Every finding on record at The Healthcare Resort of Leawood - Iron Horse HLTH

The facility identified a census of 59 residents with a census of 28 residents on the East unit. Based on observation, record review, and interviews, the facility failed to prevent two Certified Nurse Aides (CNAs) from bringing weapons into the facility and further failed to prevent gun violence between the two CNAs on the East unit. On 02/10/26 at approximately 03:28 AM, CNA M went down the Northeast (NE) corridor and unlocked the door that led to an exit outside. He then walked back down the hallway towards the nurses' station, pulled a gun out of his jacket, and fired multiple shots into the dining room where CNA N was located. CNA N returned an unknown number of rounds down the East Hall, where nine residents resided, with a bullet grazing the wall next to Resident (R) 2's room and a bullet, possibly the same one, hitting the doorframe of R1's room. CNA M ran down the NE hall and out of the NE corridor door while CNA N remained in the facility until law enforcement arrived. This deficient practice placed the residents in immediate jeopardy. Findings included:- In a written statement on 02/10/26, CNA R stated at 03:20 AM, she heard three popping sounds on the East unit, and she ran over to see what happened. She stated she saw smoke and saw three gun shell casings on the ground in front of the nurses' station. She heard CNA N yell to call 911 twice and Licensed Nurse (LN) G went with her back to the [NAME] unit to call 911. CNA R stated the police showed up and she told them the incident was on the East unit. She then checked all of her rooms to make sure the residents were safe. In a written statement on 02/10/26, LN G stated around 03:20 AM, she was taking a break in the activity room when she heard someone screaming then she heard gun shots. She said she went towards the East unit when CNA R said there were gun shells on the floor and to call the police. LN G stated she immediately ran back to the [NAME] unit and called 911. She called the clinical on-call and informed her about the gun shots and that police were in the building. LN G stated she checked on the residents to make sure they were okay. On 02/11/26 at 09:20 AM, an observation of the East Hall revealed a round indentation on the lower part of R1's door frame. There was a bullet graze mark in the middle section of the wall, approximately four to six inches in length, near R2's room. In the dining room, directly across from the East Hall, there were two bullet holes in the window and two to three bullet holes in the wall. On 02/11/26 at 09:30 AM, Administrative Staff A pulled up video surveillance from the NE corridor camera. The video, no date/time stamp located on the video, revealed CNA M walked down the NE hallway to unlock the NE corridor door. He walked back up the NE hallway towards the nurses' station, reached into his jacket, turned towards the dining room, lifted his arm up, and shot an unknown number of rounds into the dining room. CNA M then ran back down the NE hallway and out of the NE corridor door. CNA O walked from behind the nurses' station and looked down the NE hallway. On 02/11/26 at 10:17 AM, R1 sat in his wheelchair in his room. He said, in regard to the shooting incident on 02/10/26, he heard what he thought were pots and pans clanging around and that initially woke him up. He stated he then heard three to four shots and one of them hit his door frame. R1 stated when the bullet hit his doorframe, he thought the shooter was coming into his room for him but denied being scared. He stated the facility had a psychologist visit with him yesterday and he slept good last night. On 02/11/26 at 10:25 AM, R2 sat in his wheelchair in his room and watched television. He said, in regard to the shooting incident on 02/10/26, he heard gunshots which startled him awake and he was scared for a few seconds. R2 stated he felt like the facility handled the situation. On 02/11/26 at 09:12 AM, Administrative Staff A stated on 02/10/26 after 03:30 AM, he received a call that at approximately 03:29 AM, there were shots fired in the facility and the police showed up within five to six minutes. He stated CNA M had fled the facility and police searched for him and CNA N remained at the facility. Administrative Staff A stated both CNA M and CNA N had guns and CNA N stated he had an uneasy feeling about CNA M earlier in the shift and went out to his car to bring his gun in. Administrative Staff A stated CNA N did not report the uneasy feeling to anybody prior to the incident. He stated CNA M unlocked the door then fired off some shots and CNA N must have returned fire. Administrative Staff A stated the police took the staff down to the station to interview them, so he had not had a chance to interview the staff yet. He stated the facility brought in grief counseling for the residents and staff, hired a nighttime security guard, and started staff education. Administrative Staff A stated all of CNA M's shots were to an outside wall, while CNA N's went down the hallway. On 02/11/26 at 09:37 AM, Administrative Staff A said the facility brought in a grief counselor and had the employee assistance program ([NAME]) open to staff because the staff were pretty shaken up. He said the facility notified all of the residents' representatives and the facility had a town hall meeting with residents on 02/10/26 to go over any concerns. Administrative Staff A stated the residents brought up that they wanted increased security. He stated the facility hired a nighttime security guard. On 02/11/26 at 11:20 AM, Administrative Staff B stated the facility started education with staff on workplace violence, reporting protocols, security and access control, emergency response, active shooter, antiharassment and antiretaliation, and technology and social media controls. He stated the facility offered support directly for employees and provided [NAME] for ongoing counseling. He stated the facility put a security guard in place for nights and a psychologist visited with residents. On 02/11/26 at 12:01 PM, LN H said if there was an active shooter in the facility, she made sure she and everyone was safe. She stated no residents had voiced any concerns about being scared after the incident. On 02/11/26 at 12:03 PM, CNA P said if there was an active shooter in the facility, she took care of the residents and closed all of the doors. On 02/11/26 at 12:04 PM, CNA Q said if there was an active shooter in the facility, she closed all of the residents' doors and she received education on 02/10/26 on workplace violence. On 02/11/26 at 02:11 PM, Administrative Staff A stated the facility's active shooter procedure was to run, hide if you can, and fight. He stated staff were to save the residents if they could. Administrative Staff A stated CNA N stated he felt threatened by CNA M earlier in the shift and he went out to get his gun. He stated he was unaware of any problems between CNA M and CNA N prior to the incident. On 02/12/26 at 10:40 AM, LN I stated on 02/10/26 before the shooting incident at approximately 03:30 AM, she saw CNA M and CNA N exchange words then CNA M went back to the [NAME] unit. She stated CNA N left the facility around 01:00 AM or 02:00 AM and when he came back, he sat in the dining area, which he never did. LN I stated she was down on the Southeast Hall when CNA M walked towards CNA N and they exchanged words over Certified Medication Aide (CMA) S. She stated CNA M walked off like he was leaving the unit but instead of continuing straight, he turned right onto the NE Hall then turned back. LN I stated she saw CNA M peek around the corner towards the dining room then he started firing shots. She said she saw flashing lights then heard gunshots and went into an empty room. LN I heard CNA O scream, and she thought CNA O had gotten shot. LN I stated she heard four shots then one single shot and she saw CNA M exit the NE corridor door. She stated CNA N and CNA O went to the room she was in and she called the police. She told police they did not know where CNA M was, but CNA N was still on the premises and had a gun that was registered to him. LN I stated when police arrived, CNA N placed the gun on the ground, and they took him into custody. On 02/12/26 at 01:57 PM, CNA O stated on 02/10/26, she sat at the nurses' station by herself on the East Unit. She stated CNA M worked on the [NAME] Unit and he came over to the East Unit to get snacks but then he and CNA N, who sat in the dining room, started arguing. She could not hear what the conversation was about initially then when she started listening, she heard CNA M and CNA N argue about CMA S. CNA O stated the conversation had got intense and CNA N spoke in a vulgar way about women and started demeaning CNA M. CNA M paced back and forth and kept trying to leave the conversation but CNA N kept pulling him back into the conversation. CNA O stated CNA M walked down the NE hall and she thought he left until he came back then started firing from the corner of the nurses' station into the dining room at CNA N. She stated she heard return fire and did not know what was going on so she screamed, which scared CNA M and he ran out of the NE corridor door. The facility's Skilled Nursing Facility Employee Handbook, updated 09/01/21, directed the facility did not tolerate any acts or threatened acts of violence in the work environment. The list of behaviors, not inclusive, included: causing physical harm or injury to another person; threatening harm of an individual, group of individuals, or relatives of those individuals; aggressive or hostile behavior that created a reasonable fear of injury to another person or subjects another individual to emotional distress; the possession of weapons of any kind or the brandishing of any object the could reasonably be perceived as a weapon while on the property or while on a business-related outing; committing acts motivated by, or related to, sexual harassment or domestic violence; and any other conduct that could be perceived as constituting violence or a threat of violence. On 02/11/26 at 03:50 PM, Administrative Staff A was presented with the Immediate Jeopardy template and notified of the failure to prevent workplace violence between staff that put the residents in immediate jeopardy. The facility identified, implemented, and completed the following corrective measures:1. The police arrested CNA M and CNA N following the incident on 02/10/26.2. The facility began staff education on workplace violence, reporting protocols, security, anti-harassment and anti-retaliation protections, and technology and social media controls on 02/10/26, education on-going.3. The facility contracted with a security agency for a nighttime security guard on 02/10/26.4. The facility notified the residents' representatives of the incident on 02/10/26.5. The facility had a psychologist visit with residents possibly affected by the incident on 02/10/26. Due to the facility completion of all corrective actions prior to the onsite visit, the deficient practice was deemed past noncompliance at a scope and severity of a L (widespread, immediate jeopardy).

