and handling bread. At 11:50 AM, Staff G removed the lid from the steam pan that held the pureed food in bowls and placed the lid top down on top of the serving ladle used for vegetables. At 11:55 AM, Staff H, Dietary Aide (DA) donned gloves, grabbed a loaf of bread, opened it, then grabbed two slices with the same gloved hands and placed them on a plate. No hand hygiene or glove change was performed after touching the outside of the bread packaging. A document titled Food Safety and Sanitation dated 2013 indicated staff will handle all foods safely and directed staff to wash their hands when they have used their hands in an unsanitary way. On 8/22/24 at 1:18 PM, the Administrator stated staff should follow the facility's policy.

Based on clinical record review, staff interviews, personnel records and facility policy review on [DATE] the facility staff failed to implement CPR (cardiopulmonary resuscitation) for one of five residents sampled (Resident #1), who was found unresponsive with no pulse or respirations and desired CPR. This resulted in immediate jeopardy to the residents health and safety. The facility identified a census of 53 current residents, 13 of which were identified by the facility with a request for CPR at the time of cardiopulmonary or respiratory arrest. The facility was notified of the Immediate Jeopardy (IJ) and given the IJ template on [DATE] at 12:15 PM. The immediacy had been removed on [DATE] when the facility provided staff education and review of their policy. The citation is considered a past non-compliance as the facility implemented plan of correction prior to the surveyors entrance on [DATE]. Findings include: 1. A Minimum Data Set (MDS) assessment with a reference date of [DATE] documented Resident #1 was admitted to the facility from the hospital on [DATE] and a Brief Interview for Mental Status (BIMS) score of 14 which indicated intact cognitive skills for decision making. According to the MDS the resident required substantial/maximal assistance with sit to stand and chair to bed transfer and had diagnosis that included fracture of the left wrist and hip. An undated Admission Care Plan documented under the heading of Advance Directives Resident #1 was a Full Code. A document titled Cardiopulmonary Resuscitation (CPR) Directive documented that it is the policy of the facility to provide basic CPR to those resident who chose it. The document was signed and dated on [DATE] by Resident #1 indicating by a check mark that the resident had requested CPR be initiated when her heart had stopped beating and/or she had no pulse. The residents signature further documented that she understood that if she wished for CPR at the time her heart stopped beating and/or she had no pulse, basic life support procedures would be provided until paramedics arrive. The directive was signed by the provider on [DATE]. Review of an Order Recap Report for Resident #1 documented an order dated [DATE] that the resident was a full code. The electronic health record contained the Admission Record, commonly known as the face sheet, documented under the heading Advance Directive: Full Code. An electronic Progress Note dated [DATE] at 7:00 a.m. revealed documentation by Staff A, Licensed Practical Nurse (LPN) included the following: Certified Nursing Assistant (CNA) summoned to the residents room. Resident laying on bed with eyes open and fixed. Resident had no pulse, no blood pressure, and not breathing which was verified by a second nurse. The family and funeral home were notified. An electronic Progress Note dated [DATE] at 7:20 a.m. revealed Staff B, Registered Nurse, (RN) was called to verify absence of vital signs. CNA was in room and had just finished completing post mortem cares. Verified absence of apical and radial pulse and noted skin cool to touch. Review of a facility electronic Incident Report dated [DATE] at 4:33 p.m. initiated by the Director of Nursing (DON) revealed CNA had summoned the charge nurse on duty to the residents room Resident was lying on the bed, eyes open and fixed. The resident had no pulse, no blood pressure and was without respirations noted. This was verified by a second nurse and the residents daughter was notified. The coroner arrived at the facility to assess resident. Immediate action taken included: all staff educated on the importance of CPR policy and protocol and what to do in the event of a non-responsive resident. During an interview on [DATE] at 9:40 a.m., Staff C, CNA stated on [DATE] at approximately 7:00 a.m. she heard Resident #1's audible call light tone and approximated had responded to the room within ,d+[DATE] minutes. Staff C described that she walked into the room, turned off the call light at the bedside, and questioned what can do for resident? The resident hadn't answered so she rubbed her chest and asked again. The resident failed to respond then Staff C noticed her gaze was fixed. Staff C stated that knew something was wrong immediately so summoned the nurse. Staff C described that the resident was still warm to the touch, and her skin tone was pink. Staff C recalled that Staff A, LPN was in the hallway a couple rooms away, and responded to the room right away. Staff A, LPN entered the room, observed the resident, left and returned right away with a stethoscope, listened to resident's chest and commented there was nothing. Staff C described that as Staff A was assessing the resident, the resident took several sharp incomplete breaths, more of an inhale. Staff C stated that Staff A had also noticed the breaths as she had made the comment that she didn't know what those breaths were all about. Staff A, LPN then left the room, and didn't return. Staff C stated that she was in the room at all times, and CPR was not initiated. During an interview on [DATE] at 10:15 a.m. Staff B, Registered Nurse (RN) stated she had been called at approximately 7:20 a.m. as the second nurse to confirm the absence of vital signs. Staff B stated when she entered the room, Staff C, CNA had just finished post mortem cares. Staff B responded that she was not aware that Resident #1 was a full code until later, had not thought to question Staff A, LPN. Staff B further stated that if a resident was found unresponsive would expect the nurse to call for help, check for code status, and start CPR if the resident was a full code. Staff B, RN responded that she had not initiated CPR. In an interview on [DATE] at 10:40 a.m. Staff D, CNA responded she had heard Resident #1's call light, but it had gone off quickly, approximated within a couple of minutes, so knew that it had been answered. During an interview on [DATE] at 11:00 a.m. Staff A, LPN stated she had been summoned to Resident #1's room by Staff C, CNA that resident #1 had passed. Staff A further described when she entered the room noted that the resident had a fixed stare, was pale and that the resident was not cool to touch, but also not warm. Staff A stated she had noticed Resident #1's call light was on and was