Every finding on record at Tallgrass Healthcare Campus

Based on record review and interview, the facility failed to immediately implement effective measures to prevent further potential abuse or mistreatment of residents. After Resident (R) 1 made an allegation of abuse which named a facility staff member as the alleged perpetrator, the facility did not immediately suspend the staff member (AP), which allowed the AP to have further access to the alleged victim and/or other vulnerable residents. Findings included:- R1's Electronic Medical Record (EMR) documented R1 had a diagnosis of major depressive disorder (a major mood disorder that causes persistent feelings of sadness).R1's Quarterly Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview of Mental Status (BIMS) of 14, which indicated intact cognition. The MDS documented R1 required substantial/maximal staff assistance with most activities of daily living (ADLs). R1's Care Plan, revised 04/22/2026, documented R1 reported feeling uncomfortable during personal care and expressed concern regarding how care was provided. (initiated on 06/18/2026). The plan documented R1 should verbalize feeling safe during care, her care preferences would be respected, and she would express satisfaction with the care provided. The plan instructed staff to encourage R1 to report any concerns regarding care, staff interactions, or personal boundaries immediately, and ensure privacy and dignity were maintained during all personal care activities. The plan instructed staff to explain care procedures before providing personal care and obtain consent throughout the care process, honor R1's requests regarding caregiver assignment when feasible, and, according to facility staffing capabilities. The plan instructed staff to monitor for signs of anxiety, fear, withdrawal, or reluctance to receive care and report concerns to nursing or social services. The plan documented R1 had a history of previous sexual trauma that may increase emotional distress during intimate personal care and may affect feelings of vulnerability during hands-on care. (initiated 06/26/2026) The plan instructed R1 to voice any discomfort or concerns during care, and staff should stop care immediately if requested. The plan instructed staff to honor R1's preferences regarding personal care techniques whenever possible (application of powder by sprinkling only, avoiding rubbing unless specifically requested). The plan documented R1 used anti-anxiety medications and instructed staff to monitor side effects and effectiveness every shift, and educate the residents, family, and caregivers about risks, benefits, and side effects of the medication. The facility's Incident Note, dated 06/17/2026, documented on 06/17/2026, at approximately 06:30 PM, Administrative Nurse D received a telephone call from Licensed Nurse (LN) G, who reported R1 alleged that Certified Nurse Aide (CNA) M touched R1 inappropriately during the provision of care. Administrative Nurse D spoke with R1 by telephone. R1 stated, while CNA M was providing incontinent care and assisting R1 to bed, CNA M applied powder and then rubbed the powder in with her hand. When asked to clarify, R1 stated that after sprinkling the powder, CNA M used her hand to rub it into the skin. R1 reported the contact was external only and specifically stated that she did not believe the action was sexual in nature, but the interaction creeped her out and requested CNA M not provide care for her in the future. The report documented that Administrative Nurse D relayed the information to LN G, and it was agreed that another staff member would respond to R1's care needs and requests going forward. The report documented, on 06/21/2026the facility received an email from another CNA indicating R1 had reportedly stated she had been sexually assaulted by CNA M. The email referred to the same incident reported on 06/17/2026 and did not describe a new occurrence. The report documented on 06/22/2026, Administrative Nurse D and Administrative Staff A interviewed CNA M regarding the allegation. CNA M was suspended pending completion of the facility's investigation due to an escalation in the resident's characterization of the event. On 06/30/2026 at 01:48 PM, Administrative Nurse D verified CNA M was not immediately suspended when R1 alleged that CNA M had inappropriately touched her during the provision of incontinent care. Administrative Nurse D stated R1 had voiced no insertion or aggressive behavior by CNA M, so she felt like it was a personality difference. The facility's Abuse, Neglect, and Exploitation Policy, revised 10/02/2025, documented that the facility would make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to:Responding immediately to protect the alleged victim and the integrity of the investigation.Examine the alleged victim for any signs of injury, including a physical examination or psychosocial assessment if needed.Increased supervision of the alleged victims and residents.Room or staffing changes, if necessary, to protect the resident (s) from the alleged perpetrator.Protection from retaliation.Providing emotional support and counseling to the residents during and after the investigation, as needed.Revision of the resident's care plan if the resident's medical, nursing, physical, mental, or psychosocial needs or preferences change as a result of an incident of abuse.

The facility identified a census of 66 residents, with three residents reviewed for abuse and neglect. Based on record review, observation, and interview, the facility failed to protect Resident (R) 2, a cognitively impaired female, from sexual abuse. On 11/12/25 at 01:40 PM, staff found R2, who had severe cognitive impairment, was unable to consent to sexual relations, and had a history of wandering, in R1's room on his bed. R1, who had a Brief Interview for Mental Status (BIMS) score of 15 (cognitively intact) and a history of sexual behaviors, performed oral sex on R2. Staff separated the residents and placed R2 on one-to-one observation. This deficient practice placed R2 and other cognitively impaired female residents in Immediate Jeopardy.Findings included:- R1's Electronic Medical Record (EMR) documented R1 had diagnoses of lymphedema (swelling caused by accumulation of lymph), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), hyperlipidemia (condition of elevated blood lipid levels), and chronic (persisting for a long period) kidney disease (a condition where the kidneys are damaged and lose the ability to filter blood properly).R1's Quarterly Minimum Data Set (MDS) dated [DATE] documented R1 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. R1 had no behaviors documented on the assessment. R1 required moderate staff assistance with bathing, supervision for dressing and was independent with all other activities of daily living (ADL).The ADL (Activities of Daily Living) Functional / Rehabilitation Potential Care Area Assessment (CAA) dated 04/16/25 documented R1 was at the facility for medication management and assistance with ADLs. The CAA documented R1 was dependent on staff for lower extremity dressing and noted R1 ambulated with a walker.R1's Care Plan, initiated on 04/23/24, documented R1 had inappropriate sexual behaviors, including sexually explicit comments, gestures, or attempts at contact. R1's goal, dated 10/10/25, documented R1 would have a reduction in frequency and severity of inappropriate sexual behaviors and maintain socially appropriate interactions with peers. The care plan documented R1 was started on Prozac (an antidepressant-class of medications used to treat mood disorders) for hypersexuality (a condition characterized by intense, uncontrollable sexual urges, thoughts, and behaviors) (10/10/25). The care plan documented R1 started making inappropriate comments and gestures towards females and asked a female to come to his room. R1 verbalized he was aware his behaviors were inappropriate but continued exhibiting the behavior. R1 was moved to a different room on the opposite side of the facility from a particular resident in an attempt to limit their interactions (10/10/25).The Social Services Progress Note dated 09/23/25 documented Social Service X received a report that a female resident (referred to R2 and verified with Social Service X) went into R1's room to visit him. Staff found R1 and R2 in R1's room in the dark with the door shut. Social Service X talked to R1 and asked him about what was going on. R1 stated he thought the female resident liked him and said the resident snuggled up to him and was very close to him. Social Service X explained to R1 that R2 could not give consent due to her cognition, and R2 could possibly be blamed for something that did not happen. R1 expressed understanding, and Social Service X told R1 to get help from staff if he had difficulty with R2.The Social Services Progress Note dated 09/29/25 documented staff reported R1 made an inappropriate sexual gesture to a female resident (verified with Social Service X, this was R2). Social Service X questioned R1, and he did not deny the accusation. R1 reported there was a temptation involved, but he knew it was wrong. Social Service X explained to R1 the situation could become a legal problem for him. R1 expressed understanding. R1 would be moved to another location in the facility in order to deter further inappropriate interactions.The Behavior Note dated 09/29/25 documented staff assisted in having a conversation with R1 regarding recent inappropriate conduct with another resident (R2). A staff member observed an inappropriate sexual gesture performed by R1. The other resident involved did not have the ability to consent to physical touch related to her cognitive status, and the female residents responsible party did not give consent. The possible implications included the resident being asked to leave the facility and/or having legal repercussions for any further involvement were discussed at length. R1 demonstrated understanding of the implications for his action and understood he would be relocated to another unit in the facility, and R1 was to have no physical or verbal interaction with the resident (R2). The primary care provider was notified of the situation.The Alert Note dated 09/29/25 documented R1 was transferred from one area of the facility to another related to inappropriate verbal and non-verbal gestures with another female resident (R2). All medications were transferred as well as R1's belongings. R1 was aware of the reasoning for the room change.The Social Services Progress Note dated 10/08/25 documented a Certified Nurse's Aide (CNA) came to Social Service X and reported R1 blew a kiss to a female resident (Social Service X verified the female was R2) and R2 blew a kiss back to R1. After the meal, R1 went to R2 and asked her to come with him to his room. Staff intervened and stopped R2 from going to R1's room. Social Service X and Licensed Nursing Staff talked to R1about this behavior in the past. Social Service X would ask a male nurse to visit with R1 to see if that made a difference.The Social Services Progress Note dated 10/09/25 documented R1 was referred for psychiatric services.The Physician's Order Note dated 10/10/25 documented Prozac 20 milligrams (mg) one capsule by mouth daily for hypersexuality with inappropriate sexual behaviors.The Health Status Note dated 10/12/25 documented (selective serotonin reuptake inhibitor) SSRIs (a class of antidepressant medication) such as Prozac are supported in the literature as first line pharmacologic options for managing inappropriate sexual behaviors in older adults due to their libido (another term for sex drive) reducing and anti-obsessional effects which help decrease sexual preoccupation, impulsivity, and behavioral disinhibition without higher adverse effects associated with other drugs.The Social Services Progress Note dated 11/05/25 documented Social Service X received a report that R1 continued to make some slight sexual advances to R2. Staff would continue to monitor behaviors.The Health Status Note dated 11/12/25 documented at approximately 01:40 PM this afternoon, staff notified the nurse R2 was in R1's room. When staff entered the resident's room, R1 and R2 were naked from the waist down and R1 was performing oral sex on R2. R1 and R2 were immediately separated. Staff assisted R2 with her clothing and escorted from R1's room. When asked what had happened, R1 stated, She followed me down the hall. I told her to turn around, and she said no I want to be with you. R1 stated he and R2 talked for a few minutes, kissed, and then got intimate. R1 stated they were trying to make love and R2 was his female friend. When asked if R2 acted uncomfortable with the situation at any time, R1 said, No, and if she had asked me to stop, I would have stopped immediately. R1 was reminded this behavior was unacceptable and could not recur.On 11/13/25 at 11:00 AM, R1 stood in his doorway with his walker and watched the activity in the hallway outside his door. R1 said, Hey, to people as they walked by.On 11/13/25 at 11:00 AM, R1 stated R2 came into his room, and he was a tempted man and could not help himself. R1 denied R2 told him to stop, so he continued to pleasure her. R1 denied sexual penetration. R1 stated he knew it was wrong but could not help himself. On 11/13/25 at 12:00 PM, CNA M stated she had knocked on R1's door and opened it. CNA M stated she saw R2 lying on the bed unclothed from the waist down, R1 unclothed from the waist down, and R1 was performing oral sex on R2. CNA M stated she told R1 to get up, and R1 said, I am a tempted man. I cannot help myself, and then laughed and smiled.On 11/13/25 at 12:15 PM, CNA N stated she and CNA M knocked on R1's door looking for other CNAs. When they opened the door, CNA N stated she saw R2 lying in R1's bed naked from the waist down, and R1 was giving R2 oral sex. CNA N stated she asked them what they were doing, and R2 said, I came in to watch TV. I don't know. R1 said, She came into my room.On 11/13/25 at 11:30 AM, Licensed Nurse (LN) G stated he normally worked on the hall R2 lived on and R1 used to live on. LN G stated he was unaware of R1 having any hypersexual behaviors. LN G stated he and the staff on R2's hall was to check on R2 every fifteen to twenty minutes to ensure she was safe, but sometimes she made it to places she should not be when staff were in other rooms.On 11/13/25 at 01:00 PM, Social Service X stated R1 had several instances of making inappropriate gestures to R2, blowing kisses to her, and R2 being in R1's room. Social Service X stated she talked with R1 and explained to him R2 had no mental capacity to consent, and R2 did not know right from wrong. Social Service X told R1 he could get in trouble if he continued to have interactions with R2. Social Service X stated R1 stated he understood. Social Service X stated R1 was alert and oriented and knew right from wrong.On 11/13/25 at 09:30 AM, Administrative Nurse D stated R1 made obscene gestures to R2 across the dining room, and R1 and R2 lived on the same hall. R2 was in R1's room several times, so they moved R1 to a different hall to try and limit their access to one another. Administrative Nurse D stated R2 still made it across the building to R1's room no matter what was done to prevent it. The facility's undated Abuse, Neglect, and Exploitation Policy documented it is the police of the facility to prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property by implementation of specific procedures. It is the police of this facility that each resident will be free from abuse, neglect, misappropriation of resident property, and exploitation. Abuse may include verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion, and any physical or chemical restraints not required to treat a resident's medical condition. Additionally, residents will be protected from abuse, neglect, and harm while they are residing in this facility. No abuse or harm of any type will be tolerated, and residents and staff will be monitored for protection.On 11/13/25 at 02:15 PM, Administrative Staff A was provided the IJ template and notified of the facility's failure to ensure R2 remained free from sexual abuse, which placed R2 in immediate jeopardy.The facility provided an acceptable plan for the removal of the immediacy on 11/13/25 at 03:49 PM, which included:1. Staff immediately separated R1 and R2, and placed R2 under one-on-one supervision, pending assessment (11/12/25)2. R1 was placed on continuous monitoring, and R2 was restricted from unsupervised access to rooms. Initiated 11/13/25.3. Administrative Staff A and Administrative Nurse D initiated an internal investigation per the abuse policy upon knowledge of the incident, and after R1 and R2 were separated on 11/12/25.4. Staff re-education on abuse prevention, reporting, and sexual consent with cognitively impaired residents training initiated on 11/12/25 after the incident occurred and continued for all staff to be re-educated prior to working the next scheduled shift until all staff had been re-educated.The Surveyor verified the implementation of the IJ removal plan while onsite on 11/13/25 at 03:55 PM. The deficient practice scope/severity was lowered to a G indicating actual harm based on reasonable person concept, upon removal of the immediacy.