The facility had a census of 64 residents. The sample included 14 residents. Five Certified Nurse Aides (CNA) were reviewed for yearly performance evaluations and in-service training. Based on record review and interview, the facility failed to ensure one of the five reviewed CNA staff had the required yearly performance evaluations completed. This placed the residents at risk for inadequate care. Findings included: - Review of the facility's performance evaluation and in-service records revealed the following: CNA N, hired on 10/11/23, had no yearly performance evaluations provided upon request. On 08/06/25 at 12:15 PM, Administrative Nurse D stated the facility did not have the required yearly performance evaluations for CNA N. She stated that yearly performance evaluations were completed annually for all CNA staff. The facility's Staff Requirement policy 07/2010 indicated performance reviews will be conducted on each employee at least annually to identify employee strengths and goals. The policy noted the evaluation will be utilized to determine training needs for the employee.

The facility identified a census of 64 residents. The facility had one kitchen and two kitchenettes. Based on observation, record review, and interviews, the facility failed to follow sanitary dietary standards related to a dirty top of the convection oven with a water bucket on the floor with dripping water, no hairnets worn, and improper food storage. This deficient practice placed the residents at risk for food-borne illness.Findings included:- During the initial tour on 08/04/25 at 07:14 AM, observation revealed the following:Dietary staff CC and dietary staff DD were not wearing hairnets in the kitchen.In the walk-in refrigerator, there was a steam table pan with hot dogs, hamburgers, a bowl with cut-up watermelon, a bowl of lettuce, and a steam table pan with corn salad that were not labeled and were undated. The foods were covered with cling wrap. The dishwasher had documented temperatures on 08/04/25 in the dishwasher temperature monitoring notebook for August. The top of the convection oven had dirt, black gloves, and pan cover sheets that were dirty. The convection oven had a white plastic bucket catching dirty water placed on the floor. The walk-in freezer had French-fried potatoes in a canister that were unlabeled and undated. On 08/04/25 at 08:46 AM, Dietary Staff BB stated all foods should be dated and labeled. He stated that a pipe had broken and was being fixed over the convection oven. Dietary Staff BB stated he was training a new employee who had worked over the weekend, and he would be working with the new employee to ensure the kitchen was kept clean. He stated he would have the kitchen cleaned for the recheck of the kitchen.The facility did not provide a policy for foodborne illness or food storage.

The facility identified a census of 64 residents. The sample included 16, with three reviewed for accidents. Based on observation, record review, and interview, the facility failed to secure potentially hazardous cleaning chemicals in a safe, locked area and out of reach of eight cognitively impaired, independently mobile residents. The facility additionally failed to ensure Resident (R) 29's fall interventions were implemented. This placed the affected residents at risk for preventable accidents.Findings Included: - On 08/04/25 at 07:10 AM, an initial walkthrough of the facility was completed. An inspection of the Hallbrook unit revealed an unsecured soiled utility closet. An inspection of the closet revealed a bottle of solution under the sink. The bottle contained the warning, Keep out of reach of children, hazardous to humans, can cause eye irritation, harmful if swallowed.An inspection of the Hallbrook unit revealed an unsecured medical supply storage closet. An inspection of the closet revealed numerous medicated supplies. The bottles contained the warning, Keep out of reach of children, hazardous to humans, can cause eye irritation, harmful if swallowed.An inspection of the Hallbrook unit revealed purple sanitary wipes left unsecured on the counter of the nurse's station. The container contained the warning, Keep out of reach of children, hazardous to humans, can cause eye irritation, harmful if swallowed. An inspection of the Bridgewood unit revealed an unsecured soiled utility closet. An inspection of the closet revealed a bottle of solution under the sink. The bottle contained the warning, Keep out of reach of children, hazardous to humans, can cause eye irritation, harmful if swallowed. On 08/06/25 at 12:23 PM, Certified Nurse's Aide (CNA) M Certified Nurse's Aide (CNA) QQ stated cleaning products should be kept locked up when not being used or supervised. On 08/06/25 at 12:45 PM, Licensed Nurse (LN) G stated that cleaning wipes and bottles were to be locked up in the utility closet and away from the residents. On 08/06/25 at 01:04 PM, Administrative Nurse D stated that staff were expected to lock up the cleaning chemicals when not in use. The facility's Chemical Storage policy, revised 03/2016, indicated the facility would ensure an environment free from potentially hazardous materials, chemicals, and equipment.- The Medical Diagnosis section within R29's Electronic Medical Records (EMR) included diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), cognitive communication disorder (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness), need for assistance with personal care, muscle weakness, and history of falls. R29's Quarterly Minimum Data Set (MDS) completed 06/26/25 noted a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. The MDS indicated she had no upper or lower extremity impairments. The MDS noted she required supervision or touch assistance during toileting, bathing, dressing, bed mobility, transfers, and walking. The MDS indicated she had no falls since her last assessment. R29's Fall Care Area Assessment (CAA) completed 03/20/25 indicated she was at risk for falls related to her recent increase in assistance for her activities of daily living (ADL), muscle weakness, and cognitive impairment. The CAA noted care-planned interventions were implemented to minimize the risks associated with falls. R29's Care Plan initiated on 03/10/25 indicated she was at risk for falls related to her medical diagnoses. The plan indicated she required staff assistance for personal hygiene, bed mobility, transfers, meal setup, bathing, and toileting. The plan instructed staff to ensure her call light was within reach and to encourage her to use it. The plan instructed staff to keep needed items within reach and avoid rearranging her room's furniture. The plan noted she had a non-injury fall on 07/23/25. On 07/23/25, R29's plan added a call before you fall sign posted at her bedside to prevent further falls. On 08/04/25 at 09:20 AM, R29 sat in her recliner and ate her breakfast. She stated she had a recent fall due to her attempting to take herself to the restroom. She stated she fell backwards onto the bed as she attempted to stand up. An inspection of R29's bed and room revealed no signage posted to call staff. R29 reported she's never seen signs in her room alerting her to call staff. On 08/04/25 at 11:50 AM, R29 sat in her room and watched television. An inspection of her room revealed no signage posted to alert staff to call them for assistance. On 08/06/25 at 12:23 PM, Certified Nurse's Aide (CNA) M stated R29's signage should be posted next to her bed in a visible area. On 08/06/25 at 12:45 PM, Licensed Nurse (LN) G indicated the call before you fall signs were posted next to the bed to prevent residents from attempting to self-transfer. She stated staff were expected to ensure the signage was in place and remind the residents to call for assistance. On 08/06/25 at 01:04 PM, Administrative Nurse D stated the signs were placed with bright colors next to the bed to encourage residents to call before attempting to transfer or complete their own ADLs. She stated staff were expected to ensure the signage was in place each shift. The facility's Fall Management System policy, revised 06/2018, stated the facility would ensure a safe environment for all residents. The policy indicated staff would assess each resident's potential risks, including functional abilities, potential falls, assistive devices, and environment, to ensure resident safety. The policy noted interventions were implemented based on each resident's needs to minimize complications.