heading that way but saw Staff C, CNA go into the room. Staff A stated she had not checked the residents code status, and had not started CPR. Staff A responded that she should have checked the code status, had someone call 911, and started CPR. In an interview on [DATE] at 4:05 p.m. the Director of Nursing (DON) stated that on [DATE] had become aware that Resident #1 had passed and was a full code. The DON stated she had questioned Staff B, RN if CPR had been initiated and was informed that CPR had not been performed. The DON interviewed Staff A, LPN who admitted that she was aware Resident #1 was a full code, but that she was already gone when she entered the room so hadn't started CPR. The DON informed that Staff A was terminated as a result of the investigation. The DON further stated that would expect staff to start CPR in a witnessed code situation when the resident had requested resuscitation. The DON further stated that code status was available in the Electronic Health Record. The DON confirmed Resident #1 had a current and active order for CPR Review of a facility personnel form titled Termination Form dated [DATE] documented Staff A, LPN was involuntary terminated for gross misconduct and death. The form contained further explanation for the termination that included: On [DATE] Staff A was on shift and made aware that the resident was unresponsive, the resident was a full code and the employee failed to attempt resuscitation. Per the employee's job description that was reviewed and signed on [DATE] by Staff A, the employee was to administer services within the applicable scope of nursing practice to residents. Staff A failed to adhere to the essential duty and responsibility of performing CPR on a resident that was noted as a full code. Due to the severity of this action Staff A was terminated as of today [DATE]. Review of a facility policy/procedure titled Cardiopulmonary Resuscitation (CPR) identified that it is the policy of the facility to administer CPR according to current national guidelines. The policy included the following guidelines: Once CPR is initiated, it will be discontinued only by a physician's order and/or the arrival of rescue personnel who take over CPR efforts and/or transport the resident. Only staff members certified to perform CPR should perform the procedure. Review of a card dated as issued [DATE] certified that Staff A, LPN had successfully completed the Healthcare Provider (BLS) Adult, Child and Infant CPR course. The facility identified a total of 13 residents with request for full code (CPR).

Based on document review, observation, record review, and staff interviews the facility failed to protect a resident from a significant medication error. A nurse committed to giving 37 units of Aspart insulin (Novolog) to Resident #47 at 9:45 AM after drawing it up from a vial, then put the vial back into the medication cart. Resident #47 has an order that reads Levemir Subcutaneous Solution 100 UNIT/ML inject 37 units subcutaneously in the morning for 1 of 4 residents reviewed (Resident #47). The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of October 25, 2023 on October 25th, 2023 at 4:40 P.M. The Facility Staff removed the Immediate Jeopardy on October 26, 2023 through the following actions: a. Starting today (10/26/23), any insulin that is ordered for a resident will be verified by 2 nurses for correct insulin and correct dosage prior to administration. We will have a sheet where 2 nurses will sign off to verify that the correct insulin and correct dosage was administered. b. On 10/26/23, an education memo will be presented to the nurses currently on duty and then to each nurse that works so they are educated of the dual verification for the insulin for all residents as well as a review of the medication administration policy to ensure the triple check process is being completed. This will involve them signing that they have read and understand the memo at the start of their shift. The scope was lowered to a D at the time of the survey after ensuring the facility implemented education and their policy and procedures. The facility reported a census of 55 residents. Findings Include: 1. The Minimum Data Set (MDS) dated [DATE] documented Resident #47 had a Brief Interview of Mental Status (BIMS) of 15 indicating no cognitive impairment. The MDS revealed a diagnosis of type 2 diabetes. An observation on 10/25/23 at 9:45 AM revealed Staff E pushed the medication cart down the hall. Staff E removed Insulin, alcohol wipe, and cotton ball from the medication cart drawer. Staff E applied gloves. Staff E cleansed the top of Resident #47 ' s, as needed (PRN) Aspart insulin vial with alcohol wipe. Staff E drew up 37 units of Aspart into the syringe. On 10/25/23 at 9:57 AM Staff E stated her intention was to enter the room and give Resident #47 the insulin. Medication pass was stopped by the surveyor. The surveyor intervened prior to administration of medication and requested reconciliation of insulin orders. Staff E recognized the medication error and administered the correct insulin. Staff E drew up 37 units of Levemir and administered the medication. Review of Medication Administration Record (MAR) revealed orders for Resident #47 that read Novolog Injection Solution (Insulin Aspart) inject 10 units as needed. Only give if blood sugar is over 400. Levemir Subcutaneous Solution 100 UNIT/ML inject 37 units subcutaneously in the morning. On 10/25/23 at 10:13 AM Staff E stated usually she would read the residents name, the medication, and then compare the drug to the electronic MAR. Staff E stated she would draw the medication into the syringe. Staff E stated she would then compare the medications again to the electronic MAR and administer the medication. Staff E stated she did not compare the medication to the electronic MAR. Staff E stated she just grabbed the insulin that is in the usual location and the Aspart was there instead of the Levemir. Staff E stated she simply did not read the medication. On 10/26/23 at 8:47 AM Staff K stated the outcome of receiving the fast acting Aspart insulin instead of the long acting Levemir could have been very serious. Staff K stated that a very serious hypoglycemic event, possibly death could have occurred. Staff K stated Resident #47 receiving 37 units of Aspart (fast acting insulin) as opposed to Levemir (long acting insulin) would have been a life threatening event ending in death or the need for glucagon only if caught in time. On 10/25/23 at 3:10 PM The administrator stated the facility's expectation was that medications would be administered as ordered. Review of undated policy titled, Medication Administration provided by the Administrator revealed to place the medication on the cart so the medication and the EMAR are visible together. Make sure the medication labels are facing you. Then verify the medication information on the prescription label as to name of drug, strength, dose, and hour of administration with the MAR.