The facility identified a census of 62 residents. The facility had two medication rooms and three medication carts. Based on observation, record review, and interview, the facility failed to ensure staff locked and secured medications while away from the medication cart on the Sunshine Hall. This placed residents at risk for accidental ingestion of medication and adverse reactions.Findings included:- On 08/04/25 at 09:04 AM, on Sunshine Hall, the nurse's medication cart located beside the nurse's desk was found unattended and unlocked. At 09:05 AM, Administrative Nurse E walked down the hall to the medication cart and noticed it was unlocked. Administrative Nurse E locked the cart and stood beside the cart until Licensed Nurse (LN) I returned to her cart.On 08/04/25 at 09:07 AM, Administrative Nurse E stated to LN I, upon her return to her medication cart, that her cart should remain locked any time she was away from the cart. On 08/06/25 at 09:34 AM, Administrative Nurse D stated that all medication carts and rooms should remain locked when not in use or when staff walked away from direct sight of the medication cart.The facility's Medication Storage in the Facility policy dated 08/01/25 documented medications and biologicals were stored safely, securely, and properly following the manufacturer or supplier recommendations. The medication supply was accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Medication rooms, carts, and medication supplies were locked or attended by a person authorized to access.

The facility had a census of 62 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility failed to ensure a sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections when staff failed to provide enhanced barrier precautions (EBP - infection control interventions designed to reduce transmission of resistant organisms which employ targeted gown and glove use during high contact care) for Resident (R) 17. The facility staff failed to change gloves when providing incontinent care for R17. This deficient practice placed the residents at risk for possible exposure to infection.Findings included:- On 08/04/25 at 03:30 PM, observation revealed no EBP signage or personal protective equipment (PPE) outside or inside R17's room.On 08/04/25 at 03:34 PM, R17 sat in a chair in the living room area between all halls. Licensed Nurse (LN) F and Certified Nurse Aide (CNA) M assisted R17 using a walker and a gait belt to R17's room. LN F asked the resident if she could provide wound care to her left heel. R17 replied yes and smiled. CNA M applied gloves, cued R17 to sit on the bedside. LN F placed a barrier on the bed, put all items on it, applied gloves, and removed R17's heel protector boot from the left foot and sock to reveal a wound (without a dressing), with oval-shaped black eschar (dead tissue) with an opening above the eschar. Above this area was an open area with a small amount of serious (thin, clear) drainage. LN F applied wound wash on a 4 by 4 gauze pad and cleansed the wound, then removed and discarded gloves, applied new gloves, and placed betadine (prevents the growth of disease-causing microorganisms on the skin) on a 4x4 gauze pad and applied it to the wound. LN F then removed and discarded gloves, applied new gloves, and left the wound open to air. LN F placed R17's socks and heel protector back on. Further observation revealed CNA M assisted the resident to stand by the bed. R17 stood and took hold of her walker. Further observation revealed CNA M removed R17's wet incontinent brief, provided perineal (private area) care, then, without changing gloves, placed a new incontinent brief on R17, pulled R17's blouse down in the back, pulled up R17's pants up and placed blouse over her pants, then removed and discarded her gloves. When LN F was asked if R17 was on EBP, she stated she did not think so because she never used the PPE when providing wound care to R17's left heel.On 08/05/25 at 08:47 AM, Administrative Nurse D stated she was unaware R17 was not on EBP and stated the resident should be on them. When she first obtained the wound, the resident was not placed on EBP because it was not open, but on 07/30/25, the wound had serous drainage, and R17 should have been placed on EBP then.On 08/06/25 at 08:14 AM, Administrative Nurse D stated she would expect staff to change gloves between dirty and clean when providing incontinent care. The facility's Enhanced Barrier Precautions (EBP) documented that EBP would be implemented as one intervention this facility used to reduce transmission of resistant organisms that employs targeted personal PPE use during high-contact resident care activities. Standard precautions continue to apply to the care of all residents, regardless of suspected or confirmed infection or colonization status. The policy documented that EBP would be used for residents with any of the following: Central line (a type of intravenous (IV) line that is inserted into a large vein, typically near the heart, to administer medications, fluids, blood products, or nutrition, or to draw blood), Urinary Catheter (a tube inserted into the bladder to drain the urine into a collection bag), feeding tube (tube for introducing high-calorie fluids into the stomach), an tracheostomy (opening through the neck into the trachea through which an indwelling tube may be inserted)/ventilator (a machine or device used medically to support or replace the breathing of a person, and infection with a novel or targeted multiple drug-resistant organisms (MDRO- common bacteria that have developed resistance to multiple types of antibiotics).The facility's Female Perineal Care Policy, revised 05/01/25, instructed staff, when providing perineal care, to use the following procedure: wash hands, collect equipment, explain the procedure to the elder, ask another staff member to assist them if the resident is anxious or needs assistance with turning and repositioning, close bedroom door, and if a semi-private room, ensure privacy curtain provides for complete perineal privacy. The policy instructed staff to wash their hands and put on gloves, clean the perineal area with a wet washcloth or perineal wipes, discard gloves into the wastebasket, wash hands and put on clean gloves, then assist the resident with clothing and remake the bed, if needed, and reposition the resident, etc.

The facility had a census of 62 residents. The sample included 16 residents. Based on observation, record review, and interview, the facility failed to include a hospice (a program that gives special care to people who are near the end of life) plan of care that outlined visit frequency, medications, medical equipment, and the resident representative's preference for Resident (R) 4 and R32. This deficient practice placed the residents at risk of not receiving resident-directed end-of-life care.Findings included:- R4’s Electronic Medical Record (EMR) documented diagnoses of hemiplegia and hemiparesis (weakness and paralysis on one side of the body), cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), diabetes mellitus (DM- when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), chronic kidney disease (a condition where the kidneys are damaged and are unable to filter blood effectively), and hypertension (HTN- elevated blood pressure). R4’s “Significant Change Minimum Data Set (MDS)” dated 04/17/25 documented she had a Brief Interview for Mental Status (BIMS) score of two, which indicated severely impaired cognition. R4 was independent with eating but dependent on staff for activities of daily living (ADL). R4 was on hospice services. R4’s “Functional Abilities Care Area Assessment (CAA)” dated 04/24/25 documented she was a significant change in status related to a recent hospitalization for gastrointestinal (GI) bleed and aspiration pneumonia (a lung infection caused by inhaling food, liquid, vomit, or saliva into the lungs). R4 returned to the facility on hospice services. R4 has had weight loss. R4 has had a deterioration in her ADLs and required two staff to assist for safety. R4 used a wheelchair for mobility, propelled by staff. R4’s “Care Plan,” revised on 07/22/25, directed staff that she was on hospice services. The Care Plan directed staff to refer to her notebook at the nurses' station related to her care and services from hospice. The Care Plan directed staff to work cooperatively with the hospice team to ensure the resident’s spiritual, emotional, intellectual, physical, and social needs were met. R4’s Care Plan lacked staff direction on the hospice contact information, the supplies and medications provided by hospice, and hospice staff and the frequency of visits. On 08/05/25 at 07:54 AM, R4 laid in her bed with her supplemental oxygen on via a nasal cannula (a device that gives you supplemental oxygen through your nose). On 08/06/25 at 09:15 AM, Certified Nurse Aide (CNA) N stated that residents who were on hospice each had a notebook at the nurse’s station that had the hospice information. CNA N stated he could not say what supplies hospice provided, and all that information was in their notebook. CNA N stated the nurse usually would relay any hospice information to them. On 08/06/25 at 09:30 AM, Licensed Nurse (LN) G stated that R4’s care plan had information about her being on hospice and the hospice provider. LN G stated that any other information about what hospice provided was in R4’s hospice book at the nurse’s station. On 08/06/25 at 09:34 AM, Administrative Nurse D stated R4’s care plan did let staff know she was on hospice services, but did not contain the hospice contact information, the medications, or supplies that hospice provided. Administrative Nurse D stated that R4’s hospice book at the nurse’s station contained all the information on what hospice provided, and staff could find the information there. Administrative Nurse D stated she had not thought about including that information on R4’s facility care plan. The facility’s “Hospice Services” policy dated 08/01/25 documented the facility would coordinate care planning with the hospice provider including all services and supplies provided by the hospice provider including: nursing services; nurse aide services; social service; chaplaincy services; durable medical equipment; medications; and grief support to family members. - R32’s Electronic Medical Record (EMR) included diagnoses of severe protein-calorie malnutrition, chronic kidney disease, major depressive disorder (major mood disorder that causes persistent feelings of sadness), non-pressure chronic ulcer of the left lower leg, paralytic syndrome (loss of muscle function leading to weakness or inability to move), anemia (an inadequate number of healthy red blood cells to carry adequate oxygen to body tissues), disorder of arteries, peripheral vascular disease (PVD- slow and progressive circulation disorder causing narrowing, blockage, or spasms in a blood vessel), diabetes mellitus (DM- when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), and paraplegia (paralysis characterized by motor or sensory loss in the lower limbs and trunk). R32’s “Significant Change Minimum Data Set” (MDS), dated [DATE], documented R32 had mild cognitive impairment, was dependent on staff with toileting hygiene, bathing, and lower body dressing, and required partial/moderate assistance with upper body dressing. R32 received scheduled and as-needed pain medication and had pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). The MDS further documented that R32 had a condition or chronic disease that may result in a life expectancy of less than six months and received hospice care. R32’s “Functional Abilities Care Area Assessment” (CAA), dated 07/17/25, documented R32 had been admitted to hospice for palliative care (treatment designed to relieve or reduce the intensity of uncomfortable symptoms) and would proceed to the Care Plan. R32’s “Care Plan” dated 07/17/25, documented R32 had a terminal prognosis related to severe protein-calorie malnutrition secondary to chronic kidney disease. The Care Plan directed staff to adjust provisions of Activities of Daily Living (ADL) to compensate for resident’s changing abilities, encourage participation to the extent the resident wishes, and a hospice notebook kept at the nurses’ station. The Care Plan further directed staff to work cooperatively with the hospice team to ensure R32’s spiritual, emotional, intellectual, physical, and social needs were met. The care plan lacked specifics of delegation of hospice staff services, visit frequency, medication, medical equipment, and supplies provided. The Hospice Physician Order” dated 07/09/25, documented R32 admitted to hospice services with a diagnosis of severe protein-calorie malnutrition secondary to kidney disease, and weight loss was expected due to the disease process. The patient’s life expectancy was six months or less if the disease followed natural progression. Discharge from hospice upon death. The “Progress Note” dated 07/08/25 at 11:09 AM, documented that facility staff spoke with R32 regarding his current health status and his recent decision to no longer pursue hospitalizations, blood transfusions, ectara. The facility staff discussed hospice services and benefits, and R32 was in agreement with hospice services at that time and would speak to his spouse and let the spouse know of his decision. On 08/05/25 at 09:37 AM, R32 sat in bed, on a low air loss mattress, watching TV with a breakfast tray on the overbed table. On 08/05/25 at 03:41 PM, Licensed Nurse (LN) H reported that the facility care plan had included the name of the hospice provider, but lacked specifics related to supplies, medication, and treatment responsibilities for R32. LN H stated some of the information may be in the hospice notebook for R32, which was located at the nurses’ station. On 08/06/25 at 09:43 AM, Administrative Nurse D stated that each resident had a hospice notebook, which was located at the nurses’ station for review. Administrative Nurse D reported R32’s hospice provider did not specify when hospice staff was to visit the resident or specifics related to medications and supplies. The facility’s “Hospice Services” policy, dated 08/01/25, documented an interdisciplinary care plan that integrates the care and services provided by the facility and the hospice provider. The facility would coordinate care planning with the hospice provider, including all services and supplies provided by the hospice provider, including nursing services, nurse aide services, social services, chaplaincy services, durable medical equipment, medications, and grief support to family members.