The facility reported a census of 64 residents. The facility identified two medication carts and two treatment carts. Based on observations, record review, and interviews, the facility failed to secure its two treatment carts. This deficient practice placed the residents at risk for unnecessary medication and administration errors.Findings Included-- On 08/04/25 at 07:00 AM, an initial walkthrough of the facility was completed. An inspection of the Hallbrook unit revealed an unlocked treatment cart in the back nurses' station. An inspection of the cart revealed medical ointments and wound cleansers. An inspection of the Bridgewood unit revealed an unlocked treatment cart in the hallway. An inspection of the cart revealed medical ointments and wound cleansers. On 08/05/25 at 01:23 PM, an inspection of the medication storage room on the Hallbrook unit was completed. An inspection of the medication storage refrigerator revealed two vials of tuberculin serum. One vial was opened and lacked dates related to its opening and expiration. The second vial was opened on 05/30/25 and had passed the 30-day expiration date. On 08/06/25 at 12:45 PM, Licensed Nurse (LN) G stated the treatment carts were to be locked when not in use. On 08/06/25 at 01:04 PM, Administrative Nurse D staff were expected to secure the carts and patient information when stepping away from the carts. The facility's Medication Access and Storage policy, revised 10/2023, indicated the facility was to ensure all medications and biologicals remained locked and secured to prevent tampering or exposure to the environment.

The facility identified a census of 64 residents. The facility identified 14 residents on Enhanced Barrier Precautions (EBP- infection control interventions designed to reduce transmission of resistant organisms that employ targeted gown and glove use during high contact care). Based on record reviews, observations, and interviews, the facility failed to store linens in a sanitary manner, the facility further failed to ensure dirty linens were not placed on the floor, and the facility further failed to ensure a barrier was placed on the countertop, before Accu-check (blood glucose monitoring test) monitor was laid on counter. The facility additionally failed to store Resident (R) 3 and R42's respiratory equipment in a sanitary manner. These deficient practices placed the residents at risk for infectious diseases. Findings included: - On 08/04/25 at 07:05 AM, a walkthrough of the facility was completed.On 08/04/25 at 07:28 AM, towels, washcloths, and a bed sheet were laid on top of R42's Personal Protective Equipment (PPE) cart in the hallway. On 08/04/25 at 01:18 PM, R3 sat in his room talking on his phone. R3's nebulizer mask laid on his bedside table. R3's nebulizer mask was not stored in a sanitary manner.On 08/05/25 at 11:25 AM, soiled linen was on the floor of R75's room.On 08/05/25 at 11:32 AM, Licensed Nurse (LN) I removed the blood glucose machine from the medication cart and placed the machine directly onto the medication cart. LN G picked the machine from the medication cart, then walked into the shower room and placed the machine directly onto the counter by the sink. LN G donned gloves picked the glucose machine from the counter and then placed the machine onto the arm of an empty Broda chair (specialized wheelchair with the ability to tilt and recline). LN G then picked the glucose machine from the arm of the Broda chair, obtained the blood sugar, and then placed the glucose machine directly onto the medication cart and the Accu-Chek monitor should always have a barrier placed.On 08/05/25 at 12:28 PM, R42's nasal oxygen tubing laid on top of her cannister in her room. The nasal cannula was thrown on top of the canister and was at the bottom of R42's bed. On 08/06/25 at 12:14 PM, Certified Nurse's Aide (CNA) M stated all oxygen tubing and nebulizer mask equipment should be stored in a clean plastic bag to prevent contamination and respiratory infections. She stated clean linens should not be placed outside a resident's room, and dirty laundry should never be left on a resident's floor.On 08/06/25 at 12:39 PM, Licensed Nurse (LN) I stated nurses should always place a barrier before setting down an Accu-Check machine. She stated oxygen therapy tubing and nebulizer mask should be placed in a dated plastic bag, due to contamination. LN I stated clean linens should not be placed on a resident's PPE cart. She stated linens should be taken into the residents' rooms. LN I stated dirty laundry should be bagged and taken out of the resident's room and never laid on the resident's floor.On 08/06/25 at 01:13 PM, Administrative Nurse D stated that Accu-Check machines should have a clean barrier placed before setting the machine down. She stated nasal cannulas and nebulizer masks should be placed in a dated plastic bag when not in use. Administrative Nurse D stated that clean linens should not be placed on a PPE cart, and dirty linens should never be laid on a resident's floor.The facility's Infection Control policy dated 03/24 documented it was the policy of the facility to implement infection control measures to prevent the spread of communicable diseases and conditions. In long-term care, it was appropriate to make idealized decisions regarding resident placement, balancing infection risks with the need for more than one occupant in the room, the presence of risk factors that increase the likelihood of transmission, and the potential for adverse psychological impact on the infected or colonized resident.

The facility identified a census of 64 residents. The sample included 16 residents, with five residents reviewed for immunization status. Based on record reviews and interviews, the facility failed to obtain consent or declinations for the Pneumococcal Conjugate Vaccine (PCV20- vaccination for bacterial infections), pneumococcal (type of bacterial infection) vaccination for Resident (R) 12 and R75. This placed the residents at increased risk for complications related to pneumonia.Findings included:- Review of R12's clinical record revealed a declination for PCV13 and PPSV23. The clinical record lacked documentation the PCV20 was offered or declined, and lacked documentation of a historical administration. Review of R75's clinical record revealed the PPSV23 was administered on 09/14/18, and PCV13 was administered on 09/13/19. R75's clinical record lacked documentation the PCV20 was offered or declined, and lacked documentation of a historical administration. On 08/06/25 at 01:13 AM, Administrative Nurse D stated she was unsure what immunizations were offered. She stated she was not sure if the facility offered the PCV20. The facility did not provide a policy for immunizations.