Based on observation, interview and record review, the facility failed to establish adequate measures to mitigate the spread of the Covid-19 virus. In the Northshire building, residents that tested positive for Covid-19 were not separated from the population that was still testing negative. A plastic barrier was taped on to the door frames of those that were positive but the negative residents continued to remain in their rooms and doors were left open. The findings constituted an Immediate Jeopardy (IJ) to resident health and safety. The facility reported a census of 64 residents. Findings include: According to a Report of Covid-19 positive cases provided by the Administrator, on 8/19/21 a staff person tested positive and the first positive resident case was on 8/24/21. The report showed from 8/24/21 through 9/12/21, 25 residents and 5 staff had tested positive for the virus. 1. A Minimum Data Set (MDS) dated [DATE] showed Resident #2 had Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognitive ability. The MDS showed the resident required extensive assistance with the help of two staff for bed mobility, transferring, locomotion, dressing and toileting. Resident #2 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to a Care Plan dated 6/4/21, Resident #2 had impaired mobility related to oxygen dependence, [CONDITION(S)], anxiety and ineffective coping. According to a Nursing Note dated 8/24/21 at 10:29 AM Resident #2 tested negative for Covid-19 on that morning. A Nursing Note dated 9/7/21 at 10:58 AM showed the resident tested positive for COVID-19. A Nursing Note dated 9/12/21 at 4:00 AM indicated the resident passed away at the facility. In an observation on 9/8/21 at 7:35 AM Resident #2 was in her room, NW01, plastic was taped to the door frame and covered her door. According to the Census Page of the electronic chart, the resident had been in that room since 1/1/19. According to the Census Page Resident #7 remained in the room located directly across the hallway from Resident #2 and according to the spreadsheet, Resident #7 tested COVID-19 positive on 9/2/21. 2. An MDS dated [DATE] showed Resident #3 had a BIMS score of 14 out of 15, indicating intact cognitive ability. According to the MDS, the resident required extensive assistance with the help of two for transfers, locomotion, dressing, and toileting. Resident #3 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Care Plan dated 6/3/15 included a focus area of impaired mobility related to [CONDITION(S)] and oxygen therapy related to [CONDITION(S)]. According to the Nursing Note dated 9/2/21 at 3:14 PM, Resident #3 tested negative for Covid-19. According to a Nursing Note on 9/5/21 at 10:15 AM the resident was not feeling well and a Covid-19 test was administered at that time and the resident tested positive. 3. The MDS dated [DATE] showed Resident #4 had a BIMS score of 15 out of 15, indicating intact cognitive ability. The MDS showed the resident was independent with transfer, walking and toileting. A Care Plan dated 2/13/20 showed Resident #4 had anxiety related to health concerns and on 4/13/21 the resident was refusing to wear personal protective equipment when outside the room. Staff were encouraged to approach warmly and remind him to wear a mask. A Nursing Note dated 9/10/21 at 10:44 AM, documented Resident #4 tested negative for Covid-19 at that time. A Nursing Note dated 9/11/21 at 5:45 PM, indicated the resident had complained of not feeling well with some dizziness. A rapid test was administered and the resident was found to be positive for Covid-19. In an observation on 9/8/21 at 7:10 AM Resident #4 was sitting in the hallway outside of his room without a mask. At 7:40 AM he was eating his breakfast in the doorway of his room that was next to the room of a Covid-19 positive resident. In an observation on 9/7/21 at 9:45 AM room [ROOM NUMBER] and room [ROOM NUMBER] in the North hallway had plastic taped to the doorframes and according to the list of residents in isolation, these residents were Covid-19 positive. Rooms #6 and #8 across the hallway had the doors open. In the South hallway room [ROOM NUMBER] and #6 had plastic on the doorframes and according to the list of isolated residents, Covid-19 positive residents resided there. Rooms #3, #5 and #7 across the hallway had the doors open. In an observation on 9/7/21 at 12:25 PM lunch was served to the Covid-19 negative residents in the North and South hallways. Bedside tables were set up in the hallway and the residents sat just inside their doorways to eat. Once the negative residents were served, the staff moved in and out of the rooms of the positive residents and changed their personal protective equipment (PPE) in the hallway just outside the rooms of those that were negative. The doors to the rooms of the negative residents were still open and some were still eating. In an interview on 9/8/21 at 9:48 AM the Director of Nursing (DON) said that when the outbreak started in the South building, they used the empty rooms at the end of a hallways for residents that first tested positive. She said they didn't have any empty rooms in the North building and sometimes the residents didn't want to be moved so they had chosen to put plastic on the doorways rather than move the residents. On 9/8/21 at 3:35 PM Registered Nurse (RN) Staff A, also the Infection Control Specialist said they had a couple rooms open at the end of the hallway in the South building when the outbreak started in August. She said they first put the positive cases at the end of the hallway but did not move the residents that were negative and the virus seemed to move up the hallway. At that point, they put a plastic barrier up in the fire door doorway to try to keep them isolated but then some started testing positive in the West hallway, but they didn't put up the plastic barrier to that hallway because there were still a couple of negative residents in that hallway. She said she would have liked to be able to move the positive residents in the North building to isolate them. She agreed it is not ideal to have negative residents across the hallway from the positive ones. She said she thought they were going to try to keep the residents further back into their rooms when they were eating rather than having them in the doorways. She said they were