The facility had a census of 62 residents. The sample included 16 residents. Based on observation, record review, and interview, the facility failed to obtain a stop date for Resident (R) 32's as-needed (PRN) antianxiety (a class of medications that calm and relax people) lorazepam, which placed R32 at risk of receiving unnecessary medication.Findings included:- R32's Electronic Medical Record (EMR) included diagnoses of severe protein-calorie malnutrition, chronic kidney disease, major depressive disorder (major mood disorder that causes persistent feelings of sadness), non-pressure chronic ulcer of the left lower leg, paralytic syndrome (loss of muscle function leading to weakness or inability to move), anemia (an inadequate number of healthy red blood cells to carry adequate oxygen to body tissues), disorder of arteries, peripheral vascular disease (PVD- slow and progressive circulation disorder causing narrowing, blockage, or spasms in a blood vessel), diabetes mellitus (DM- when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), and paraplegia (paralysis characterized by motor or sensory loss in the lower limbs and trunk).The Significant Change Minimum Data Set (MDS), dated [DATE], documented that R32 had mild cognitive impairment, was dependent on staff with toileting hygiene, bathing, and lower body dressing, and required partial/moderate assistance with upper body dressing. R32 received an antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality), an antianxiety, antidepressant (a class of medications used to treat mood disorders), antibiotic (a class of medications used to treat infections), diuretic (a medication to promote the formation and excretion of urine), opioid (a class of medication used to treat pain) and anticonvulsant (a class of medications used to treat seizures). R32 had pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). The MDS further documented that R32 had a condition or chronic disease that may result in a life expectancy of less than six months.R32's Care Plan dated 07/17/25, documented high-risk Black Box Warning (BBW- the highest safety-related warning that medications can have assigned by the Food and Drug Administration) use of lorazepam and opioids may result in profound sedation, respiratory depression, coma, and death.The Physician Order dated 07/07/25, directed staff to administer a lorazepam, one to two milligrams (mg) tablet by mouth every four hours as needed for agitation, anxiety, or shortness of air. The order lacked a stop/discontinue date.The Progress Note dated 07/07/25 at 11:25 AM documented before the noon medication administration, R32 was minimally responsive. R32 was able to open eyes with tactile stimulation but was unable to vocalize anything; pupils were sluggish, and radial pulses bilaterally were faint. The Progress Note further documented that the noon medications were held due to R32's inability to safely swallow.The Progress Note dated 07/08/25 at 11:09 AM documented that facility staff spoke with R32 regarding his current health status and his recent decision to no longer pursue hospitalizations, blood transfusions, ectara. The facility staff discussed hospice services and benefits, and R32 was in agreement with hospice services at that time and would speak to his spouse and let the spouse know of his decision.On 08/05/25 at 09:37 AM, R32 sat in bed, on a low air loss mattress, watching TV with a breakfast tray on the overbed table.On 08/05/25 at 03:41 PM, Licensed Nurse (LN) H reported the PRN lorazepam did not have a stop date and was indefinite.On 08/05/25 at 09:43 AM, Administrative Nurse D reported the PRN lorazepam order should have a stop date, and the facility generally implemented a stop date of six months from the original order.The facility's Psychotropic Medication Use policy, dated 08/01/25, documented that the Centers for Medicare & Medicaid Services (CMS) regulations state that each resident's drug regimen must be free of unnecessary drugs and define what is considered an unnecessary drug. An unnecessary drug is any drug used in excessive doses, for excessive duration, without adequate indications, without adequate monitoring, or in the presence of adverse consequences, which indicate the dosage should be reduced or discontinued.

The facility had a census of 62 residents. The sample included 16 residents. Based on observation, record review, and interview, the facility failed to ensure the Consultant Pharmacist (CP) identified Resident (R) 32's as-needed antianxiety (a class of medications that calm and relax people) without a stop date and R2's fluid restriction parameter monitoring with the use of a diuretic (a medication to promote the formation and excretion of urine). This placed the residents at risk for inappropriate and/or unnecessary medication.Finding included:- R32's Electronic Medical Record (EMR) included diagnoses of severe protein-calorie malnutrition, chronic kidney disease, major depressive disorder (major mood disorder that causes persistent feelings of sadness), non-pressure chronic ulcer of the left lower leg, paralytic syndrome (loss of muscle function leading to weakness or inability to move), anemia (an inadequate number of healthy red blood cells to carry adequate oxygen to body tissues), disorder of arteries, peripheral vascular disease (PVD- slow and progressive circulation disorder causing narrowing, blockage, or spasms in a blood vessel), diabetes mellitus (DM- when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), and paraplegia (paralysis characterized by motor or sensory loss in the lower limbs and trunk).The Significant Change Minimum Data Set (MDS), dated [DATE], documented that R32 had mild cognitive impairment, was dependent on staff with toileting hygiene, bathing, and lower body dressing, and required partial/moderate assistance with upper body dressing. R32 received an antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality), an antianxiety, antidepressant (a class of medications used to treat mood disorders), antibiotic (a class of medications used to treat infections), diuretic (a medication to promote the formation and excretion of urine), opioid (a class of medication used to treat pain) and anticonvulsant (a class of medications used to treat seizures). R32 had pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). The MDS further documented that R32 had a condition or chronic disease that may result in a life expectancy of less than six months.R32's Care Plan dated 07/17/25, documented high-risk Black Box Warning (BBW- the highest safety-related warning that medications can have assigned by the Food and Drug Administration) use of lorazepam and opioids may result in profound sedation, respiratory depression, coma, and death.The Physician Order dated 07/07/25, directed staff to administer lorazepam, one to two milligram (mg) tablet by mouth every four hours as needed for agitation, anxiety, or shortness of air. The order lacked a stop/discontinue date.The CP monthly review dated 07/25/25 failed to identify R32's PRN lorazepam lacked a stop date and documented no recommendations.The Progress Note dated 07/07/25 at 11:25 AM documented that before the noon medication administration, R32 was minimally responsive. R32 was able to open eyes with tactile stimulation but was unable to vocalize anything; pupils were sluggish, and radial pulses bilaterally were faint. The Progress Note further documented that the noon medications were held due to R32's inability to safely swallow.On 08/05/25 at 09:37 AM, R32 sat in bed, on a low air loss mattress, watching TV with a breakfast tray on the overbed table.On 08/05/25 at 03:41 PM, Licensed Nurse (LN) H reported the PRN lorazepam did not have a stop date and was indefinite.On 08/05/25 at 09:43 AM, Administrative Nurse D reported that the PRN lorazepam order should have a stop date, and the facility generally implemented a stop date of six months from the original order; the CP should have caught the lack of a stop date.The facility's Drug Regimen Review Report Distribution policy, 08/01/25, documented the CP will report any recommendations of apparent irregularities resulting from the medication regimen review of each resident to the attending physician and/or the director of nursing on a medication regimen review report form. Each recommendation must be acted upon.

The facility identified a census of 62 residents. The sample included 16 residents. Based on observation, record review, and interview, the facility failed to ensure that Resident (R) 9's dialysis (a procedure where impurities or wastes were removed from the blood) physician order was in his orders of the Electronic Medical Record (EMR). This deficient practice placed R9 at risk for missed dialysis visits and complications related to dialysis.Findings included:- R9's EMR documented diagnoses of end-stage renal disease (ESRD- a terminal disease of the kidneys), and dependence on renal dialysis.R9's admission Minimum Data Set (MDS) dated 04/01/25 documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. R9 had a functional limitation in the range of motion impairment on both lower extremities. R9 used a walker and a wheelchair to assist with his mobility. R9 required substantial staff assistance with toileting and was dependent on staff for bathing. R9 was on a dialysis program.R9's Functional Abilities Care Area Assessment (CAA) dated 04/01/25 documented he had a diagnosis of stage renal disease. R9 has a central venous catheter (CVC- a thin, flexible tube inserted into a large vein to provide long-term access to the bloodstream for medical purposes) port in the right chest and a shunt (tube or device implanted in the body to redirect a body fluid from one cavity to another) in his left arm. R9's dialysis days are Tuesday, Thursday, and Saturday. R9 was alert and oriented with clear speech. R9's hearing and vision were adequate. R9 was currently on physician therapy and occupational therapy services and would be on a restorative program upon completion. R9's Care Plan dated 03/25/25 directed staff that he had end-stage renal disease. The Care Plan directed staff that R9 had a shunt for dialysis in his left arm. Staff was directed to monitor, document, and report any signs and symptoms of infection to his dialysis access site to the physician. The Care Plan directed staff not to do blood pressure in the left arm. The Care Plan directed staff to monitor the access site for bleeding for 24 hours after he returned from his dialysis treatment. The Care Plan lacked staff direction on the dialysis center location and contact information. The Care Plan lacked staff direction on the days that R9 had his dialysis treatment. R9's Orders tab of the EMR lacked the physician's order for dialysis.R9's Misc. tab of the EMR did contain a scanned Communication Form that documented pre- and post-dialysis vital signs. The form also contained information on any labs drawn or new orders from the dialysis clinic. On 08/05/25 at 12:58 PM, R9 sat in his wheelchair in his room and stated that he had returned from his dialysis appointment earlier. R9 stated that he went to dialysis on Tuesdays, Thursdays, and Saturdays early in the morning.On 08/06/25 at 09:15 AM, Certified Nurse Aide (CNA) N stated that the nurses usually told the CNAs which residents were on dialysis or hospice. CNA N stated the nurse would usually tell staff in the mornings which resident had dialysis that day. CNA N stated the facility did not have a dialysis book for R9 that he was aware of.On 08/06/25 at 09:30 AM, Licensed Nurse (LN) G stated R9 should have his dialysis order on his Medication Administration Record (MAR) or Treatment Administration Record (TAR). LN G stated that R9 had dialysis on Tuesdays, Thursdays, and Saturdays. LN G stated R9's pre-dialysis form and vital signs were completed prior to his transportation to his dialysis appointments.On 08/06/25 at 11:15 AM, Administrative Nurse D stated that R9's order did not have his physician's dialysis order in it, but now it did. Administrative Nurse D stated that it must have been overlooked upon R9's return from the hospital in April. Administrative Nurse D stated R9 did go to dialysis out of town on Tuesday, Thursday, and Saturday mornings, the pre-dialysis form was completed by the nurse before each visit, and the form was returned with the resident post-clinic.The facility's Hemo-Dialysis Policy dated 08/01/25 documented the medical management of the resident receiving hemo-dialysis was under the direction of the resident's chosen attending primary care physician in collaborative consultation with the Medical Director of the dialysis unit. This facility would establish and maintain a written agreement with the renal dialysis unit that clearly identified the roles and responsibilities of each party for the care and services of the resident. Management of the resident's overall comprehensive plan of care was the responsibility of this facility in collaborative cooperation with the dialysis unit. Coordination of care included: times of dialysis therapy and dialysis access orders; dialysis clinic appointments and laboratory schedule; transportation arrangements; information transmitted to the dialysis unit by the facility prior to dialysis; and information transmitted to the facility by the dialysis unit after dialysis.

The facility identified a census of 62 residents. The sample included 16 residents. Based on observation, record review, and interview, the facility failed to ensure that Resident (R) 9's comprehensive care plan was revised with information about his dialysis (a procedure where impurities or wastes were removed from the blood). This deficient practice placed R9 at risk for missed dialysis visits and complications related to dialysis.Findings included:- R9's EMR documented diagnoses of end-stage renal disease (ESRD- a terminal disease of the kidneys) and dependence on renal dialysis.R9's admission Minimum Data Set (MDS) dated 04/01/25 documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. R9 had functional limitation in range of motion impairment on both lower extremities. R9 used a walker and a wheelchair to assist with his mobility. R9 required substantial staff assistance with toileting and was dependent on staff for bathing. R9 was on a dialysis program.R9's Functional Abilities Care Area Assessment (CAA) dated 04/01/25 documented he had a diagnosis of stage renal disease. R9 has a central venous catheter (CVC- a thin, flexible tube inserted into a large vein to provide long-term access to the bloodstream for medical purposes) port in the right chest and a shunt (tube or device implanted in the body to redirect a body fluid from one cavity to another) in his left arm. R9's dialysis days are Tuesday, Thursday, and Saturday. R9 was alert and oriented with clear speech. R9's hearing and vision was adequate. R9 was currently on physician therapy and occupational therapy services and would be on a restorative program upon completion. R9's Care Plan dated 03/25/25 directed staff that he had end-stage renal disease. The Care Plan directed staff that R9 had a shunt for dialysis in his left arm. Staff were directed to monitor, document, and report any signs and symptoms of infection to his dialysis access site to the physician. The Care Plan directed staff not to take blood pressure in the left arm. The Care Plan directed staff to monitor the access site for bleeding for 24 hours after he returned from his dialysis treatment. The Care Plan lacked staff direction on the dialysis center location and contact information. The Care Plan lacked staff direction on the days that R9 had his dialysis treatment. R9's Orders tab of the EMR lacked the physician's order for dialysis.R9's Misc. tab of the EMR did contain a scanned Communication Form that documented pre- and post-dialysis vital signs. The form also contained information on any labs drawn or new orders from the dialysis clinic. On 08/05/25 at 12:58 PM, R9 sat in his wheelchair in his room and stated that he had returned from his dialysis appointment earlier. R9 stated that he went to dialysis on Tuesdays, Thursdays, and Saturdays early in the morning.On 08/06/25 at 09:15 AM, Certified Nurse Aide (CNA) N stated that the nurses usually told the CNAs which residents were on dialysis or hospice. CNA N stated the nurse would usually tell staff in the mornings which resident had dialysis that day. CNA N stated he could not say if R9's care plan had dialysis information in it that he was aware of.On 08/06/25 at 09:30 AM, Licensed Nurse (LN) G stated R9 should have his dialysis information in his care plan. LN G stated that R9 had dialysis on Tuesdays, Thursdays, and Saturdays out of town. LN G stated R9's pre-dialysis form and vital signs were completed prior to his transportation to his dialysis appointments.On 08/06/25 at 11:15 AM, Administrative Nurse D stated that R9's care plan did contain the dialysis provider name in his care plan but not the information on the days that R9 went to dialysis. Administrative Nurse D stated that it must have been overlooked upon R9's return from the hospital in April. Administrative Nurse D stated R9 did go to dialysis out of town on Tuesday, Thursday, and Saturday mornings, the pre-dialysis form was completed by the nurse before each visit and the form was returned with the resident post-clinic.The facility's Care Plan Revisions policy dated 08/01/25 documented changes in a resident's condition always required changes to be made in the plan of care, either by a change in the individual approaches or by the addition of new problems to the plan of care. All physician orders, progress notes, and consultant notes would be reviewed and appropriately added to the care plan. The revisions to the care plan would be the responsibility of a licensed nurse in collaboration with the resident, the representative/family, direct care staff, and the entire interdisciplinary team, and changes would be communicated with all staff and all shifts.