The facility identified a census of 64 residents. The sample included 16 residents, with two reviewed for reasonable accommodation of needs related to assistive devices. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 51 had a way to communicate her needs due to her call light being left out of reach. This deficient practice placed the R51 at risk for preventable accidents and injuries. Findings Included:- The Medical Diagnosis section within R51's Electronic Medical Records (EMR) included diagnoses of muscle weakness, overactive bladder, need for assistance with personal care, history of falling, and cognitive communication disorder (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness). R51's Quarterly Minimum Data Set (MDS) completed 04/08/25 noted a Brief Interview for Mental Status (BIMS) score of six, indicating mild cognitive impairment. The MDS noted she required substantial to maximal assistance for transfer, bathing, toileting, bed mobility, dressing, and personal hygiene. The MDS noted she had no falls. R51's Fall Care Area Assessment (CAA) completed 04/07/25 indicated she was at risk for a decline in her activities of daily living (ADL) related to her medical diagnoses. The CAA noted she will work with therapy services on strength training and provide interventions to minimize the risk related to her decline in ADL and potential falls. R51's Care Plan initiated on 02/25/25 indicated she was at risk for falls and a deficit of her ADLs related to her medical diagnoses. The plan indicated she required substantial to maximal assistance from staff for transfers, toileting, bathing, personal hygiene, dressing, and bed mobility. The plan noted she had a history of falls and instructed staff to ensure her call light was within reach. The plan instructed staff to ensure she had a Dycem (a nonslip mat placed to prevent sliding in her wheelchair and maintain a clear path in her room. The plan noted she required two staff members for transfer assistance. The plan instructed staff to ensure her call light remained within reach while in her room. On 08/04/25 at 07:05 AM, R51 slept in her bed. R51's soft-touch call light was located on top of her bedside table. R51's bedside table was across the room next to her recliner and out of her reach. On 08/04/25 at 08:15 AM, R51 remained asleep in her bed. R51's soft-touch call light remained on her bedside table next to her recliner. On 08/06/25 at 12:23 PM, Certified Nurse's Aide (CNA) M stated call lights were to be placed within reach or clipped onto the resident's clothing. On 08/06/25 at 12:45 PM, Licensed Nurse (LN) G stated staff were expected to ensure the call light remained within reach during each interaction. On 08/06/25 at 01:04 PM, Administrative Nurse D stated staff were expected to check the call light placement each shift and ensure the residents had access to the lights if they needed assistance. The facility's Fall Management System dated 06/2018 indicated the facility promoted an environment that remains free from accident hazards. The policy indicated that the facility assessed and provided the appropriate equipment to ensure resident safety. The policy indicated the facility appropriately assessed and implemented interventions to prevent falls and minimize complications if falls occurred.

The facility identified a census of 64 residents. The sample included 16 residents, with two residents reviewed for hospitalization. Based on observation, record review, and interviews, the facility failed to provide a final summary of the resident's status at discharge for Resident (R) 6. This deficient practice placed R6 at risk of delayed care or uncommunicated care needs.Findings included:- R6's Electronic Medical Records (EMR) documented diagnoses infection and inflammatory reaction due to internal right knee prosthesis (an artificial body part), Methicillin-Resistant Staphylococcus Aureus (MRSA- a type of bacteria resistant to many antibiotics), pain, need for assistance with personal care, age related cognitive decline (related to the mental process), major depressive disorder (major mood disorder that causes persistent feelings of sadness), and dysphagia (swallowing difficulty). R6's Admissions Minimum Data Set (MDS) completed 07/13/25 noted a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. The MDS documented she had an impairment of her lower extremity. The MDS documented R6 needed setup or cleanup assistance with eating and oral hygiene. The MDS documented R6 was dependent on staff for toileting.R6's Functional Abilities (Self-Care Mobility) Care Area Assessment (CAA), dated 07/13/25, documented R6 had a reduction in activities of daily living (ADL), and she needed increased staff assistance with ADLs, which included transfers, bed mobility, toileting, and hygiene. The CAA documented R6 continued with skilled services to regain strength and return to the highest functioning level. R6's goal was to return home. The CAA for R6 documented the risk factors, including further ADL decline, falls, incontinence, skin breakdown, and pain. The care plan would be initiated and reviewed to improve or maintain current ADL status and functional ability, maintain or improve continence status, decrease pain, decrease falls, and pressure ulcer risk.R6's EMR recorded a Discharge Assessment-Return Not Anticipated MDS documenting R6's discharge date d 07/14/25.R6's Care Plan, revised 08/01/25, documented that the facility would establish a pre-discharge plan with R6 and her family and caregivers, and evaluate progress and revise the plan as needed.R6's EMR under Progress Notes revealed a Nursing Note completed on 07/14/25, documenting R6's husband was in the facility, stated he was going to pack R6's belongings, and take her home. Nursing explained to R6's guardian the facility was waiting for labs for her wound. R6's guardian stated he was taking R6 home. Nursing called the physician to inform him of R6's discharge from the facility.R6's medical record lacked documentation showing recompilation of her stay in the facility.On 08/06/25 at 12:39 PM, Licensed Nurse (LN) I stated it was the responsibility of the nurse in charge on the day the resident was discharged to do a summary of the resident's stay. She stated this would include how the facility cared for the resident, medications, and follow-up appointments.On 08/06/25 at 01:13 PM, Administrative Nurse D stated it was the charge nurse's duty to ensure a recompilation of stay was documented. She stated if the charge nurse did not document the resident's stay, it was the director of nursing's responsibility.The facility's Discharge policy dated 05/17 documented it was the policy of this facility to set forth the circumstances and conditions under which the facility could require the resident to be involuntarily transferred, discharged , or evicted.

The facility identified a census of 64 residents. The sample included 16 residents, with 16 reviewed for care planning. Based on observation, record review, and interviews, the facility failed to identify the level of care assistance needed for activities of daily living (ADL) on Resident (R) 54's care plan. This deficient practice placed R54 at risk for ineffective treatment and preventable accidents.Findings Included: - The Medical Diagnosis section within R54's Electronic Medical Records (EMR) included diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), cognitive communication disorder (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness), need for assistance with personal care, muscle weakness, and diabetes mellitus (DM- when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin).R54's Quarterly Minimum Data Set (MDS) completed 01/07/25 noted a Brief Interview for Mental Status (BIMS) score of 12, indicating mild cognitive impairment. The MDS noted no upper or lower extremity impairments. The MDS noted she required partial to moderate assistance for lower body dressing, footwear, bathing, toileting, and oral hygiene. The MDS noted she required supervision or touch assistance with upper body dressing, personal hygiene, bed mobility, and walking. R54's Functional Abilities Care Area Assessment (CAA) completed 06/16/25 indicated she needed assistance from staff for her ADLs and self-care related to her medical diagnoses. R54's Care Plan initiated on 11/15/24 indicated she was at risk for an ADL deficit related to her medical diagnoses. The plan noted she would maintain her current level of function in bed mobility, transfers, eating, dressing, grooming, toileting, and personal hygiene. The plan noted she preferred assistance with personal hygiene and instructed staff to wash her hair with her showers. The plan lacked documentation showing R54's level of functioning and the required level of assistance needed to complete bathing, transfers, dressing, oral hygiene, meals, and bed mobility. On 08/04/25 at 08:05 AM, R54 walked from the hallway to the dining area with her walker. R54 sat down at the dining room table and prepared herself for breakfast. R54 reported no issues or concerns related to her care. R54 was clean and well-groomed. On 08/06/25 at 12:23 PM, Certified Nurse's Aide (CNA) M stated the care plans needed to include the resident's current level of functioning and assistance needed. She stated the Kardex should also include this information. On 08/06/25 at 12:45 PM, Licensed Nurse (LN) G stated care plans were updated to reflect each resident's level of functioning and assistance needed. On 08/06/25 at 01:04 PM, Administrative Nurse D stated the care plan should identify each resident's required level of functioning and assistance needed. She stated that the interdisciplinary team meets each week to review the plans and update them with changes. The facility's Comprehensive Person-Centered Planning policy, revised 08/2017, indicated each resident was to have a comprehensive assessment and provided individualized interventions to reflect their treatment needs. The policy indicated care plans were reviewed and updated to reflect changes that may occur with the resident's goals and care needs.