having the dietary staff go into residents rooms so to have the bedside tables in the hallway has been more convenient. According to a policy title: Pandemic Policy and Procedure, one core prevention strategy included implementing environmental and engineering infection control measures. Adhere to droplet precautions to place patients with suspected or confirmed illness in a private room or area. Consolation with infection control personnel is recommended to assess the risks associated with other patient placement options (e.g., cohorting [i.e., grouping patients infected with the same infectious agents together to confine their care to one area and prevent contact with susceptible patients], The facility was notified of the IJ on 9/9/21 at 9:45 AM per phone call and then given the IJ template.The immediate jeopardy was abated on 9/10/21 by the following action: 1. West hall, is the short hall, and had only 2 resident rooms. The residents in these rooms were positive with COVID. We currently have plastic over both of their doorways. We are going to place a barrier in this hallway to block their rooms off from the rest of the hallway. 2. The 2 residents located down South Hall were relocated to the end of North Hall. 3. The 2 residents located down North Hall were moved closer to the end of North Hall. 4. Four of the positive residents were located down at the end of North Hall and a plastic barrier was put up in the hallway to separate them from the healthy residents. 5. When done relocating, all COVID positive residents will be located at the end of West Hall and North Hall behind a plastic barrier separating the healthy from the unhealthy residents. At the time of exit, the scope and severity was lowered to an E after verification the staff had implemented the room changes and hanging the plastic barriers.

Based on record review and interviews, the facility failed to provide adequate supervision to protect one (1) of four (4) residents from hazards (Resident #1); and failed to implement the resident's care plan. Record review established the resident's care plan directed staff to use alarms to alert staff of Resident #1's need to self-transfer or when left unattended. On 3/11/16, Resident #1 fell and sustained a hip fracture when staff left him/her unattended. Record review and staff interviews revealed the resident's alarm was not sounding to alert staff of Resident #1's attempt to self-transfer. The facility identified a census of 89 current residents. Findings include: 1. According to the Minimum Data Set ((MDS) dated [DATE] Resident #1 had [DIAGNOSES REDACTED]. The MDS identified the resident had a Brief Interview for Mental Status (BIMS) summary score of 10 which indicated moderate cognitive impairment. According to the MDS the resident required one (1) staff assistance with bed mobility, transfers, and toilet use. The MDS identified the resident had functional impairment on both sides of the lower extremities and required use of a walker and wheelchair. According to the MDS the resident had 1 fall with no injury and 1 fall with injury since the prior assessment period. The care plan dated 8/4/15 documented the resident had a potential for injury due to his/her history of falls and [DIAGNOSES REDACTED]. The care plan update on 8/17/15 and included a seat alarm provided when unattended. The care plan updated on 8/28/15 and added the intervention to offer toileting and walk in the hall daily around 3:00 PM to 4:00 PM. Review of the Fall Risk assessment dated [DATE] revealed the resident had a total score of 14. A total score above 10 represented a high risk for falls. Review of the Fall Report and assessment dated [DATE] at 3:15 PM revealed the resident observed on the floor of his/her room lying on the left side between the wheel chair and bed. The resident's call light not on. The resident attempted a self-transfer and fell , the alarms did not sound. The resident had shoes on and complained of left hip pain. A portable x-ray completed and the resident sent to the emergency room . The report documented the resident should not be left unattended in his/her wheelchair. Review of the portable x-ray final report dated 3/11/16 revealed the resident had left hip pain with the findings of a subcapital, mildly angulated left femur fracture. Review of the facsimile to the physician dated 3/11/16 at 3:15 PM revealed the resident observed lying on his/her left side in his/her room on the floor between the bed and wheelchair. The assessment indicated a probable hip injury. The resident sent to the hospital emergency room and positive for a left femur fracture. Review of the Consultation Note dated 3/11/16 at 9:59 PM revealed the resident had left femoral neck fracture, displaced. The resident admitted for surgical treatment. Review of the Nurses Notes dated 3/11/16 at 3:15 PM revealed the nurse called to the resident's room by the Certified Nursing Assistant (CNA). The resident observed on the floor of his/her room on the left side between the bed and wheelchair. No alarms sounded. The resident stated he/she attempted to self-transfer no one had been present in the resident's room. The resident denied hitting his/her head. Neuro checks initiated and were within normal limits. The resident stated he/she had left hip and right knee pain. The notes identified the nurse had difficulty assessing rotation or shortening of the resident's leg since the resident's limbs did not extend normally. The resident assisted up with a mechanical lift and 3 person assistance. During an interview with Staff A, CNA (Certified Nursing Assistant), Restorative Aid on 3/29/16 at 2:30 PM she stated that she provided restorative therapy for the resident on 3/11/16 at approximately 2:30 to 2:45 PM. She stated that she remembered the alarms were in place on the wheelchair and they sounded when she transferred the resident from the wheelchair to the exercise table. She had to turn them off. The exercises took approximately 1/2 hour to complete. She transferred the resident back to the wheelchair and did not remember putting the alarms back on. She then transferred the resident to an activity. The resident had been ready to return to his/her room and she assisted him/her in the wheelchair and then removed the foot pedals to allow him/her to self-propel. Staff A reported