The facility had a census of 62 residents. The sample included 16 residents, with one reviewed for discharge. Based on record review and interview, the facility failed to notify the Office of the Long-Term Care Ombudsman (LTCO- a public official who works to resolve resident issues in nursing facilities) of Resident (R) 1 and R67's. The facility also failed to develop a discharge summary that included a recapitulation (a concise summary of the resident's stay and course of treatment in the facility) of the resident's stay for R67's unplanned discharge. This placed the residents at risk for uninformed care choices and impaired rights.Findings included:- R1's Electronic Medical Record (EMR) documented R1 had diagnoses of sepsis (a life-threatening systemic reaction that develops due to infections that cause inflammation throughout the entire body), Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness), and aspiration pneumonia (an inflammatory condition of the lungs caused by inhaling foreign material or vomit). R1's Quarterly Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview of Mental Status (BIMS) score of 14, which indicated intact cognition. The MDS documented R1 had pneumonia. R1's Care Plan, revised 07/14/25, documented R1 had Parkinson’s and instructed staff to monitor, document, and report to the physician as needed (PRN) any signs and symptoms of aspiration or dysphagia (swallowing difficulty), choking, fever, and or coughing. R1's Progress Notes dated 06/30/25 at 03:18 AM documented the resident was transferred to the hospital. R1's clinical record lacked evidence the LTCO was notified of the hospital transfer. On 08/05/25 at 10:45 AM, R1 ambulated around the facility with a walker without signs of shortness of breath. On 08/05/25 at 02:10 PM, Administrative Staff B stated she was responsible for notifying the LTCO when a resident was transferred to the hospital. Administrative Staff B verified she had not notified the LTCO when R1 was transferred to the hospital on [DATE]. Administrative Staff B stated she must have missed it. The facility's Resident Admission, Transfer, and Discharge Rights Policy, undated, documented that the facility must send a copy of the transfer or discharge notice to the LTCO program promptly after issuing the transfer notice to the resident. - R67’s Electronic Medical Record (EMR) documented diagnoses of chronic iron deficiency (an inadequate number of healthy red blood cells to carry adequate oxygen to body tissues ), low back pain, Barrett’s esophagus (a condition caused by inflammation and damage to the lining of the esophagus), and cognitive communication deficit (an impairment in organization, sequencing, attention,, memory, planning, problem-solving, and safety awareness). The” Quarterly Minimum Data Set” (MDS), dated [DATE], documented R67 had intact cognition. R67 was independent with all activities of daily living (ADL), had disorganized thinking, rejection of care for four to six days during the look-back period, and had no medications. The MDS further documented R67 did not want any agency referrals before discharge. R67’s “Care Plan,” dated 06/09/25, initiated on 11/6/24, documented staff would provide R67 with options related to discharge planning, medication education, and community health services. The care plan further documented, R67 planned to discharge to the street, as he had been homeless for many years, and he chose to live that way. The “Nurse’s Note,” dated 06/20/25 at 09:16 AM, documented R67 was adamant about leaving AMA (against medical advice) today. R67 had his wagon packed up with his things, and he reiterated his wishes as above. The nurse asked him to sit tight until she was able to consult with management and his physician. The note further documented, the nurse left R67 in the front commons area while notifying management of the situation, and the social worker was requested to consult with the resident. The” Nurse’s Note,” dated 06/20/25 at 11:16 AM, documented the social worker was notified that R67 planned to leave the facility. She spoke with him about how they were in the summer season and how hot it was going to be in the coming days, but he stated he was a country boy and that he was used to the heat. R67 stated he did not need any medications or medical interventions as he had lived off the land, and living inside was killing him. The note further documented that other staff members tried to talk him into staying in the facility. APS (Adult Protective Services) and the local police department were notified of his discharge. R67’s clinical record lacked evidence that the ombudsman was notified of the discharge. R67's EMR lacked evidence that a thorough recapitulation of R67’s stay was developed. On 08/05/25 at 10:05 AM, Administrative Nurse E stated she did not know what a recapitulation was and that she only completed a nursing discharge when a resident left the facility. On 08/05/25 at 10:15 AM, Administrative Staff B stated she did not notify the ombudsman when R67 was discharged from the facility and only notified the ombudsman for hospital discharges. On 0805/25 at 11:00 AM, Administrative Nurse D stated she was unsure what a recapitulation was but verified that the discharge summary that was completed was not a thorough representation of R67’s stay in the facility. Administrative Nurse D further stated, the ombudsman should have been notified of his discharge. The facility’s “Resident Admission, Transfer, and Discharge Rights” undated policy documented that the facility shall not request or require residents to waive any rights related to admission, transfer, or discharge. Residents would be admitted , transferred, or discharged only for reasons permitted by law and by established procedures that safeguard their rights. The facility must send a copy of the transfer or discharge notice to the Long-Term Care Ombudsman program promptly after the resident is discharged . Regular audits and case reviews would be conducted to ensure the Ombudsman was properly and promptly notified. The facility’s “Discharge summary” undated policy documented that the facility shall prepare and provide a discharge summary, including a recapitulation of stay. The recapitulation shall include the disposition of pre- and post-medications, diagnoses and conditions, course of their illness and treatment, pertinent lab, other diagnostic tests, and results. The recapitulation shall also include documented consultations, physician verification for discharge and/or transfer, and any other pertinent information.

The facility identified a census of 62 residents. The sample included 16 residents. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 2's physician ordered fluid restriction was followed by staff. This placed R2 at risk of fluid overload and possible complications.Findings included:- R2's Electronic Medical Record (EMR) documented diagnoses of congestive heart failure (CHF- a condition with low heart output and the body becomes congested with fluid), respiratory failure (a condition where the lungs cannot adequately exchange oxygen and carbon dioxide between the blood and the air, leading to insufficient oxygen or excessive carbon dioxide in the bloodstream), and hypertension (HTN- elevated blood pressure).R2's Significant Change Minimum Data Set (MDS) dated 01/31/25 documented a Brief Interview for Mental Status (BIMS) score of 11, which indicated moderately impaired cognition. R2 used a wheelchair to assist with mobility. R2 had a functional limitation in the range of motion with impairment on one side of her lower extremity. R2 required partial assistance from staff with dressing, required substantial assistance with bathing, and was dependent on staff with toileting and lower body dressing. R2 had a pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) that was present on admission. R2 required oxygen therapy.R2's Nutritional Status Care Area Assessment (CAA) dated 02/03/25 documented a recent hospitalization from 01/19/25 to 01/24/25. R2 was on a 2000 milliliter (ml) fluid restriction per 24 hours. Dietary allowed 16 ounces(oz) (480 mL) beverage of choice with meals to equal 48 oz (1440 mL) per 24 hours. Nursing allowed 18 oz (560 mL) per 24 hours. R2 was to have no bedside water pitcher. The Registered Dietitian was to remain available to assist with R2's nutritional needs and concerns as identified.R2's Care Plan last revised on 06/24/25 directed staff of her 2000 ml fluid restriction in 24 hours, dietary allowed 16 ounces(oz) (480 mL) beverage of choice with meals, 48 oz (1440 mL) per 24 hours; nursing allowed 18 oz (560 mL) per 24 hours. R2 was to have no bedside water pitcher. The Care Plan directed staff that R2 was on a no-added salt diet.R2's Orders tab documented a physician's order dated 05/15/25 for a fluid restriction 2000 ml daily. Nursing may provide 500 ml between meals with med pass per shift. Dietary may provide 500 ml with each meal. Review of R2's June 2025 Treatment Administration Record (TAR) revealed that R2's physician ordered 2000 ml fluid restriction was exceeded on 10 of 30 days.Review of R2's July 2025 TAR revealed that R2's physician ordered 2000 ml fluid restriction was exceeded on three of 31 days.Review of R2's August 2025 TAR revealed that R2's physician ordered 2000 ml fluid restriction was exceeded on two of six days.On 08/05/25 at 01:15 PM, R2 sat in her wheelchair in her room, her supplemental oxygen on. R2 stated she did not always follow her fluid restriction. On 08/06/25 at 09:15 AM, Certified Nurse Aide (CNA) N stated that R2 used to be the director of nursing at this facility, so she was one who was going to do just what she wanted to. CNA N stated R2 knew about her fluid restriction, but she did not always follow it.On 08/06/25 at 09:30 AM, Licensed Nurse (LN) G stated R2 was a special resident. LN G stated R2 was a former director of nursing at the facility. LN G stated R2 did have a fluid restriction that included how much fluid she could have a meals and how much other fluid she could have throughout the day. LN G stated R2 did not always follow her fluid restriction and was aware of what that could cause with her health.On 08/06/25 at 09:34 AM, Administrative Nurse D stated that R2 knew of her fluid restriction but would not always follow the orders and would drink more than she should. Administrative Nurse D stated R2 was a former nurse and director of nursing here at this facility, and had told staff that she would drink as much fluids as she wanted, regardless of what the doctor said.The facility's Fluid Restrictions policy dated 08/01/25 documented that fluid restrictions ordered by a physician were carried out by the nursing and dietary departments. Unless otherwise specified, the nursing department, in collaboration with the registered dietician, determined the allotment of fluids for meal trays, med-passes, and water provided in the room. Nursing would record the residents' consumption of fluids in the room, during meals, and during med passes using facility input and output documentation. A CNA would review fluid restrictions documented on the resident's individualized, comprehensive care plan to make sure that allotted amounts were not exceeded on meal trays and in-room water services.

The facility had a census of 63 residents. Based on observation, record review, and interview, the facility failed to implement a water management program for Legionella disease (Legionella is a bacterium spread through mist, such as air-conditioning units in large buildings. Adults over the age of 50 and people with weak immune systems, chronic lung disease or heavy tobacco use are most at risk of developing a pneumonia caused by Legionella). This deficient practice placed the residents at increased risk of infectious disease. Findings included: - On 11/20/23 at 12:51 PM Maintenance Staff U stated he was not aware of the need for a water management system for the prevention of Legionella. Maintenance Staff U stated the facility drained the hot water tanks every couple of months to prevent the build of scale. On 11/20/23 at 01:26 PM, Administrative Staff A reported the facility did not have tanks with standing water and the city ran tests on a daily basis and would report to the facility if there were any issues. The facility's Water Management Policy dated 2023 documented the purpose of the policy was to ensure that as far as possible, all users of the facility were protected from the incidence of Legionnaire's disease. The Director of Environmental Services was responsible for all relevant details regarding rolls and responsibilities and testing regimens contained in the policy and procedure. All results were reported to the Quality Assessment Performance Improvement committee on a quarterly basis and the Administrator of the facility was responsible for reporting all results and findings to the Board of Governance on an annual basis. The facility failed to implement a water management program to test and manage waterborne pathogens placing the residents who resided in the facility at risk of contracting Legionella pneumonia.

The facility had a census of 63 residents. Based on observation, interview, and record review, the facility failed to serve food in one of two dining rooms in a sanitary manner. This deficient practice placed residents at risk for food borne illness. Findings included: - On 11/13/23 at 11:58 AM, observation in the facility's main dining room revealed Dietary Staff (DS) CC dropped the lid from a soda bottle, picked it up from the floor, and did not wash her hands before obtaining and placing an unwrapped straw in a resident's glass. Observation at 12:16 PM revealed DS CC touched a resident on the shoulder, cut up his food, then handled another resident's silverware, to cut up his food, without washing or sanitizing her hands. DS CC then went to another table and accepted a resident's silverware from her and cut up her food without handwashing or using sanitizer. On 11/20/23 at 10:32 AM, DS BB verified staff were to wash their hands after picking up items from the floor and before handling resident straws. She stated staff should wash their hands or use hand sanitizer between handling other residents' silverware when cutting up their food. The facility's Handwashing Policy and Procedure policy, dated 08/2023, stated all food workers must wash their hands after assisting residents in the dining room (touching silverware, cups, straws) prior to assisting another resident. Hand sanitizer may be used in place of handwashing. All food workers must wash their hands after picking items up off the floor or any other contamination to the hands. The facility failed to serve food in one of two dining rooms in a sanitary manner, placing residents at risk for food borne illness.