The facility identified a census of 64 residents. The sample included 16 residents, with one resident reviewed for quality of care. Based on observation, record review, and interviews, the facility failed to ensure the physician's order was followed for a daily weight for R5 to monitor for congestive heart failure (CHF - a condition with low heart output and the body becomes congested with fluid). This deficient practice placed R5 at risk of delayed treatment and untreated illness.Findings included:- R5's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of overactive bladder, pain, congestive heart failure (CHF- a condition with low heart output and the body becomes congested with fluid), dementia (a progressive mental disorder characterized by failing memory and confusion), cellulitis (a common bacterial infection of the skin and underlying tissues) of right lower limb, lack of coordination, communication deficit, need for assistance with personal car, closed fracture with routine healing, and Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness).The admission Minimum Data Set (MDS) dated 07/15/25 documented a Brief Interview of Mental Status (BIMS) score of 13, which indicated intact cognition. The MDS documented R5 had received diuretic (a medication to promote the formation and excretion of urine) medication during the observation period. R5's Psychotropic Drug Use Care Area Assessment (CAA) dated 07/18/25 documented a licensed nurse would monitor for adverse effects of R5's medication every shift.R5's Care Plan, dated 07/18/25, documented nursing staff would administer medications as ordered. The plan of care documented the nursing staff would monitor for side effects and document the effectiveness.R5‘s EMR under the Orders tab revealed the following physician orders: Lasix (diuretic) oral tablet 20 milligram (mg) (Furosemide) give one tablet by mouth one time a day every Tuesday, Thursday, and Saturday for edema, dated 07/09/25.Daily weight for the next three days, dated 07/09/25. Weekly weights every seven days, dated 07/09/25.Review of R5's July 2025 Medication Administration Record (MAR), Treatment Administration Record (TAR), and the Weights/Vital Signs tab lacked evidence of documentation of daily weights for 07/10/25, 07/11/25, and 07/12/25. R5's EMR also lacked evidence of weekly weights for 07/17/25 and 07/31/25. On 08/05/25 at 02:12 PM, R5 sat on her wheelchair in her room, as she listened to her book on her tablet. R5 stated she walked 75 feet with therapy.On 08/06/25 at 12:14 PM, Certified Nurse Aide (CNA) M stated everyone worked to obtain the resident's weights as ordered. CNA M stated the charge nurse would let the staff know every day which residents needed to be weighed that day. CNA M stated she would let the charge nurse know the weight after she obtained the weight.On 08/06/25 at 12:40 PM, Licensed Nurse (LN) I stated the nurse was the person responsible to ensure a physician's order was followed. LN I stated if the physician had ordered a resident to be weighed daily or weekly that order would be placed on the MAR or TAR to prompt the nurse to ensure the weight was obtained and documented in the resident's EMR. On 08/06/25 at 01:14 PM, Administrative Nurse D stated the charge nurse was responsible for ensuring the physician's orders were followed. Administrative Nurse D stated the physician order for daily or weekly weights would be placed on the MAR or TAR to prompt the nurse to obtain the weight as ordered.The facility's Quality of Care policy, revised on 01/25/25, documented based on comprehensive assessments. The facility would ensure that residents receive treatment and care by qualified persons in accordance with professional standards of practice, the comprehensive person-centered care plans, and the residents' choices.

The facility identified a census of 64 residents. The sample included 16 residents, with five residents reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, because of pressure, or pressure in combination with shear and/or friction). Based on observation, record review, and interviews, the facility failed to ensure pressure-reducing devices were in place for Resident (R) 12, who was at risk for the development of pressure ulcers. This deficient practice placed R12 at risk for complications related to skin breakdown.Findings included:- R12's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of difficulty walking, dementia (a progressive mental disorder characterized by failing memory and confusion), lack of coordination, muscle weakness, and need for assistance with personal care.The admission Minimum Data Set (MDS) dated 04/22/25 documented a Brief Interview of Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS documented R12 was at risk for the development of pressure-related injuries. The Quarterly MDS dated [DATE] documented a BIMS score of 10, which indicated moderately impaired cognition. The MDS documented that R12 was at risk for the development of pressure-related injuries.R12's Pressure Ulcer Care Area Assessment (CAA), dated 05/10/25, documented he was at risk for the development of pressure ulcers related to his incontinence and impaired mobility. R12's Care Plan, dated 04/16/25, documented R12 required monitoring, reminding, and assistance for turning and repositioning.R12‘s EMR under the Orders tab revealed the following physician orders: Cushion to wheelchair, dated 06/05/25.On 08/04/25 at 12:06 PM, R12 laid on his bed. R12's wheelchair was next to the bed and lacked a cushion. R12 stated he used the wheelchair frequently.On 08/05/25 at 01:58 PM, R12 laid on his bed with the wheelchair next to the bed. R12's wheelchair lacked a cushion, and no cushion was seen in the room.On 08/06/25 at 12:14 PM, Certified Nurse Aide (CNA) M stated the therapy department would do staff education for each resident on any pressure-reducing devices for any new resident. CNA M stated it was everyone's responsibility to ensure any pressure-reducing devices for all the residents were in place. CNA M stated the pressure-reducing devices should be listed on the resident's individualized care plan or on their Kardex (a nursing tool that gives a brief overview of the care needs of each resident). CNA M stated she was not sure if every resident who was in a wheelchair required a pressure-reducing device on the chair.On 08/06/25 at 12:40 PM, Licensed Nurse (LN) I stated the nurse would be the person who would be responsible for ensuring pressure-reducing devices were in place. LN I stated everyone was to assist with ensuring pressure-reducing services were in place. LN I stated that every resident who used a wheelchair for mobility should have a pressure-reducing device. LN I stated the resident's pressure-reducing devices should be listed on the resident's individualized care plan or on their Kardex. On 08/06/25 at 01:14 PM, Administrative Nurse D stated that all staff were responsible for ensuring the resident's pressure-reducing devices were in place. Administrative Nurse D stated she would expect the resident's pressure-reducing devices to be listed on their care plans.The facility's Pressure Injury Prevention policy, last revised on 03/2022, documented the purpose of the policy was to provide for early detection and intervention of all breakdowns evident upon admission to the facility. To maintain the integrity of the residents' skin, a significant factor in health. To minimize the risks and prevent the occurrence of skin breakdown. To promote prompt evaluation and intervention of any changes in skin integrity during the facility stay. For individuals restricted to a chair was to use pressure-reducing devices for seating surfaces.

The facility identified a census of 64 residents. The sample included 15 residents, with one resident reviewed for respiratory care. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 3's nebulizer (a device that changes liquid medication into a mist easily inhaled into the lungs) mask was stored in a sanitary manner. This placed R3 at an increased risk for respiratory infection and complications. Findings included:- R3's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of hypertension (HTN- elevated blood pressure), benign prostatic hyperplasia (urinary frequency, urgency, a weak or intermittent stream, needing to strain, a sense of incomplete emptying, and nocturia (frequent urination at night), acquired absence of right leg below the knee, acquired absence of left leg below the knee, peripheral vascular disease (a circulatory disorder where narrowed or blocked blood vessels reduce blood flow to the limbs, affection the arms, hands and limbs), colostomy (surgical creation of an artificial opening on the stomach wall to excrete feces from the body), communication deficit, muscle weakness, need for assistance with personal care, unsteadiness on feet, and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear).The Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 13, which indicated intact cognition. The MDS documented R3 needed setup and clean-up assistance from staff for eating and oral care. The MDS documented R3 was dependent on staff for toileting and showers, and needed substantial/maximal assistance with dressing.R3's Functional Abilities (Self-Care Mobility) Care Area Assessment (CAA) dated 03/29/25 documented R3 had a reduction in activities of daily living (ADL); he needs increased staff assistance with ADLs, including transfers, bed mobility, toileting, and hygiene. Staff assist with ADLs and encourage guests to fully participate.R3's Care Plan dated 02/17/23 documented R3 had a risk for alteration in comfort, and staff were to monitor and report any signs to nursing. R3's care plan lacked an indication for a nebulizer and the storage of a nebulizer mask.R3‘s EMR under the Orders tab revealed the following physician order:Ipratropium-Albuterol solution 0.5-2.5 milligram (mg) per 3milliliters (ml), inhale orally three times a day for wheezing, dated 07/31/25.On 08/04/25 at 08:23 AM, R3 sat in his room, and his nebulizer mask was sitting on his bedside table. The nebulizer mask was not stored in a sanitary manner.On 08/04/25 at 01:18 PM, he sat in his room talking on his phone. R3's nebulizer mask laid on his bedside table. R3's nebulizer mask was not stored in a sanitary manner.On 08/06/25 at 12:14 PM, Certified Nurse's Aide (CNA) M stated the nebulizer mask was rinsed, air dried, and then placed in a bag with the date on the bag.On 08/06/25 at 12:39 PM, Licensed Nurse (LN) I stated that nebulizer masks were washed and placed in a plastic bag. LN I stated that anyone from nursing can put the mask in a bag to store when not in use.On 08/06/25 at 01:13 PM, Administrative Nurse D stated nebulizer masks were to be placed in a plastic bag with the date on the bag. She stated nebulizer mask should not be left on the bedside table.The facility did not provide a policy for the storage of a nebulizer mask.