she thought the resident would put on his/her call light. She further stated that she returned to provide restorative exercises for another resident. She would have toileted the resident if she had been working as a CNA that day. She stated that she did not notify staff that she helped the resident to his/her room. Staff A reported she went to the Director of Nursing after the incident and reported it was her fault. Staff A stated she felt terrible and had been too distracted. During an interview with Staff B, CNA on 3/29/16 at 3:30 PM she stated that she worked 6:00 AM to 10:00 PM shift on 3/11/16. She toiled the resident after lunch approximately 1:00 to 2:00 PM. At that time he/she had the alarms on, they seat and personal alarm. She stayed with him/her and then transferred him/her into the wheelchair and activities took him/her in the dining room to go outside. She did not see the resident again until she went down the hall with Staff B, CNA and saw him/her on the floor. Staff C stayed with the resident and she went to tell the nurse and went to get the Hoyer lift. She did not hear the resident's alarms sound. During an interview with Staff C, CNA on 3/19/16 at 3:50 PM she stated that she worked 2:00 PM to 10:00 PM on 3/11/16. She received report and had been told that the resident had been at an activity. She did rounds that included passing towels and did not see the resident in the room. She went down the hall with Staff B and looked in the room and saw the resident on the floor. She further stated that she did not hear an alarm sound. She stayed with the resident and asked him/her what they were doing. The resident stated he/she did not know and complained of the right knee and left hip hurting. The resident denied the need to toilet. Staff transferred the resident back into the wheelchair with a Hoyer lift. The alarms had been on the wheelchair and were functional when she hooked them up to the resident and turned them on. During an interview with Staff D, Activity assistant on 3/30/16 at 3:15 PM she stated that she took the resident outdoors and recalled the alarms in place and attached to the resident. She brought the resident back inside and he/she had been by a visiting animal. During an interview with the Director of Nursing (DON) on 3/30/16 at 2:00 PM she stated that staff are shown the different alarm types and there use in orientation. She talks to the CNAs about the types of alarms and staff also orientate with other staff members and learn about the alarms. Administration did follow-up education with staff and all staff aware of resident's alarms and the pocket care plans.

Based on record review and interviews, the facility failed to provide timely assessments and interventions after a fall for 1 of 4 residents reviewed. (Resident #1) The facility identified a census of 87 current residents. Findings include: Resident #1 had a MDS with a reference date of 9/12/15. The MDS identified the resident as severely cognitively impaired and had [DIAGNOSES REDACTED]. The MDS reflected the resident had unclear speech and could rarely understand others or others understand the resident. Review of the Order Summary Report dated 9/21/15 revealed an order for [REDACTED]. Review of the MAR (Medication Administration Record) dated 10/1/15 through 10/31/15 identified the order for APAP 650 mg every 4 hours as needed for pain/fever. The MAR indicated [REDACTED]. The Nurse's Notes reflected the following: Documentation dated on 10/10/15 at 1:45 PM indicated that at 7:15 AM the resident was in the whirlpool getting a bath. Staff heard the CNA (certified nursing assistant) yell for help. Staff went into the whirlpool room to see the chair up in the air. The resident slid out of the chair and the strap of the whirlpool chair under the resident's breasts. The CNA unstrapped the belt and the resident was lowered to the bottom of the tub by staff assistance. The resident then assisted by 3 staff members to get on the lift sheet and out of the tub with use of the Hoyer lift. Vital signs blood pressure (BP) 142/82, apical pulse (P) 92 and respirations (R) 16. Staff performed passive range of motion to the extremities and the resident had no facial grimacing. No injuries noted. On 10/10/15 at 6:50 PM, the resident had a large emesis at the dining room table. Lung sounds clear to auscultation (CTA) bilaterally and axillary temperature (T) - 98.2. At 8:00 PM the document revealed the resident had no signs or symptoms of pain noted related to the fall. On 10/11/15 at 5:40 AM, the resident had no complaints of pain or discomfort related to the fall. The lung sounds CTA bilaterally. No further emesis noted. At 7:35 AM the resident's T-97.5 (normal-98.6) AP-112 (elevated-normal 60-100), R-32 (elevated-normal 16-20), B/P 128.82 (normal), pulse oxygen saturation 92% (low-normal 96-100%). Unable to verbalize any pain or discomfort. The resident walked a few steps with the nursing assistant in the AM. Lung sounds clear CTA bilaterally. The resident does not take deep breaths when cued to. No emesis at this time. The resident grinding his/her teeth in the AM. At 1:40 AM the resident's spouse reported he/she thought the resident in some pain because when touched, he/she winces. Tylenol given for comfort. At 9:45 PM the resident had no signs or symptoms of pain noted related to the fall. The resident assisted with transfers and had no emesis. Lung sounds CTA bilateral. The facility failed to provide further assessment of the increased heart rate and respirations. On 10/12/15 at 9:45 PM the resident had no signs or symptoms of pain noted related to the fall. Two staff members assisted with transfers and no emesis during the shift. At 9:00 AM the resident up per wheelchair and ate good with assistance and no nausea. At 11:00 AM the resident's spouse noted increase in facial expressions and questioned pain with movements. Staff noted the left great toe discolored. APAP given to promote comfort. At 1:00 PM the resident ate a good lunch, walked with walker and the assistance of 2 staff. No increase in discomfort noted. On 10/13/15 at 5:00 AM the resident had no emesis noted and no signs or symptoms of pain from the fall. At 2:00 PM APAP given to promote increased comfort today. The resident turns to the right side of the chair with possible change of the frequency. APAP