The facility had a census of 63 residents. The sample included 16 residents with one reviewed for dental care. Based on observation, record review and interview, the facility failed to facilitate the necessary dental care services for Resident (R) 26. This placed R26 at risk for pain, weight loss, and worsening dental issues. Findings included: - R26's Electronic Medical Record (EMR) recorded diagnoses of hemiplegia (paralysis one side of the body), hemiparesis (muscular weakness of one half of the body), dysphagia (swallowing difficulty), and gastroesophageal reflux (GERD-backflow of stomach contents to the esophagus). R26's Admission Minimum Data Set (MDS), dated [DATE], recorded R26 had a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. The assessment revealed R26 required staff to help with more than half the effort for oral hygiene. R26's Care Area Assessment (CAA), dated 08/16/23, recorded R26 had a history of poor dental care. R26 denied having a dentist and denied pain or discomfort with her teeth. The CAA indicated the facility would have the in-facility dental service provider evaluate the resident. R26's Oral Assessment, dated 07/25/23, recorded the resident had broken, carious (decayed) teeth, and loose teeth. The assessment lacked any additional documentation. R26's Care Plan, dated 07/25/23, lacked any reference to R26's broken, decayed teeth or the dental services to be provided. On 11/13/23 at 12:30 PM, observation of R26's mouth revealed she had missing, decayed teeth and some broken teeth on the lower jaw with brown discoloration along the gum line. Observation revealed R26 continued to act like she was chewing during the interview but did not have anything in her mouth. On 11/16/23 at 09:00 AM, Social Service X verified R26 had broken, decaying teeth, and verified the resident was not currently on the facility dental services provide by an outside source. Social Service X said the resident and/or representative was informed of the services upon admission and had the choice to sign up for the dental services. Social Service X reviewed R26's EMR and verified the resident and/or representative had not been provided the form to elect for the in-facility dental services provided. Social Service X stated she would contact R26's representative and inform her of the dental services provided. The facility's Oral Health policy, dated 07/12/23, documented every elder would receive oral care twice daily to ensure the highest level of oral health and oral function. Each elder will receive an oral assessment by a dental practitioner within 90 days prior to admission or 90 days of admission. The policy documented each elder would receive an oral assessment by a licensed nurse on admission and according to their MDS schedule. The assessment includes the condition of the oral cavity, teeth, and tooth supporting structures, the presence or absence of natural teeth or dentures and the ability to function with or without natural teeth or dentures including assessment of the ability of the resident to perform oral care tasks and the amount and type of assistance required for appropriate oral hygiene care. A dental hygienist/designee would assess the resident every 3 months as long as the elder and/or surrogate decision maker consent. The elder has the right to go to a dentist of his/her choice in preference to the dentist contracted by the facility. The facility would arrange for transportation for residents if dental services were provided outside the facility. Emergency dental care would be provided to the elder in need of emergency services within 24 hours. Oral hygiene care will be provided by nursing and other staff members will be documented in the resident's clinical record along with any changes in oral health status. The facility failed to facilitate the necessary dental care for R26's broken, decaying teeth. This placed the resident at risk for pain, weight loss, and worsening dental issues.

The facility had a census of 63 residents. The sample included 16 residents. Based on record review and interview, the facility failed to provide Resident (R)5 and R20, or their representative, the completed Skilled Nursing Facility Advanced Beneficiary Notices (ABN) form 10055 which included the cost to continue services. This placed the resident at risk of uninformed decisions about their skilled services. Findings included: - The Medicare ABN form 10055 informed the beneficiary that Medicare may not pay for future skilled therapy services. The form included an option for the beneficiary to receive specific services listed, and bill Medicare for an official decision on payment. The form stated 1) I understand if Medicare does not pay, I will be responsible for payment, but can make an appeal to Medicare, (2) receive therapy listed, but do not bill Medicare, I am responsible for payment for services, (3) I do not want the listed services. Review of the form 10055 the facility provided to R5 revealed the form lacked the cost of continued service. The resident's skilled services ended on 09/27/23. Review of the form 10055 the facility provided to R20 revealed the form lacked the cost of continued service. The resident's skilled services ended on 08/11/23. On 11/14/23 at 10:30 AM, Social Services X verified she had not provided R5 or R20, or their representative, the amount of money it would cost the resident for continued services on the form 10055. On 11/20/23 at 09:15 AM, Administrative Nurse D verified the facility had not provided R5 or R20, or their representative, the amount it would cost the resident if they wished to continue services. The facility's Advance Beneficiary Notices policy, dated January 2023, recorded the facility would ensure Medicare residents are informed of their right to appeal and request demand billing of services when it is determined that a resident will no longer qualify for Medicare covered services as evidenced by the following policy and procedure. Upon notification that a resident will no longer be eligible for Medicare covered services, Social Services or facility representative will give no less than two days' notice prior to the end of Medicare covered services, verbal and written notification 9OMB Approval No 0938-0953/ form No CMS 10123 and Form No CMS 10055 (2018) of non-coverage to the resident advising them of their rights to appeal the decision and/or to request demand billing of services. The facility would obtain signed receipt of written notification from resident along with their decision regarding appeal and/or demand bill. Social Services will notify the Accounting Office of any requests for demand billing services. The facility failed to provide R5 and R20 (or their representatives) the completed 10055 form which included an estimated cost of continued services when discharged from skilled care. This placed the residents at risk for uninformed decisions about their skilled services.

The facility had a census of 61 residents. The sample included 16 residents. Based on observation, record review, and interview the facility failed to distribute and serve food in accordance with professional standards for food service safety for the 61 residents who resided in the facility and received their food from the facility kitchen, when the facility failed to ensure clean and sanitary food prep areas, and failed to dispose of expired food items. This placed the 61 residents at risk for foodborne illness. Findings included: - On [DATE] at 09:02 AM, observation in the kitchen revealed the following: The kitchen ceiling had three areas of peeling paint, one approximately 12 inches (jn) x 12 in and two with approximately 8 in diameter, above the three-compartment sink. An area of bubbling paint, approximately 8 in x 12 in above the preparation table. Two of 28 fluorescent lights with gray fuzzy particles. Three box air/heat units on the ceiling with grease coated filters and lint on the pipes. The cord to the electrical box, on the ceiling, over the taller preparation table, with two dead flies. The windowsill beside the clean dishracks had numerous dead bugs. The wall behind the soiled dish/sprayer area had an area, approximately two foot by one foot, with a black substance. Two of the five drawers by the steam table, with serving utensils, had a small amount of dried food particles. The large uncovered mixer had dried pink and cream-colored food on the machine over the bowl. The walk-in refrigerator had the following undated opened or expired food items: One-gallon bag of shredded mild cheddar cheese. Two packages (one-gallon bag) sliced cheese. One (two gallon) bag of shredded mozzarella cheese. A small jar of pickles One-gallon pitcher of thickened juice. Two (one gallon) pitchers of thickened water. Three (five-pound (lb.) containers of sour cream Two (five lb.) containers of cottage cheese. One-gallon bag of tater tots. One-gallon bag of onion rings. One-gallon partial bag of bacon toppings dated [DATE] On [DATE] at 02:10 PM, Certified Dietary Manager (CDM) BB verified the above issues in the kitchen. The facility's Food Receiving and Storage policy, revised [DATE], documented all foods stored in the dry storage, refrigerator or freezer would be covered, labeled and dated with open date. The facility's Daily Kitchen and Hallway Cleaning Logs policy, revised [DATE], documented it would be the facility's practice all kitchen and dining areas would always be cleaned and remained presentable. The facility failed to store, prepare and serve food in accordance with professional standards for food service safety. This placed the 61 residents who resided at the facility and received food from the facility kitchen at risk for receiving a foodborne illness.

The facility had a census of 61 residents. The sample included 16 residents. Based on observation, interview, and record review, the facility failed to label Resident (R) 36's insulin (hormone which allows cells throughout the body to uptake glucose) pen with the opened and expiration date, and discard expired stock medications on one of three medication carts. This placed the residents at risk for ineffective medications. Findings included: -On 05/02/22 at 01:30 PM, observation of the Sunshine medication cart, revealed the following: R36's [MEDICATION(S)] (long acting insulin) flex pen lacked a date opened, and a date of expiration. One bottle of [MEDICATION(S)] (Vitamin B1), 100 milligrams (mg), 100 count tablets, expired 03/22. On 05/02/22 at 01:35 PM, Licensed Nurse (LN) G, verified the stock medication in the Sunshine cart had expired, the nurses are to look at the bottles before administering the medications to the residents, and discard expired medications. LN G stated the nurses dated the insulin pens/vials when opened and expired and discarded expired medications. The facility's Medication Storage in the Facility, dated 01/10/22, documented medication and biologicals are stored safely, securely, and properly following the manufacture or supplier recommendations. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Outdated, contaminated, or deteriorated drugs and those in containers, which are cracked, soiled or without secure closures will be immediately withdrawn from the stock. They will be disposed according to drug disposal procedures, and reordered from the pharmacy if a current order exists. Expiration dates of dispensed medications shall be determined by the pharmacist at the time of dispensing. Certain medications or package types, such as IV solutions, multiple dose injectable vials, ophthalmic, [MEDICATION(S)] tablets, blood sugar testing solutions and strips, once opened, require expiration date shorter than the manufacture's expiration date to ensure medication purity and potency. The nurse will check the expiration date of each medication before administering it. The facility failed to label and date R36's [MEDICATION(S)] insulin flex pen with an opened and expiration date, and discard expired stock medications, placing the residents at risk for ineffective medications.