The facility identified a census of 64 residents. The sample included 16 residents. Based on observation, record review, and interviews, the facility failed to ensure physician-ordered laboratory test results for Resident (R) 42, R5, and R75 were included in the clinical record. This deficient practice could result in unnecessary tests and delayed treatment.Findings included:- R5's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of Overactive bladder, pain, congestive heart failure (CHF- a condition with low heart output and the body becomes congested with fluid), dementia (a progressive mental disorder characterized by failing memory and confusion), cellulitis (a common bacterial infection of the skin and underlying tissues) of right lower limb, lack of coordination, communication deficit, need for assistance with personal car, closed fracture with routine healing, and Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness.The admission Minimum Data Set (MDS) dated 07/15/25 documented a Brief Interview of Mental Status (BIMS) score of 13, which indicated intact cognition. The MDS documented R5 had received diuretic (a medication to promote the formation and excretion of urine) medication during the observation period. R5's Psychotropic Drug Use Care Area Assessment (CAA) dated 07/18/25 documented a licensed nurse would monitor for adverse effects of R5's medication every shift.R5's Care Plan, dated 07/17/25, documented a complete blood count (CBC- laboratory blood test) and complete metabolic panel (CMP- laboratory blood test) would be obtained weekly. R5‘s EMR under the Orders tab revealed the following physician orders:CBC and CMP weekly, dated 07/09/25. Review of R5's clinical record lacked evidence of the results of the physician-ordered laboratory tests. The facility was not able to provide a copy of the results dated 07/16/25 and 07/30/25.On 08/05/2025 at 02:12 PM, R5 sat on her wheelchair in her room, as she listened to her book on her tablet. R5 stated she walked 75 feet with therapy.On 08/06/25 at 12:40 PM, Licensed Nurse (LN) I stated the physician would order the laboratory tests, and then the nurse would verify the orders. LN I stated that the lab order would be entered into the laboratory provided system to be obtained as ordered. LN I stated the results would be printed and reviewed by the physician. LN I stated the physician would initial and date the results when reviewed, and signed results would be placed in the folder to be scanned into the resident's EMR.On 08/06/25 at 01:14 PM, Administrative Nurse D stated the physician ordered laboratory orders would be entered into the laboratory provider's system to be obtained as ordered. Administrative Nurse D stated the order would be placed on the Medication Administration Record or the Treatment Administration Record. Administrative Nurse D stated the results should be printed, then reviewed by the physician, and placed in the folder to be scanned into the resident's EMR. Administrative Nurse D stated the lab results should be scanned into the resident's EMR within 24 to 48 hours after being reviewed by the physician. The facility's Laboratory, Radiology, Other Diagnostic Services policy last reviewed 01/2025 documented it was the policy of the facility to obtain laboratory and radiology services when ordered by a Physician, Physician Assistant (PA), Nurse Practitioner (NP), or Clinical Nurse Specialist (CNS) and to promptly notify the ordering provider of test results. Laboratory and radiology services would be arranged as ordered. Results of laboratory, radiological, and diagnostic tests outside the clinical reference ranges would be promptly reported to the resident's attending physician, PA, NP, or CNS, or as specified in the order. Notification of test results would be documented in the resident's clinical record. Results of lab, radiology, and diagnostic services would be made a part of the resident's medical record.- R42's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of venous thrombosis (a clot that develops within a blood vessel), embolism (an obstruction in a blood vessel due to a blood clot or other foreign matter that gets stuck while traveling through the bloodstream), and dementia (a progressive mental disorder characterized by failing memory and confusion).The admission Minimum Data Set (MDS) dated 07/23/25 documented a Brief Interview of Mental Status (BIMS) score of 12, which indicated moderately impaired cognition.R42's Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) dated 07/28/25 documented she had a decline in activities of daily living and required an increase in staff assistance. R42's Care Plan, last revised on 08/.04/25 documented labs would be obtained as ordered by the physician. The plan of care documented the staff would report any abnormal lab results to the physician. The plan of care documented the nursing staff would obtain R42's international normalized ratio (INR) (laboratory blood test to check for blood clotting time) on Monday and Thursday.R42‘s EMR under the Orders tab revealed the following physician orders:Warfarin sodium (anticoagulant - a class of medications used to prevent the blood from clotting) oral tablet five milligram (mg) give one tablet by mouth at bedtime for embolism, dated 07/31/25.Review of R42's clinical record lacked evidence of the results of the physician-ordered laboratory tests. The facility was able to provide a copy of the results dated 07/28/25 and 07/31/25. On 08/05/2025 at 01:58 PM, R42 laid on her bed with the head of her bed elevated as she watched TV. R42 stated she was happy to be out of isolation. On 08/06/25 at 12:40 PM, Licensed Nurse (LN) I stated the physician would order the laboratory tests, and then the nurse would verify the orders. LN I stated that the lab order would be entered into the laboratory provided system to be obtained as ordered. LN I stated the results would be printed and reviewed by the physician. LN I stated the physician would initial and date the results when reviewed, and signed results would be placed in the folder to be scanned into the resident's EMR.On 08/06/25 at 01:14 PM, Administrative Nurse D stated the physician ordered laboratory orders would be entered into the laboratory provider's system to be obtained as ordered. Administrative Nurse D stated the order would be placed on the Medication Administration Record or the Treatment Administration Record. Administrative Nurse D stated the results should be printed, then reviewed by the physician, and placed in the folder to be scanned into the resident's EMR. Administrative Nurse D stated the lab results should be scanned into the resident's EMR within 24 to 48 hours after being reviewed by the physician. The facility's Laboratory, Radiology, Other Diagnostic Services policy last reviewed 01/2025 documented it was the policy of the facility to obtain laboratory and radiology services when ordered by a Physician, Physician Assistant (PA), Nurse Practitioner (NP), or Clinical Nurse Specialist (CNS) and to promptly notify the ordering provider of test results. Laboratory and radiology services would be arranged as ordered. Results of laboratory, radiological, and diagnostic tests outside the clinical reference ranges would be promptly reported to the resident's attending physician, PA, NP, or CNS or as specified in the order. Notification of test results would be documented in the resident's clinical record. Results of lab, radiology, and diagnostic services would be made a part of the resident's medical record.- R75's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of anemia (an inadequate number of healthy red blood cells to carry adequate oxygen to body tissues), fracture of left femur, hypertension (high blood pressure), congestive heart failure (CHF- a condition with low heart output and the body becomes congested with fluid), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), heart failure, and dysphagia (swallowing difficulty). The admission Minimum Data Set (MDS) dated 06/05/25 documented a Brief Interview of Mental Status (BIMS) score of five, which indicated severely impaired cognition. The MDS documented R75 had heart failure and CHF.R75's Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) dated 06/06/25 documented she required staff assistance with her activities of daily living.R75's Care Plan, dated 06/16/25, documented the nursing staff would administer as ordered. The plan of care documented the nursing staff would monitor and document any adverse effects or side effects. R75‘s EMR under the Orders tab revealed the following physician orders:Complete blood count (CBC- laboratory blood test) and complete metabolic panel (CMP-laboratory blood test) weekly on Wednesday, dated 06/02/25.Review of R75's clinical record lacked evidence of the results of the physician-ordered laboratory tests for 06/04/25, 06/11/25, 06/18/25, 06/25/25, 07/02/25, 07/09/25, 07/16/25, and 07/30/25. The facility was able to provide a copy of the results dated 06/25/25, 07/02/25, 07/09/25, 07/16/25, and 07/30/25. The facility was unable to provide results for the following dates: 06/04/25, 06/11/25, and 06/18/25. On 08/05/25 at 01:58 PM, R75 laid awake on her bed. R75 stated she was okay and did not need anything at that time.On 08/06/25 at 12:40 PM, Licensed Nurse (LN) I stated the physician would order the laboratory tests, and then the nurse would verify the orders. LN I stated that the lab order would be entered into the laboratory provided system to be obtained as ordered. LN I stated the results would be printed and reviewed by the physician. LN I stated the physician would initial and date the results when reviewed, and signed results would be placed in the folder to be scanned into the resident's EMR.On 08/06/25 at 01:14 PM, Administrative Nurse D stated the physician ordered laboratory orders would be entered into the laboratory provider's system to be obtained as ordered. Administrative Nurse D stated the order would be placed on the Medication Administration Record or the Treatment Administration Record. Administrative Nurse D stated the results should be printed, then reviewed by the physician, and placed in the folder to be scanned into the resident's EMR. Administrative Nurse D stated the lab results should be scanned into the resident's EMR within 24 to 48 hours after being reviewed by the physician. The facility's Laboratory, Radiology, Other Diagnostic Services policy last reviewed 01/2025 documented it was the policy of the facility to obtain laboratory and radiology services when ordered by a Physician, Physician Assistant (PA), Nurse Practitioner (NP), or Clinical Nurse Specialist (CNS) and to promptly notify the ordering provider of test results. Laboratory and radiology services would be arranged as ordered. Results of laboratory, radiological, and diagnostic tests outside the clinical reference ranges would be promptly reported to the resident's attending physician, PA, NP, or CNS, or as specified in the order. Notification of test results would be documented in the resident's clinical record. Results of lab, radiology, and diagnostic services would be made a part of the resident's medical record.