effective and walked with a walker and assistance a short distance. On 10/14/15 at 8:00 AM, APAP given to promote comfort. No emesis. On 10/15/15 at 6:45 AM, APAP given to promote increased comfort. The resident holds his/her head and looks fretful. The resident walked with the walker and assistance of 2 staff (members). No increased facial grimace with walking. Gait belt on with walking and no increased pain noted with placement. At 5:00 PM the resident's spouse approached the nurse and voiced concerns that he/she felt the resident in pain. The resident unable to vocalize needs and answers yes/no questions occasionally. The resident in the reclining chair in the common area. T-98.5, AP-120 (elevated) R-30 (elevated) and oxygen saturation 85% (low-normal 95-100%). Lungs diminished and no cough noted. No facial grimacing or yelling out. The resident's spouse insisted his/her gut feeling that something is wrong and would like the resident transferred to the emergency room . On 10/16/15 at 3:15 PM, the hospital notified the staff that the resident had been admitted into the hospital for multiple rib fractures. Review of the Fall Assessment Policy and Procedure dated May 2012 directed staff to do the following after a fall: a. Continue to monitor resident's physical and mental status for 72 hours. Every shift is to document their assessments in the nurse's notes. Orthostatic blood pressure and vitals to be completed on the shift that the fall occurred for 72 hours following the fall and documented in the nurses notes. On 11/4/15 at 5:30 PM, the resident ' s spouse was interviewed and stated when he/she arrived at the facility at 5:00 PM on 10/10/15, the resident had been sitting in the commons area (near the nurses station). The spouse stated the resident had been in the same area following eating the noon meal. He/she further stated the resident had been really out of it and did not eat well for the noon meal while he/she had been there earlier. The resident had been in view of staff and they did not notice the resident's changes. The spouse stated he/she told the nurse about the changes that he/she saw and the resident had remained out of it. On 11/5/115 at 10:50 AM, the Director of Nursing stated that after a fall, follow-up assessments are to be completed and documented in the Nurse ' s Notes. Vital signs are taken daily on the shift of the fall and the pulse oximetry reading not necessarily done routinely On 11/4/15 at 11:00 AM Staff B, Certified Nursing Assistant, was interviewed and stated she had thought the resident had been in pain. When lifted with the gait belt to transfer, the resident grabbed staff's arms really hard and acted really different. Staff B stated she told the nurses she thought the resident had been in pain. On 11/4/15 at 2:20 PM Staff E, Certified Nursing Assistant, was interviewed and stated she saw the resident put his/her head in his/her hands at times. The activity increased after the fall. The resident also grabbed and had been more resistant and pushed on the side rails when staff assisted like he/she tried to stop the roll. Staff E stated she told nursing staff but did not remember who she told, about the resident's changed behavior. Staff E stated the resident did not want to stand up and fought the standing movement. On 11/4/15 at 4:15 PM Staff H, Registered Nurse, was interviewed and stated she had been the nurse to send the resident to the hospital. Staff H stated the resident's spouse insisted something had been wrong. The resident had a low grade temperature and she could not hear the resident's breathing. The resident's blood pressure, pulse and respirations were also elevated. The resident also had not been responding to questions.

Based on record review, observation and staff interviews, the facility failed to provide adequate supervision and protect residents from hazards from self when transferring a resident in a whirlpool chair (Resident #1, #3). The sample consisted of 4 residents and the facility identified a census of 87 residents. Findings include: 1. Resident #1 had a MDS (Minimum Data Set) assessment with a reference date of 9/12/15 which identified the resident had [DIAGNOSES REDACTED]. The MDS identified the resident had short and long term memory problems and severely impaired cognitive skills for daily decision making. According to the MDS the resident required extensive assistance with bed mobility, transfers and total dependence with bathing. The Care Plan dated 6/3/15 directed staff to give the resident a whirlpool bath 2 times each week and to wash the resident's hair 1 time a week unless indicated differently by the spouse. Review of the Fall Risk Assessment tool dated 9/25/15 identified the resident had a total score of 13. A total score above 10 represented a high risk for falls. Review of the Fall Report and assessment dated [DATE] at 7:15 AM revealed the CNA (Certified Nursing Assistant) yelled for help. Staff went into the whirlpool room and noted the whirlpool chair in the air with the resident slid out of the chair being suspended by the belt on the whirlpool chair. The CNA removed the belt that had been under the resident ' s breasts and lowered the resident into the bottom of the tub. The resident was assisted by 3 staff members to get onto the Hoyer (mechanical lift) sheet and then lifted out of the tub. The resident denied pain (not noted by facial expression or with passive range of motion). Review of the Facsimile to the Physician dated 10/10/15, reflected the resident had been getting a whirlpool bath and slid out under the belt that hold him/her in (the chair). The resident assisted up by 3 staff with use of a Hoyer lift. No injuries noted and no display of pain with passive range of motion. Staff will monitor. Review of the Nurse's Notes dated 10/10/15 at 1:45 PM reflected at 7:15 AM, the resident was in the whirlpool getting a bath. Staff heard the CNA (certified nursing assistant) yell for help. Staff went into the whirlpool room to see the chair up in the air. The resident slid out of the chair and the strap of the whirlpool chair under the resident's breasts. The CNA unstrapped the belt and the resident was lowered to the bottom of the tub by staff assistance. The resident then assisted by 3 staff members to get on the lift sheet and out of the tub with the use of the Hoyer lift. The resident ' s vital signs were: blood pressure (BP) 142/82, apical pulse (P) 92 and respirations (R) 16. The passive range of motion performed to the extremities identified no facial grimacing. The resident had no noted injuries. Review of the Radiology Report dated 10/16/15 identified the resident had fractures that involved the right 5th through 11th ribs and a deformity of the anterior right 4th rib which is age indeterminate. The right 9th and 10th ribs had fractured in 2 locations. There is a nondisplaced right L1 transverse fracture. Review of the Operation/Procedure manual for Whirlpool Bathing System (not dated) directed staff to do the following: a. Transfer the patient into the Saf-Kary using the proper nursing techniques. Secure the seat belt around the patient's lap, using the method that will provide the most security for your patient, as noted. 