The facility had a census of 61 residents. The sample included 16 residents, with five reviewed for activities of daily living (ADLs). Based on observation, record review, and interview, the facility failed to provide consistent bathing services for three sampled residents, Resident (R) 38, R49, and R9 . This placed the residents at risk for complications related to poor hygiene. Findings included: - The electronic medical record (EMR) for R38 recorded diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R38's Quarterly Minimum Data Set (MDS), dated [DATE], documented the resident had severely impaired cognition and required extensive assistance with bed mobility, transfers, dressing, toileting, and personal hygiene. The MDS documented R38 required extensive assistance of one staff for bathing. The ADL Care Plan, dated 03/14/22, documented R38 preferred a whirlpool for bathing and directed staff to assist the resident on his scheduled bath days. The March and April 2022 Bathing Record documented R38 requested whirlpool baths on Wednesday and Saturday evenings and documented the resident had not received a bath during the following days: 03/27/22-04/08/22 (13 days) 04/17/22-04/29/22 (13 days) The EMR lacked evidence R38 refused any baths. On 04/28/22 at 12:17 PM, observation revealed R38 unshaven and eating lunch in the dining room. On 05/02/22 at 09:40 AM, observation revealed R38 unshaven and lying in his bed. On 05/03/22 at 11:48 AM, Certified Nurse Aide (CNA) M stated R38 sometimes refused his showers, staff continued to ask him, and if he continued to refuse, staff filled out a shower sheet that stated he refused and gave it to the charge nurse. On 05/03/22 at 01:40 PM, Licensed Nurse (LN) H stated when a resident refused a shower or bath, they are asked again and a shower sheet with refusal was marked and given to the care coordinator. On 05/04/22 at 09:16 AM, Administrative Nurse D verified R38 had not received his whirlpool baths as requested and staff should document any refusals. The facility's Activities of Daily Living policy, dated 03/01/22, documented the facility provided each elder with care, treatment, and services according to the elders individualized care plan. Based on the individual elder's comprehensive assessment, facility staff would ensure that each elder's abilities in activities of daily living do not diminish unless circumstances of the elders clinical condition demonstrated that the decline was unavoidable, including bathing, dressing, grooming, transferring, locomotion, ambulation, toileting, and eating. The facility failed to provide consistent bathing for R38, placing the resident at risk for complications related to poor hygiene. - The electronic medical record (EMR) reported R49 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R49's Admission Minimum Data Set (MDS), dated [DATE], documented the resident had intact cognition and required extensive assistance with bed mobility, transfers, dressing, toileting, and personal hygiene. The MDS documented R49 required extensive assistance of one staff for bathing. The ADL Care Plan, dated 04/25/22, documented R49 preferred showers for bathing and requested two showers per week. The Care Plan directed staff to offer the resident a choice between a shower or bath on her bath days. The April 2022 Bathing Record documented the resident requested bathing twice per week and documented R49 had not received a bath or shower during the following days: 04/05/22-04/13/22 (9 days) The EMR lacked evidence R49 refused any bath or shower. On 04/28/22 at 09:59 PM, observation revealed R49 resting on top of the covers in bed watching television. On 05/03/22 at 11:48 AM, Certified Nurse Aide (CNA) M stated, when staff got to work, they looked in the EMR tasks to see which resident was to receive a bath for that day, and a list was given to staff for bathing. On 05/03/22 at 01:40 PM, Licensed Nurse (LN) H stated when a resident refused a shower or bath, they are asked again and a shower sheet with refusal was marked and given to the care coordinator. On 05/04/22 at 09:16 AM, Administrative Nurse D verified R49 had not received her showers as requested. The facility's Activities of Daily Living policy, dated 03/01/22, documented the facility provided each elder with care, treatment, and services according to the elders individualized care plan. Based on the individual elder's comprehensive assessment, facility staff would ensure that each elder's abilities in activities of daily living do not diminish unless circumstances of the elders clinical condition demonstrated that the decline was unavoidable, including bathing, dressing, grooming, transferring, locomotion, ambulation, toileting, and eating. The facility failed to provide consistent bathing for R49, placing the resident at risk for complications related to poor hygiene. - Resident (R) 9's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R9's Admission Minimum Data Set (MDS), dated [DATE], recorded R9 had a Brief Interview for Mental Status (BIMS) score of six which indicated severely impaired cognition. The MDS recorded she required staff supervision with personal hygiene and bathing. The Activities of Daily Living (ADL) Care Plan, dated 01/18/22, directed one staff to provide R9 assistance with hygienic cares. The ADL Care Plan recorded the resident recently moved from her family member's house and R9 did not like to bathe. The Care Plan directed staff to continue to offer encouragement for compliance and if R9 refused, set up a bath kit in her room, and assist her with completing her hygienic cares with one staff assist. The January Bathing Report documented R9 received a shower/bath on the following day: 01/25/22 The February Bathing Report documented R9 received a shower/bath on the following days: 02/13/22 (no bath for 19 days) 02/15/22 The March Bathing Report documented R9 received a shower/bath on the following days: 03/01/22 (no shower/bath for 14 days) 03/22/22 (no shower/bath for 20 days) The April Bathing Report documented R9 received a shower/bath on the following day: 04/29/22 (no shower/bath for 39 days) On 04/28/22 at 10:25 AM, observation revealed R9 sat in the doorway of her room with her shoes off. Her hair appeared uncombed and disheveled. On 05/03/22 at 03:30 PM, Administrative Nurse D verified the residents had scheduled bath/shower days including a skin assessment. The aides documented in the electronic health records when the resident received a shower/bath, and if it was not documented, it was not completed. Administrative Nurse D verified R9 was diagnosed with Alzheimer's and dementia and it was a struggle to get her to take a bath. The facility's Activities of Daily Living (ADLs) policy, dated 03/01/22, documented the facility would provide each elder with care, treatment and services according to the elder's individualized care plan, based on the individual elder's comprehensive assessment, facility staff will ensure that each elder's ability in activities of daily living do not diminish unless circumstance of the elder's clinical condition demonstrates that the decline was unavoidable, including bathing, dressing, grooming, transfers, locomotion, ambulation, toileting, eating and communication. The facility failed to provide the necessary care and bathing services for R9, placing the resident at risk for poor hygiene, and skin breakdown. - Resident (R) 9's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R9's Admission Minimum Data Set (MDS), dated [DATE], recorded R9 had a Brief Interview for Mental Status (BIMS) score of six which indicated severely impaired cognition. The MDS recorded she required staff supervision with personal hygiene and bathing. The Activities of Daily Living (ADL) Care Plan, dated 01/18/22, directed one staff to provide R9 assistance with hygienic cares. The ADL Care Plan recorded the resident recently moved from her family member's house and R9 did not like to bathe. The Care Plan directed staff to continue to offer encouragement for compliance and if R9 refused, set up a bath kit in her room, and assist her with completing her hygienic cares with one staff assist. The January Bathing Report documented R9 received a shower/bath on the following day: 01/25/22 The February Bathing Report documented R9 received a shower/bath on the following days: 02/13/22 (no bath for 19 days) 02/15/22 The March Bathing Report documented R9 received a shower/bath on the following days: 03/01/22 (no shower/bath for 14 days) 03/22/22 (no shower/bath for 20 days) The April Bathing Report documented R9 received a shower/bath on the following day: 04/29/22 (no shower/bath for 39 days) On 04/28/22 at 10:25 AM, observation revealed R9 sat in the doorway of her room with her shoes off. Her hair appeared uncombed and disheveled. On 05/03/22 at 03:30 PM, Administrative Nurse D verified the residents had scheduled bath/shower days including a skin assessment. The aides documented in the electronic health records when the resident received a shower/bath, and if it was not documented, it was not completed. Administrative Nurse D verified R9 was diagnosed with Alzheimer's and dementia and it was a struggle to get her to take a bath. The facility's Activities of Daily Living (ADLs) policy, dated 03/01/22, documented the facility would provide each elder with care, treatment and services according to the elder's individualized care plan, based on the individual elder's comprehensive assessment, facility staff will ensure that each elder's ability in activities of daily living do not diminish unless circumstance of the elder's clinical condition demonstrates that the decline was unavoidable, including bathing, dressing, grooming, transfers, locomotion, ambulation, toileting, eating and communication. The facility failed to provide the necessary care and bathing services for R9, placing the resident at risk for poor hygiene, and skin breakdown.

The facility had a census of 61 residents. The sample included 16 residents. Based on observation, record review, and interview the facility failed to ensure one of six residents reviewed during medication administration pass, remained free of medication error. This placed the resident at risk for adverse reaction from the medication. Findings included: - Resident (R) 39's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R39's Physician Order, dated 04/12/22 instructed staff to administer, Pristique (antidepressant) ER (extended release), 25 milligrams (mg) 1 tablet a day, Potassium Chloride (potassium supplement) ER, 10 milliequivalents (mEq) 1 tablet a day, and [MEDICATION(S)] (anticonvulsant and mood stabilizer) DR (Delayed Release), 1 tablet in the morning. On 05/03/22 at 07:20 AM, observation revealed License Nurse (LN) I crushed R39's pills, including the Pristique ER, Potassium Chloride ER, and the [MEDICATION(S)] DR and mixed the medication with strawberry jello. LN I administered two spoons full of the medication and the resident ingested all of the medications. On 05/03/22 at 07:20 AM, LN I stated R39 did not like to take her medications, so staff crushed them, and mixed the medication into strawberry jello. On 05/04/22 at 09:30 AM, Administrative Nurse D verified the extended release medication should not be crushed, should be administered whole due to the extended release of the medication over time, and would get the medications in a liquid if available. The Wed MD recommended Pristique ER, Potassium Chloride ER and [MEDICATION(S)] DR should be administered whole, and not crushed, chewed or sucked, as it can release all the medication at once, increasing the risk for side effects. The facility's Medication Crushing Guidelines policy, dated October 2017, documented most crushed tablets or emptied capsules may be mixed with applesauce, pudding, or jelly immediately prior to administration if necessary, to improve their palatability (Check compatibility before mixing). Water may also be used. Juice should only be used when so ordered by the physician. No other products should be mixed with food or beverages other than water unless a physician specific order is obtained. Medication should not be mixed with eternal feeding solutions unless ordered by physician. Medication that should not be crushed or chewed when a resident's condition prohibits the administration of solid dosage forms (tablets, capsules, etc) the nurse administering the medication should check to see that there is no contradiction to crushing the medications in question in liquid form, if possible. The rationale for not crushing some medications include-timed released tablets are designed to release medication over a sustained period usually 8-24 hours. These formulations are utilized to reduce stomach irritation in some cases and to achieve prolonged medication action in other cases. In either case these tablets should not be crushed. The facility failed to ensure staff administered the extended release medication whole to R39, which placed the resident at risk for adverse reaction from the medication.

The facility had a census of 61 residents. The sample included 16 residents, with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to monitor and provide the physician ordered interventions for bowel management for one sampled resident, Resident (R) 38. This placed the resident at risk for constipation and decline. Findings included: - The electronic medical record (EMR) for R38 recorded diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R38's Quarterly Minimum Data Set (MDS), dated [DATE], documented the resident had severely impaired cognition, required extensive assistance with bed mobility, transfers, dressing, toileting, and personal hygiene, and was always incontinent of bowel. The Pain Care Plan, dated 03/14/22, directed staff to monitor and document for side effects of pain medication and monitor for constipation. R38's Incontinence Assessment, dated 03/10/22, documented the resident did not have hard or difficult bowel movements, had several bowel movements daily, and did not use laxatives (stimulates or facilitates bowel movements) or suppositories (medication inserted into the rectum [the final section of the large intestine, terminating at the anus] to treat constipation) for regulation. The Orders tab revealed the following medications which could contribute to constipation: 3/10/22 [MEDICATION(S)] (narcotic pain medication) patch 72hr 25 micrograms/hr-apply one patch one time a day every three days for pain and remover per schedule. 3/10/22 [MEDICATION(S)] ( narcotic pain reliever) tab 10-325 milligrams give one tab every six hours as needed for pain. 3/16/22 [MEDICATION(S)] tab 10-325 milligrams give one tab daily for pain. The Orders tab recorded the following medications for bowel maintenence: 3/9/22 dulcolax (medication used to treat constipation) suppository. Give one suppository rectally every 24 hours as needed for constipation The Bowel Monitoring Record, dated March 2022, revealed R38 did not have a bowel movement for the following days: 03/25/22-03/31/22 (7 consecutive days) The Treatment Administration Record (TAR), dated March 2022, lacked documentation the staff provided interventions during the lack of bowel elimination on the above dates. The Bowel Monitoring Record, dated April 2022, revealed R38 did not have a bowel movement for the following days: 04/14/22-04/20/22 (7 consecutive days) The Treatment Administration Record (TAR), dated April 2022, lacked documentation the staff provided interventions during the lack of bowel elimination on the above dates. On 04/21/22, the orders tab was updated with the following orders: 4/21/22 [MEDICATION(S)] (stool softner) cap 100 milligrams by mouth twice daily for constipation. 4/21/22 milk of magnesia ( [MEDICATION(S)]) 1200 milligrams in15 milliliters, give 30 milliliters every 24 hours as needed for constipation for three days. On 04/28/22 at 12:17 PM, observation revealed R38 ate lunch in the dining room. On 05/03/22 at 11:48 AM, Certified Nurse Aide (CNA) M stated bowel movements are documented in the computer and was unaware if R38 had concerns with constipation. On 05/03/22 at 01:40 PM, Licensed Nurse (LN) H stated she looked in the computer daily for residents who had not had a bowel movement and if R38 had not had a bowel movement in three days, she would look at the facility standing orders and administer Milk of Magnesium (a [MEDICATION(S)]) to the resident. LN H further stated, she relied on the nurse aides to also tell her if R38 had not had a bowel movement as R38 was too confused to be able to tell staff if he had or had not had a bowel movement. On 05/04/22 at 09:16 AM, Administrative Nurse D verified R38 had not had interventions provided for the resident during the above dates he had not had a bowel movement and stated staff are to follow the bowel management protocol. The facility's Bowel Habits policy, dated 03/10/22, documented each elder were assessed by shift for bowel patterns per CNA reporting in the charting system. The LN on each shift would generate a bowel report from the system at the beginning of the shift and initiate the bowel protocol as appropriate. If the elder had no bowel movement in the previous six-eight-hour shift, a [MEDICATION(S)] would be ordered by the physician. The policy documented the LN would document follow up on the intervention within eight hours after a [MEDICATION(S)] had been administered. The LN and CNA were responsible for following the bowel protocol document and all attempts to assist the elder in having a bowel movement with prune juice, power pudding, increased fiber laxatives and notification of the physician. The facility failed to monitor bowel movements and provide interventions for R38, who had multiple days without a bowel movement, placing the resident at risk for constipation and decline.