The facility identified a census of 64 residents. The sample included 15 residents, with two residents reviewed for hospice (a type of health care that focuses on the terminally ill patient's pain and symptoms and attending to their emotional and spiritual needs at the end of life) services. Based on observation, record review, and interview, the facility failed to ensure a coordinated plan of care, which coordinated care and services provided by the facility with the care and services provided by hospice, was developed and available for Resident (R) 13. This placed the resident at risk for inappropriate end-of-life care. Findings included:- R13's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of fibromyalgia (condition of musculoskeletal pain, spasms, stiffness, fatigue, and severe sleep disturbance), hypertension (high blood pressure), peripheral vascular disease (a circulatory disorder where narrowed or blocked blood vessels reduce blood flow to the limbs, often affection the arms, hands, legs, and feet), major depressive disorder (major mood disorder that causes persistent feelings of sadness), diabetes mellitus (DM- when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), muscle weakness, senile degeneration of the brain (age-related cognitive decline, including memory loss and other thinking problems), muscle weakness, need for assistance with personal care. The Significant Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of six, which indicated severely impaired cognition. The MDS documented R13 needed set-up or cleanup for oral hygiene, supervision or touching assistance for toileting, and partial to moderate assistance for bathing. The MDS documented R13 was dependent on staff for toileting, bathing, and dressing, and was independent with eating. R13's The Functional Activities (Self-Care Mobility) Care Area Assessment (CAA) dated 06/12/25 documented R13 had a reduction in activities of daily living (ADL); she needs increased staff assistance with ADLs, including transfers, bed mobility, toileting, and hygiene. R13 had risk factors included further ADL decline, falls, incontinence, skin breakdown, and pain. R13's Care Plan dated 06/27/25 documented R13 was admitted to hospice, with staff to maintain R13's comfort. The plan of care documented dignity and autonomy would be maintained. The plan of care documented staff were to encourage R13 to express feelings, listen with non-judgmental acceptance, and compassion. The plan of care documented staff were to keep R13's environment quiet and calm and observe R13 closely for signs of pain; nursing was to administer pain medications as ordered and notify the physician immediately if there is breakthrough pain. The plan of care for R13 documented hospice services would supply her supplies as needed. A review of the hospice-provided communication binder revealed R13 was admitted to hospice services on 06/12/25. On 08/04/25 at 10:14 AM, R13 sat in her chair doing crossword puzzles in her room.On 08/05/25 at 09:50 AM, R13 sat on her bed with her elbows leaning on her bedside table.On 08/06/25 at 12:14 PM, Certified Nursing Aide (CNA) M stated nursing had a notebook at the nurse's station with sheets that were printed every day, which told the CNA's pertinent information about each resident. CNA M stated the hospice providers communicated with the nursing staff, and they know when they are giving showers and what supplies they have brought to the resident. CNA M stated she could also look in the notebook provided by the hospice supplier. She stated she did not think hospice information was in the facility's care plan. On 08/06/25 at 12:39 PM, Licensed Nurse (LN) I stated she communicates with the hospice service provider, which was how she knew when hospice aides would be coming to the building. She stated she could also look in the hospice binder kept at the nurse's station. LN I stated she did not think supplies and when hospice staff would be in the building were in the facility care plan. She stated she thought the care plans should match. On 08/06/25 at 01:13 PM, the Administrator Nurse D stated the facility had good communication with nursing and the CNAs. She stated the nursing staff would know when the hospice provider would be in the building and what supplies the hospice provider brings to the facility through communication and the hospice binder kept at the nurse's desk. She stated there should be collaboration of care, and the care plans for the facility and the care plan provided by hospice should match. The facility's Quality of Care policy dated 07/19 documented it was the policy of the facility to provide end-of-life care for dying residents that emphasizes prevention and relief of symptoms as well as compassionate attention to the resident's dignity and preferences. Through continuing interdisciplinary assessment, individualized plans would be developed and implemented to address the resident's physical, intellectual, emotional, social, spiritual, and practical needs. Support and reassurance for the family and friends close to the resident would be an integral part of the plan.