1. For smaller patients: Facing the front of the patient, loop the belt back through the rear opening of the right side of the seat. Bring the belt around the front of the patient, and then back through the rear opening of the left side of the seat. Secure the belt around and through the D-ring. 2. For larger patients: Bring the belt around the front of the seat and secure it through the D-rings in the proper manner. (Warning! Failure to secure the patient properly with the seat belt could result in injury to the operator or patient) During an interview with Staff A, Licensed Practical Nurse, on 11/4/15 at 10:15 AM she stated that she walked into the whirlpool room and saw the resident in the whirlpool chair. The chair was up and the resident had slid in the chair. The chair belt below the resident's breast. She had been in the room and CNA released the strap. The chair had still been up and staff able to slowly lift the resident into the tub. The resident did not fall into the tub. Staff A stated the whirlpool chair belt placement on the inside area or outside of the seat, depended upon the size of the resident On 11/4/15 at 11:00 AM, Staff B, Certified Nursing Assistant was interviewed and stated if a larger resident, then the staff put the whirlpool belt on the outside of the seat to prevent skin tears. If very large the resident should receive a shower and not a whirlpool bath. Staff B stated she had been instructed to place the whirlpool belt on the inside of the whirlpool chair 1st and to then place the belt on the outside of the chair if unable. She had always placed the whirlpool belt on the inside for the residents. On 11/4/15 at 2:20 PM Staff E, Certified Nursing Assistant was interviewed and stated she had been taught to place the whirlpool strap inside the holes of the chair and not on the outside. The strap should be close to the resident's skin. On 11/5/15 at 2:00 PM Staff L, Certified Nursing Assistant was interviewed and stated she placed the resident in the whirlpool chair. She then put the chair belt inside the hole on the residents left and on the outside of the chair on the right side. She further stated that if the resident was larger in size, the belt should go on the outside of the chair. 2. According to the MDS dated [DATE], Resident #3 had [DIAGNOSES REDACTED]. The MDS identified the resident independent with bed mobility, transfers. The MDS reflected the resident weighed 135 pounds and 65 inches tall. A Fall Risk Assessment identified the resident not at risk for falls with a scored 5 on 9/11/15. Observation on 11/5/15 at 10:00 AM revealed Staff M, Certified Nursing Assistant,, transferred the resident to the whirlpool chair. She placed the belt and put it through the opening on the left side of the chair and in front of the chair on the right side of the chair.

Based on observation, clinical record review and staff interviews, the facility failed to provide adequate supervision when positioning Resident #1 in bed. The nurse positioned the resident in bed while standing on the opposite side of the bed during the turning process. The resident rolled out of bed and onto the floor. The resident was to be positioned in bed with the assistance of 2 staff persons. The sample consisted of 4 residents. The facility identified a census of 96 residents. Findings include: 1. Resident #1 had a Minimum Data Set (MDS) assessment with a reference date of 2/23/13, which identified [DIAGNOSES REDACTED]. The MDS assessment documented the resident required extensive assistance of two persons with bed mobility and the resident experienced functional limitation in range of motion on both sides of the lower extremities, A 7 day Observation Period dated 2/17/13 to 2/23/13, documented the maximum number of staff that assisted the resident with bed mobility on all 3 shifts throughout the assessment period was two people (staff members). An undated Care Card directed staff to position the resident with the assistance of one or two (staff members), side to side. The Care Plan dated 12/18/12, identified the resident had impaired mobility with approaches that included: a. Transfer with two (staff) assistance and (a) sit to stand lift, dated 1/18/13 (discontinued 4/30/13). b. 1/2 side rail up times two for positioning and boundary. c. Side to side positioning in bed. Pillows between legs when side lying in bed (discontinued 4/30/13). d. Reposition in bed with two assistance, dated 4/30/13. e. Hoyer lift as needed 12/27/13 (discontinued 4/30/13). f. Total lift with two assistance, dated 4/30/13. A Fall Report and assessment dated [DATE] at 4:30 a.m., documented staff pulled the soaker pad to reposition the resident onto his/her right side and the resident slid out of bed onto his/her knees. The resident's torso remained on the bed. The resident complained of pain in his/her head. Staff noted a bruise to the resident's outer right eye in position of the side rail. The resident's right hand was caught under his/her torso. The injuries were a 4 by 2.5 centimeter (cm) bruise to the right outer eye, an 8 by 6.5 cm bruise with 3 small abrasions to the right hand and a swollen right knee with a hard raised area of the outer top right knee. The immediate intervention was to turn the resident with the air mattress on the bed with two (staff) assistance. A Transfer Sheet dated 4/22/13, documented the resident was repositioned in bed on one side (of bed) and she/he slid out of