The facility had a census of 81 residents. The sample included 16 residents. Based on observation, interview, and record review the facility failed to provide cares to promote healing and prevent further decline in a pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony area, as a result of pressure, or pressure in combination with shear and/or friction) for 1 of 1 sampled resident admitted to the facility with 2 pressure ulcers, which deteriorated and merged into 1 unstageable pressure ulcer and a second new Stage II pressure ulcer.(#1) Findings Included: - Resident #1's physician order [REDACTED]. Type 2 Diabetes Mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin). Review of the medical record revealed the admission (MDS) Minimum Data Set assessment and (CAA) Care Area Assessment were in progress. The admission care plan, dated 4/7/19, directed the staff to reposition the resident every round (staff walking through the facility visually checking the residents), due to wounds located on his/her bottom. The care plan lacked further direction to the staff regarding wound care. The 4/8/19 care plan update, documented staff placed a recliner in the resident's room per his/her request for sleeping and directed staff to continue with repositioning. The 4/6/19 Braden scale (a pressure ulcer risk prediction assessment) had a score of 14, which indicated the resident was at low risk for pressure ulcers. On 4/6/19 the admission assessment documented a stage 1 pressure ulcer (intact skin with redness) located below the resident's left buttock which measured 8.5 (cm) centimeters x 6.5 cm and a stage 2 pressure ulcer (localized damaged skin and/or soft tissue usually over a bony area) to the resident's coccyx (small triangular bone at the base of the spine), which measured 1.5 cm x 1.5 cm. The 4/7/19 wound update, provided by Administrative Nurse E, documented open area #1 measured 1.6 cm x 1.0 cm x 0.1 cm of 100 (%) per cent pink tissue classified as a Stage 2 pressure injury. The skin around the wound was pink and intact, with no sign of infection, drainage, or odor. The 4/8/19 (TAR) treatment administration record instructed staff to cleanse the wounds with wound wash spray, pat dry, apply Calcium Alginate dressing (a highly absorbent natural dressing derived from seaweed which maintained a moist environment that promoted healing), and cover with a foam dressing. The 4/9/19 wound update, provided by Administrative Nurse E, documented open area #2 measured 1.5 cm x 0.9 cm x 0.1 cm with 100% pink, non-granulated tissue, partial thickness skin loss with exposed dermis, and classified as a Stage 2 pressure injury. The skin was pink, intact, with no signs of infection, drainage, or odor. On 4/9/19, the facility-initiated orders for a multivitamin daily and an 8 (oz) ounce glass of whole milk with meals to promote wound healing. The 4/12/19 at 12:55 PM, nurse's note documented the facility transferred the resident to the hospital (ICU) Intensive Care Unit for administration of 2 units of blood. The 4/13/19 at 5:42 PM, nurse's note documented the resident returned to the facility on [DATE] from the hospital ICU at 10:30 PM. The nurse's note lacked documentation of a skin assessment upon return to the facility. The resident's hospital medical records, dated 4/12/19, documented the resident arrived at the hospital at 1:20 PM and discharged back to the facility at 10:05 PM. The hospital records lacked documentation of the resident's skin condition on admission to the hospital, or any pressure-relieving interventions used during his/her stay at the hospital. Review of the resident's medical records lacked documentation of a transfer sheet sent with the resident, with information regarding wounds on the resident's left buttock and coccyx areas. The 4/15/19 wound update documented the two Stage II pressure injuries to the coccyx and left gluteal cleft had merged into an unstageable pressure ulcer which measured 7.0 cm x 3.0 x 0.3 cm with dark brown drainage to the coccyx, and a new stage 2 pressure ulcer, which measured 2.5 cm x 1.1 cm x 0.1 cm to left buttock. On 4/16/19, the (RD) Registered Dietician recommended Med Pass 2.0, a dietary supplement, (10 days after admission to the facility), 60 (ml) milliliters twice a day, and high protein snacks at 10 AM, 2 PM, and bedtime. The 4/16/19 at 12:17 PM, nurse's note documented the resident experienced a change in condition, refused meals, moaned and grimaced during transfer into his/her wheelchair, and was transferred to the hospital emergency department after a verbal report was given to the hospital staff. The 4/16/19 at 9:49 PM, nurse's note documented the resident returned to the facility and was confined to bed. On 4/16/19 at 9:19 AM, observation revealed Direct Care Staff P and Q assisted the resident from his/her wheelchair to bed with a mechanical lift (a lift used to transfer a patient, who has difficulty standing). Upon removal of the incontinent brief, the dressing to the coccyx was noticeably soiled with brown drainage and odor noted. Direct Care Staff Q verified the odor was from the sore. The Surveyor notified Administrative Nursing Staff E of the soiled dressings and Nursing Staff E applied clean dressings to the coccyx and left buttock. On 4/17/19 at 8:22 AM, observation revealed Administrative Nursing Staff E removed soiled dressings from the coccyx wound and the left buttock wound, both with a foul odor. Administrative Nursing Staff E measured wound #1 at 10.5 cm x 5 cm x 1.5 cm with tunneling (a passageway underneath the skin that may extend into soft tissue) of 2.1 cm in 2 different areas, with yellow/green slough (dead tissue which is normally cream or yellow). Administrative Nursing Staff E measured wound #2 at 3.2 cm x 1.1 cm x 0.1 cm with bleeding. Administrative Nursing Staff E cleansed both areas with wound cleanser, applied Santyl gel (gel used to assist in removing dead tissue from a wound), gauze, and a foam cover to wound #1 and Calcium Alginate, with a foam cover, to wound #2. On 4/15/19 at 3:46 PM, Administrative Nursing Staff E stated the resident had been sitting in the recliner to sleep at night, the alternative for positioning had been his/her wheelchair. Administrative Nursing Staff E stated a pressure-relieving cushion had not been placed in the recliner due to the soft nature of the recliner seat. On 4/15/19 at 3:46 PM, Administrative Nursing Staff E stated staff had not requested the resident's physician assess the wound or contacted the Nurse Practitioner, who was available for wound consultation. On 4/17/19 at 3:15 PM, Licensed Nursing Staff K stated he/she worked the evening the resident returned from the hospital following the blood transfusion. The resident was alert and oriented, responded to Licensed Nurse K, but he/she had not assessed the condition of the resident's wounds. On 4/17/19 at 11:15 PM, Administrative Nursing Staff D and E confirmed staff had not informed the hospital staff of the resident's skin condition prior to transfer to the hospital for the blood transfusion, and the nursing staff had not completed skin assessments prior to and upon return from the hospital, following treatment. The facility's Pressure Ulcer policy, dated 12/2017, documented a skin assessment would be done each time a change in the resident's condition was noted. After conducting an inspection of the resident's skin, the nurse would review the resident assessment protocol for pressure ulcers to identify risk factors of pressure ulcers or to treat an existing pressure ulcer. The facility failed to provide cares to promote healing and prevent further decline in a pressure ulcer, for Resident #1, who admitted to the facility with one Stage I and one Stage II pressure ulcer, when they failed to place a pressure relieving cushion in the resident's recliner where he/she slept at night, provide specific instructions to the facility staff for wound care, and consult a wound care specialist for assessment. The facility failed to communicate with hospital staff on transfer of the resident for a blood transfusion, which took approximately 8 ½ hours, placing the resident at risk for further deterioration of the wounds, formation of new wounds, increased risk for infection, and overall decline.