bed on the opposite side (of bed)-landing on both knees. The resident bumped outer right eye on the (bed) side rail and the right hand caught under the torso. A Diagnostic Imaging report dated 4/22/13, documented the resident had a comminuted right femoral metadiaphyseal fracture with significant overriding of fracture fragments. A History and Physical report dated 4/22/13, documented the resident was in their usual state of health. The resident had problems with progressive dementia and became more and more bedridden as time went on. Evidentially staff were rolling the resident to change body positions and the resident kept on rolling and rolled out of the bed and ended up falling onto the floor. The resident sustained [REDACTED]. The resident had a bruised and black and blue right hand, and had a lot of pain in his/her right leg. The resident had a comminuted displaced fracture of the distal femur. The plan documented the resident was at extremely high risk for any surgical intervention. They needed to do a surgical procedure to pin the leg. They would try to keep the resident as comfortable as possible, but he/she was at high risk for severe and life threatening complications. A Consultation report dated 4/23/13, documented the resident went through surgery and postoperatively had some hypotension (low blood pressure). The Nurse ' s Notes dated 4/30/13 at 11:50 a.m., documented the resident returned to the facility. During a re-enactment and staff interview on 5/8/13 at 8:36 a.m., Staff A (Licensed Practical Nurse); LPN stated the resident faced the wall with his/her back to the door. Staff A stated the resident was wet (incontinent of urine), had a pillow behind him/her and laid on his/her left side. Staff A told the resident she would turn him/her. Staff A took the soaker pad and pulled slightly over and up and the resident rolled. Staff A stated before she knew what happened, the resident landed on the floor with his/her body waist up on the bed. Staff A stated they could reposition the resident and do pericare by themselves (without additional staff assistance). Staff A did not always do (care) for the resident by themselves, it just depended. Staff A thought the (mattress) overlay was very slippery, but stated the sheet did not slip. Staff A stated she thought Staff C, (Certified Nurse Aide), CNA would come in which was why she stood on that side of the bed. Staff A stated when repositioning alone they would be on the side of the bed they turned the resident to. Staff A stated the resident did not reposition him/her or assist in repositioning. On 5/8/13 at 9:26 a.m., Staff C, CNA was interviewed and stated she would reposition the resident herself at times. The resident usually had a soaker pad and she would turn him/her with it. Staff C stated the resident did not help with repositioning. Staff C stated she would be on the side and turn the resident toward her. Staff C did not know how the resident fell out of bed. Staff C stated it was normal for her to go and start a resident by herself. Staff C helped get the resident off the floor and he/she complained of aching all over. Staff C stated they turned the resident together the previous time. They turned him/her 1 time prior that night. Staff C stated the resident was care planned to reposition with one staff person. Staff C stated she only rolled someone away from her if the bed was against the wall. On 5/8/13 at 9:44 a.m., Staff B, CNA was interviewed and stated she did not work on the resident's unit. Staff B stated she repositioned according to the resident's care plan. It depended on the resident ' s mood, but most generally they used two at night to reposition the resident. Staff B stated she would roll a resident toward her, unless the bed was against the wall. During an interview on 5/7/13 at 4:26 p.m., Staff D, (Registered Nurse), RN she came after the CNA returned from assisting the resident off the floor. Staff D stated they worked from time to time in that area and they had assisted in repositioning and changing the resident ' s undergarments. Staff D would go with the CNA and assist with rounds. Staff D preferred to do it that way and it made it easier. On 5/8/13 at 8:55 a.m., the Director of Nursing (DON) was interviewed and stated the facility used the Preventing Injuries; Transferring Procedures material in orienting staff. The DON stated the resident did not reposition him/herself and did not assist in repositioning him/herself. On 5/9/13 at 12:48 p.m., the Restorative Nurse Consultant stated she did an in-service regarding transfers and positioning. The Consultant stated the staff should see if a resident could help with the repositioning and if they could not assist, they should use two people to reposition. The Consultant stated when repositioning someone alone, she was sure she told them (staff) that they should turn the resident toward them, not away from them, and they (staff) should have their hands on the resident. The Consultant stated they should not turn by pulling on the soaker pad because it could cause friction (to skin) and if two people repositioned, they (staff) could use the soaker pad because they could lift the resident off the surface of the bed and avoid friction. On 5/9/13 at 1:50 p.m., the DON was interviewed and stated she did an in-service last year regarding transfer and repositioning geared toward CNA's and Staff A did not attend since she was a nurse. An undated post incident discussion/education report documented while reviewing the fall of Resident #1 with Staff A, she reenacted the situation at the bedside, demonstrating how the resident fell off the bed. When asked what she would do different, Staff A offered that she should have stood on the other side of the bed, turning the resident toward her. The facility policy, Preventing Injuries: Transferring Procedures dated February 2013 included turning a resident side to side, and the following steps: a. Cross the resident's arms, and cross his/her legs in the direction turning the resident. b. Have a helper stand on the other side of the bed and hold the edge of the draw sheet. c. Hold the edge of the draw sheet. On the count of 3 slide the resident closer to the middle of the bed. d. Take the edge of the draw sheet from the helper. Pull the draw sheet toward you to turn the resident.