The facility identified a census of 81 residents. The sample included 23 residents. Based on observation, interview, and record review the facility failed to develop and implement intervention to prevent falls with injury for 1 (#45), failed to assess for safety prior to the use of electric lift chairs for 2 (#45, #58) residents with a history of falls, and failed to follow previous interventions to prevent falls for 1 (#51) of the 5 residents reviewed for accidents. Findings included: - The quarterly Minimum Data Set ((MDS) dated [DATE] for resident #45 revealed a Brief Interview for Mental Status (BIMS) score of 3, indicating severe cognitive impairment. He/she displayed fluctuating signs and symptoms of delirium (sudden severe confusion, disorientation and restlessness) including inattention and disorganized thinking. The resident required extensive assistance from 2 or more staff members for bed mobility, transfer, locomotion on and off the unit, dressing, and toilet use. The resident was not steady and was only able to stabilize with staff assistance when moving from a seated to standing position, walking, turning around while walking, moving on and off the toilet, and surface-to-surface transfers. He/she was frequently incontinent of bladder and bowel and received scheduled pain medications. The resident sustained [REDACTED]. The 8/20/14 Care Area Assessment (CAA) regarding cognitive loss and dementia revealed the resident had significant cognitive impairments which placed him/her at an increased risk for injury. He/she had a marked short term memory deficit and due to his/her inattention to surroundings was at a higher risk of injury related to lack of awareness of potential hazards in the environment. The 8/20/14 CAA regarding falls revealed the resident had a fall prior to admission to the facility which led to a deterioration in his/her mobility status. The care plan with a revision date of 2/25/15 revealed since 11/30/2011 staff provided the resident with reminders since at times he/she forgot to use his/her call light for assistance. The care plan showed the resident had falls on 12/20/14 and 2/6/15 related to not using his/her call light for assistance prior to attempting to self transfer. The care plan showed the resident sustained [REDACTED]. Since the fall staff implemented new interventions including a new toileting program after completion of a voiding diary, completed a therapy screen, and offered the use of hipsters (a fall protection product used for residents at risk for injury). The care plan also stated due to his/her cognition he/she forgot to use the call light, so staff were to keep his/her walker and wheelchair out of reach when he/she was in his/her bed or recliner. Staff were to intervene if they observed the resident getting up on his/her own. Record review on 3/29/15 at 1:27 P.M. lacked evidence staff completed a safety assessment for the electric recliner prior to use. The nurses note dated 9/23/14 at 9:17 P.M. revealed staff found the resident lying on the floor in front of his/her recliner. He/she had stood to answer his/her phone and fell getting back into the recliner. The nurse's note dated 12/2/14 at 2:03 A.M. revealed staff lowered the resident to the floor while staff were taking him/her to the bathroom. The resident's legs gave out in front of the toilet. The nurse's note dated 12/20/14 at 3:47 P.M. revealed staff found the resident sitting on the floor in front of the recliner in his/her room. The nurse's note dated 2/6/15 at 10:11 P.M. revealed the resident's family member called staff to the resident's bathroom. The resident had attempted to pull down his/her pants in the bathroom without assistance, lost his/her balance, started to fall forward, and hit his/her head on the wall. Staff found the resident standing with his/her walker with his/her head against the wall. The nurse's note dated 2/11/15 at 3:35 A.M. revealed an aide called the nurse to the resident's room by the aide due to a fall. The nurse found the resident lying face down on the floor between the bedroom and bathroom. The aide reported he/she provided the resident assistance to the commode at 1:40 A.M. during rounds, and checked on the resident at 1:50 A.M. but the resident was not done. The aide returned at 2:05 A.M. and found the resident face down on the floor calling for help. Staff asked the resident why he/she did not use the call light and he/she responded, Well, I don't know why. The resident had a contusion (bruise) above his/her right eyebrow with a 1 inch by 1/4 inch laceration. Staff notified the physician and the resident was sent to the emergency room . The fall investigation provided by the facility for the 2/11/15 fall showed the hospital staff evaluated the resident after the incident and staff discovered the resident to have a right nasal bone fracture and received 4 staples to the laceration above his/her right eyebrow. The corrective actions taken were to have the resident move rooms, use hipsters, complete a pharmacy review, complete a therapy screen, staff reviewed and revised his/her toileting plan, staff limited toilet sitting time, and staff were to not leave the resident unattended in the bathroom. The voiding diary dated 2/16/15 through 2/18/15 lacked evidence that staff analyzed the data collected to develop a new toileting program as indicated on the fall investigation. Observation on 3/25/15 between 1:50 P.M. and 2:10 P.M. revealed the resident sat in the electric lift recliner with the remote in his/her lap. At 2:10 P.M. a nurse's aide entered the resident's room responding to the call light. The resident reported he/she was cold. Staff retrieved a blanket for the resident but did not offer toileting. From that time until 2:38 P.M. the resident remained in the electric recliner. At 2:38 P.M. the resident called out for assistance, staff entered the room. The resident asked for help getting voicemails from his/her phone. Staff failed to offer toileting. The resident remained in the electric recliner until 3:45 P.M. when 2 staff knocked and entered the resident's room and assisted the resident using a gait belt to transfer from the recliner to the wheelchair, propelled the resident into the hall, weighed him/her in the wheelchair, propelled him/her back to his/her room, transferred him/her back into the recliner, placed the remote to the recliner into his/her hand, and left the room. Staff did not offer toileting. The resident remained in the electric recliner until 4:33 P.M. when 2 staff knocked and entered the resident's room and offered assistance to the dining room for dinner. The resident asked the staff if he/she could stop by the bathroom on the way to dinner. Staff verbalized understanding, provided limited assistance with a gait belt and verbal encouragement and cueing for transfer from the recliner to the bathroom using his/her walker. The resident's brief was moderately saturated with urine. Staff failed to offer toileting for a total of 2 hours and 43 minutes. Interview on 3/26/15 at 2:26 P.M. with direct care staff Q revealed the resident was at risk for falls and staff checked on him/her frequently due to him/her forgetting to use the call light. Interview on 3/26/15 at 3:19 P.M. with licensed nursing staff J revealed the resident was at risk for falls. Staff moved him/her closer to the nurse's station for safety and toileting him/her often, at least every 2 hours. Staff J reported the aides filled out the voiding diaries and the MDS coordinator analyzed the data and developed the toileting program. Interview on 3/30/15 at 10:18 A.M. with administrative nursing staff F revealed staff based the resident's current toileting program off a voiding diary from prior to the fall with injury. Interview on 3/30/15 at 10:53 A.M. with licensed nursing staff I revealed the resident still believed he/she was able to be independent so staff provided reminders to call for assistance. Staff I stated the resident was not safe to be left alone in the bathroom. Staff I acknowledged the resident had falls prior to the fall with injury on 2/11/15 related to not using his/her call light for assistance. He/she also acknowledged the resident was most likely not safe to be left alone in the bathroom prior to the 2/11/15 fall, and said someone should have been there with him/her. Staff I reported the facility did not complete safety assessment for the use of electric lift recliner prior to having them in resident's rooms. He/she also said the aids filled out the voiding diaries which were then reviewed by the MDS coordinator who developed the toileting program based off the information collected. Staff I felt the MDS coordinator should have developed a new toileting program using the 2/16/15 through 2/18/15 voiding diary since it was an intervention implemented after the resident's fall with injury. Interview on 3/30/15 at 11:44 A.M. with direct care staff O revealed the resident's cognition fluctuated and some days he/she required more assistance than others. Staff O expected staff to offer toileting to the resident hourly, but at least every 2 hours. Staff O reported the resident did use the electric lift chair independently. Interview on 3/30/15 at 12:24 P.M. with administrative nursing staff F revealed he/she acknowledged one of the intervention to be implemented after the resident's fall with injury was to complete a voiding diary and develop a new toileting program. Staff F acknowledged it had been over a month since staff completed the voiding diary and the data had not been analyzed to develop a new appropriate toileting program for the resident. Interview on 3/30/15 at 12:58 P.M. with administrative nursing staff D revealed the resident came to the facility due to a decline in cognition and physical abilities. Staff D reported the staff had reminded the resident to use the call light when they toileted him/her prior to the fall on 2/11/15. Staff D stated, at the time of the incident he/she was not concerned about the resident's ability to use the call light but was aware that at times he/she did not use it appropriately. He/she stated that none of the resident's previous falls made him/her feel like the resident would have a fall like he/she sustained on 2/11/15. Staff D stated the resident's cognition fluctuated. He/she would have expected a new toileting program to be developed based off the voiding diary from 2/16/15 through 2/18/15 and acknowledged that was a concern since it was part of the new interventions implemented to prevent future falls after the resident's injury fall. Staff D reported the facility did not complete a safety assessment for electric recliners prior to use and said the facility did not have a policy regarding the use of the electric lift recliners. The April 22, 2013 policy provided by the facility regarding assessing falls and their causes revealed staff recorded appropriate interventions that were taken to prevent future falls. The policy failed to address the need to follow the new interventions. The facility failed to implement appropriate interventions to prevent falls for this resident with severe cognitive impairment resulting in a fall with major injury and failed to assess for his/her safety prior to the use of an electric lift recliner. - Resident #51's electronic medical record included [DIAGNOSES REDACTED]. The resident's quarterly Minimum Data Set ((MDS) dated [DATE] identified the resident scored 3 (severely impaired cognition) on the Brief Interview for Mental Status on BIMS, required limited staff assistance with bed mobility, transfers, walking in the room/corridor and locomotion on/off the unit. The MDS identified the resident required extensive staff assistance with dressing, toilet use, hygiene, was not steady and was only able to stabilize with staff assistance when moved from a seated to a standing position, walking, turning around and facing the opposite direction while walking, moving on/off the toilet and surface to surface transfers. The MDS coded the resident utilized a walker and without falls since the prior assessment. The resident's Cognitive Loss/Dementia Care Area Assessment (CAA) dated 8/8/14 included the resident was at risk of injury related to short and long term memory impairment. The resident was unable to stand up from the couch without staff assistance and recently the resident fell and fractured his/her hip. The resident's Fall CAA dated 8/8/14 documented the resident had a fall which resulted in an odontoid process fracture (upwards extension from the body of the Axis (C2, Second cervical vertebral body), a C2 cervical fracture and a thoracic compression fracture (when forced together bone surfaces caused a bone to break in the middle part of the spine) which occurred when the resident attempted to sit down in the dining chair and missed the chair. The resident was at risk for falls due to history of falls, a [DIAGNOSES REDACTED]. The resident had a major injury fall (right hip fracture) on 4/5/14 when he/she misjudged the chair in dining area and fell to floor. The resident required extensive staff assistance with activities of daily living and utilized a wheelchair for locomotion. The resident's Fall CAA dated 3/17/14 documented the resident as at risk for falls related to a history of falls, current medications and generalized muscle weakness. The resident's balance was steady at times and required the use of an assistive device with transfers/ambulation. Staff provided cueing/directional assistance as needed. The resident's Cognitive Loss/Dementia CAA dated 3/21/14 included the resident was at high risk for injury related to his/her cognitive impairment. The resident's Fall assessment dated [DATE] identified the resident was at moderate risk for falls. The resident's care plan dated 1/30/15 addressed the resident had a [DIAGNOSES REDACTED]. The resident was at risk for falls due to a history of falls, dementia, incontinence of bladder, medication usage and generalized muscle weakness. Staff provided appropriate assistance to the resident with activity of daily living (ADLs) and transferred via a walker with a gait belt and one person assistance. On 4/5/14, the resident had a major injury fall and sustained a right hip fracture and upon return from the hospital staff guided the resident with seating in the dining room. A nurse's note (NN) dated 4/5/2014 and timed 6:35 P.M. documented the resident fell in the dining room, the resident laid on his/her right side and complained of right lower extremity pain. The resident sustained [REDACTED]. The resident cried out in pain when staff assessed the resident's right hip/lower extremity and the resident's right lower extremity had an outward rotation. Staff notified the resident's physician and obtained a physician's orders [REDACTED]. A NN dated 4/5/2014 and timed 7:27 P.M. documented the resident was transferred to another hospital due to a hip fracture. The facility's Fall Investigation Report dated 4/5/14 included at 4:00 PM the resident attempted to sit in a dining room chair, misjudged the location and fell to the floor. Intervention included upon the resident's return to the facility, staff was instructed to help guide the resident with seating in the dining room. A hospital's History and Physical dated 4/6/14 documented the resident fell and fractured his/her right hip and would require surgery to repair. A NN dated 7/16/2014 at 6:21 P.M. documented the nurse heard a loud noise in the dining room and the resident laid on his/her right side beside a dining room chair. Staff noted an open area on the back of the resident's head and the resident complained of a headache. The facility notified the resident's physician and obtained physician's orders [REDACTED]. A NN dated 7/17/2014 and timed 8:43 A.M. documented the resident admitted to a hospital for a C2 spinal fracture. The facility's Fall Investigation report dated 7/16/14 and timed 4:45 P.M. documented the resident pulled out a dining room chair to sit, lost his/her balance and fell backwards. A hospital's discharge summary dated 7/18/14 documented the resident tried to sit when he/she toppled backwards and landed on the ground. The resident sustained [REDACTED]. A NN dated 11/3/2014 and timed 1:11 P.M. documented the resident sat on the doorway of his/her bathroom. Staff stated while walking the resident out of bathroom, the resident's knees buckled and staff lowered the resident to the floor. The resident sustained [REDACTED]. On 3/25/15 at 4:00 P.M. a staff assisted the resident utilizing a walker and a gait belt to the dining room. On 3/26/15 at 7:55 A.M. the resident sat at a dining room table. On 3/26/15 at 9:30 A.M. administrative nursing staff D confirmed the resident fell sustained a right hip fracture during the month of 4/2014 and a cervical fracture during the month of 7/2014 as the resident attempted to sit in a dining room chair. He/she stated after the hip fracture staff assisted the resident to the dining room to avoid falls. He/she stated at the time of the cervical fracture the resident ambulated independently, staff was not aware of when the resident ambulated to the dining room therefore staff did not assist the resident to the dining room. On 3/26/15 at 3:12 P.M. licensed nurse K stated the resident required cueing, assistance of 1 staff utilizing his/her walker and a gait belt. He/she stated the resident was at risk for falls and staff reminded the resident to call for assistance. Licensed nurse K stated staff assisted the resident to and from the dining room. On 3/30/15 at 1:04 P.M. direct care staff R stated the resident required staff assistance with ambulation. He/she stated the care plan was the communication tool that informed staff of resident's care needs. The facility's Assessing Falls and Their Causes Policy and Procedure dated 4/22/2013 included the policy and procedure provided guidelines for assessing residents and to assist staff in identifying the cause of the fall. The facility failed to assist this severely cognitively impaired resident who fell and sustained a hip fracture on 4/5/14 when he/she attempted to sit in a dining room chair. The facility failed to assist the resident to the dining room as planned and the resident fell and sustained a C2 cervical and thoracic compression fracture and a scalp laceration on 7/16/14. - The resident ' s 9/8/13 electronic physician order [REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status score of 3, indicating severe cognitive impairment. The resident required extensive assistance with bed mobility and dressing, limited assistance with personal hygiene, toilet use, locomotion on and off of the unit, and walking in his/her room or corridor. He/she had 2 or more falls since admission without injury and 2 or more falls with minor injuries. The annual MDS dated [DATE] revealed the resident had a BIMS of 3 and required extensive assistance with bed mobility, supervision with transfers, and was independent with walking in his/her room/corridor, locomotion off of the unit, and eating. He/she required limited assistance with toilet use, dressing, and personal hygiene. He/she had 2 or more falls since admission that were non- injury. The Fall Risk Care Area Assessment CAA dated 9/14/14 revealed the resident had a history of [REDACTED]. He/she was at risk due to poor decision making skills, incontinence, use of Ambien (medication for sleeping), and impaired mobility. The resident required assistance with his/her Activities of Daily Living (ADLs). He/she was ambulatory with a seated walker independently in the building. The care plan revised on revised on 3/20/15 revealed that on 12/16/14 he/she sat on the edge of his/her bed and fell asleep and fell . Education was provided on the care plan and the resident was not left to sit on his/her bed due to numerous falls. The 10/2/14 care plan revealed the resident sat on the edge of his/her bed and had a fall. Staff assisted the resident to his/her recliner, and assistance to lay the resident down in bed. The lift recliner assessment was not completed for this resident. The Fall Risk evaluation dated 3/20/15 revealed the resident exhibited loss of balance while standing, changed his/her gait (walking) pattern when walking through door way, and strayed off the straight path of walking. A nurses note dated 3/15/15 at 6:56 A.M. from licensed nursing staff LL documented the resident was found in the seated position in front of his/her recliner. His/her legs were extended and his/her walker was in front of him/her. He/she stated, I slipped out of my chair. An investigation communication form provided by the facility documented on 1/22/14 the resident had a lift recliner and staff reported he/she often fell asleep with it in the up position. Upon interview with the resident ' s spouse, he/she stated the resident often fell asleep with the recliner in the up position during his/her visits. Staff and the resident were instructed the lift recliner could not be left in the up position. The residents spouse suggested to remove the recliner control but due to the resident being ambulatory independently, staff instructed him/her they would start with reminders and cueing. An observation on 3/25/15 at 2:27 P.M. the resident appeared asleep in his/her recliner. The recliner was raised so the resident ' s body was tilted toward the floor. He/she held the recliner remote in his/her hand while he/she slept. At 2:32 P.M. staff entered the resident ' s room and lowered his/her chair. At 2:48 P.M. the resident was asleep in his/her recliner with the call light in reach and the recliner remote beside the resident ' s hand. An observation on 3/26/15 at 1:30 P.M. the resident was awake with his/her recliner up and his/her body tilted toward the floor. Staff entered the resident ' s room and asked the resident to move his/her seat back down. An observation on 3/26/15 at 2:41 P.M. the resident began to raise his/her recliner in the up position and stopped when staff entered the room. Staff moved the chair back down so the resident ' s feet were raised and left the room. The recliner remote remained in reach of the resident. An interview on 3/26/15 at 3:31 P.M. with direct care staff Q stated the resident tried to get up on his/her own and used the remote for his/her chair often to raise him/herself in the up position. He/she looked like he/she would fall out of the chair and fell asleep in the up position. An interview on 3/30/15 at 9:01 A.M. with direct care staff O stated staff checked on the resident as much as they can and encourage him/her to recline his/her feet. Staff lay the resident back and he/she would set him/herself up again. He/she liked to hold the recliner remote control and if staff set it in the holder beside his/her chair, he/she would search for it. The resident was really confused some days and staff continuously checked on the resident to make sure he/she was safe. An interview on 3/30/15 at 2:13 P.M. with therapy staff HH stated they did not do lift chair assessment for residents. He/she watched the resident transfer from his/her recliner but did not address safety use of lift chairs. An interview on 3/30/15 at 2:02 P.M. with administrative nursing staff F stated he/she did not do lift chair assessments. Therapy completed lift chair assessments. The resident fell asleep on the edge of his/her bed and that was care planned. An interview on 3/30/15 at 1:30 P.M. with licensed nursing staff I stated he/she would fall asleep with his/her recliner in the up position. The resident normally handled the controls. The resident was alert and oriented to him/herself but did forget where he/she was at. The resident had only been back at the facility a couple of weeks since returning from the hospital. Since his/her return the Dementia (progressive mental disorder characterized by failing memory, confusion) had advanced. He/she did not feel the resident was very safe in his/her recliner. Staff I revealed there was no recliner assessment completed and the care plan did not address the resident falling asleep with the recliner in the up position. An interview on 3/30/15 at 2:49 P.M. from administrative nursing staff D stated he/she would expect a recliner assessment to be completed for the resident. The care plan should reflect the resident used his/her recliner and he/she fell asleep in the up position. The recliner was a fall risk for the resident. The Assessing Falls and Their Causes policy dated 4/22/13 documented staff and physician would identify significant potential complications of falling for each resident at risk for falling. When possible, the attending physician or nursing staff would document the basis for identifying specific factors as the cause of falls. The facility failed to implement appropriate interventions to prevent falls for this resident with severe cognitive impairment resulting in a falls failed to assess for his/her safety prior to the use of an electric lift recliner.