The facility identified a census of 63 residents. The facility had one main kitchen and two kitchenette serving areas. Based on observation, record review and interview, the facility failed to ensure that dietary staff appropriately dated, labeled, and stored opened foods. This deficient practice had the potential for food borne illnesses for residents. Findings included: - On 11/13/23 at 07:37 AM during the initial tour of the facility's main kitchen observation revealed an opened box of cream of wheat in the dry storage area with a piece of plastic wrap over the top of the box; it was not in a sealed bag/container. There was a bag of spaghetti that was wrapped in plastic wrap that did not have a date on it. On 11/13/23 at 07:40 AM observation of the walk-in refrigerator revealed an open gallon plastic container of hard-boiled eggs. The lid was not closed to the container and there was no label that indicated the open date. There was an opened bag of diced potatoes that was not labeled and/or dated and was not stored in a sealed bag. There was an opened bag of pepperoni in a box that had not been placed in a sealed bag and did not have an open date on it. On 11/13/23 at 07:50 AM Dietary Staff BB stated he did his best to keep everything labeled and dated and in sealed containers, but he was just one person and was not always able to make sure everything was labeled and dated as they should be. On 11/14/23 at 10:30 AM Dietary Staff CC stated she had been working with dietary staff to ensure that they dated and labeled and stored opened items in a sealed container. Dietary Staff CC stated she had been educating staff on the proper storage of foods. The facility policy Food Safety Requirements revised 01/01/23 documented: It is the policy of this facility to procure food from sources approved or considered satisfactory by federal, state, and local authorities. Food will be stored, prepared, distributed, and served in accordance with professional standards for food service safety. Storage of food in a manner that prevents deterioration or contamination of the food, including growth of microorganisms (a living thing that cannot be seen with the naked eye). Facility staff shall inspect all food, food products, and beverages for safe transport and quality upon delivery/receipt and ensure timely and proper storage. Dry food storage - keep foods/beverages in a clean, dry area off the floor and clear of ceiling sprinklers, sewer/waste disposal pipes, and vents. Labeling, dating, and monitoring refrigerated food, including, but not limited to leftovers, so it was used by its use-by date, or frozen/discarded; and keeping foods covered or in a tight container. The facility failed to ensure that dietary staff appropriately dated, labeled, and stored opened foods. This deficient practice had the potential for food borne illnesses for residents.

The facility reported a census of 63. Based on observations, record review, and interviews, the facility failed to adequately address and resolve recurring issues reported by the Resident Council. This deficient practice placed the residents at risk for decreased psychosocial wellbeing and impaired quality of life. Findings Included- - A review of the facility's Resident Council Minutes from 11/2022 through 11/2023 indicated the council had recurring concerns with staff not verifying meal tickets, offering choices, availability of snacks and fruits and vegetables, not taking orders before meal service, and posting the daily menus. Further recurring issues were call light response times. The Resident Council Minutes form instructed any old business that was unresolved be moved to new business. The 11/2022 Resident Council Minutes documented new business (concerns) that meal menus were not displayed, there were no snacks and fruit and/or vegetables were not always available. Further concerns included nursing staff were not asking the residents what they wanted or offering choices, staff were turning off call lights without providing services and lack of staff to attend to call lights during meals. The 12/2022 Resident Council Minutes listed new business concerns included lack of options at mealtimes, and no snacks were available. Further new business concerns included low availability of supplies and lack of restocking of towels and supplies. The minutes lacked actions taken or outcomes for the repeat concerns. The 01/2023 Resident Council Minutes listed new business concerns included lack of options at mealtimes, lack of vegetable variety, cold food and meal tickets. Further new business concerns included nursing staff were not asking the residents what they wanted or offering choices. The minutes lacked actions taken or outcomes for the repeat concerns. The 02/2023 Resident Council Minutes listed new business concerns included fresh fruits and vegetable availability, and small portion sizes. Further new business concerns included nursing staff were not asking the residents what they wanted at meals. The minutes lacked actions taken or outcomes for the repeat concerns. The 04/2023 Resident Council Minutes lacked documentation of concerns on the form but included a handwritten page which listed topics under Dietary heading including double portion not consistent and under Nursing call light times/issues. The minutes lacked actions taken or outcomes for the repeat concerns. The 05/2023 Resident Council Minutes listed new business concerns included meal tickets again. Further new business concerns included nursing staff were not asking the residents what they wanted at meals and call light times. The minutes lacked actions taken or outcomes for the repeat concerns. The 06/2023 Resident Council Minutes listed new business concerns the lack of fresh fruit and problems with snack availability again. Further new business concerns included call light times. Notes under appreciation listed the food was getting better. The minutes lacked actions taken or outcomes for the repeat concerns. The 07/2023 Resident Council Minutes listed new business concerns included snacks not available/stocked, no stocking of supplies such as napkins and utensils in kitchenette, and no fresh fruit again. Further new business concerns included nursing staff were not asking the residents what they wanted at meals, food trays were served late, and staff would say be right back and not return and poor call light times again. The minutes did record action taken was to stock the kitchenette with sandwiches and snacks. The issue was marked as resolved. Further actions included management staff would be dining rooms for lunch and dinner meals and staff were educated on mealtimes. Call light times were reviewed. The concerns were marked as resolved. The 08/2023 Resident Council Minutes listed new business concerns which included running out of food and nursing staff were still not asking residents regarding meal preferences. Further new business concerns included call light times again. The minutes listed actions taken were the facility made a large back stock order and provided staff education. No outcomes were indicated for the repeat concerns. The 09/2023 Resident Council Minutes listed new business concerns which included poor availability of utensils, fresh fruit items, The minutes listed actions taken were the facility would prep and order more options and would stock the kitchenettes for late night snacks. No outcomes were indicated for the repeat concerns. The 10/2023 Resident Council Minutes listed new business concerns which included inconsistent portion seizes, meal ticket issues, and poorly stocked kitchenettes. The minutes listed actions taken were the facility restocked the kitchenette and provided staff education on portion size. No outcomes were indicated for the repeat concerns. The 11/2023 Resident Council Minutes listed new business concerns which included cold food and meal ticket issues again. Further new business concerns included nursing staff were not asking the residents what they wanted at meals. The minutes lacked actions taken or outcomes for the repeat concerns. On 11/15/22 at 11:43AM the Resident Council reported the facility continually struggled to ensure meal tickets were followed. The council reported the facility provided staff education, but the meal tickets were still not matching what was ordered or requested. The council reported staff were not verifying the meals choices with all the residents before meal service and the menu boards were not updated daily. The council reported concerns with only one hallway's meal preferences being checked but the other hallway being ignored. The council reported concerns with the timing of meals and portion sizes being inconsistent. On 11/16/23 at 08:05AM R26 sat in her room and stated she was waiting on breakfast to arrive. At 08:10AM Certified Nurse's Aide (CNA) N entered the room with R26's meal tray. CNA N brought R26's plate to her bedside table and stated it was biscuits and gravy. R26 immediately refused the plate. An inspection of the plate revealed the gravy had pepper sausage. CNA N stated all the resident received the same meals for breakfast. An inspection of the meal ticket revealed the sausage gravy was scratched out. CNA N confirmed the sausage-based gravy was on the plate. R26 stated staff did not asked her about her meals choices before serving her biscuits and gravy. On 11/16/23 at 01:12PM Dietary Staff BB stated the facility was still improving at ticket verification and the staff should be asking the residents their food choices before each meal service and review the tickets for accuracy of the food served. He stated the daily menu were posted in both dining areas daily for the residents to review. On 11/16/23 at 02:26PM Activities Staff Z stated she helped the council arrange meeting each month and reported concerns to the responsible department. She stated each concern should have a prompt response from staff and be resolved as quickly as possible. A review of the facility's Resident Rights policy revised 01/2023 indicated the facility will make prompt efforts to address grievances or reported concerns by the residents. The policy indicated the residents have the rights to receive care and services based upon the needs and preferences of the residents. The facility failed to adequately address and resolve recurring issues reported by the Resident Council. This deficient practice placed the residents at risk for decreased psychosocial wellbeing and impaired quality of life.

The facility identified a census of 63 residents. The sample included 17 residents with two reviewed for grievances. Based on observation, record review, and interviews, the facility failed to adequately resolve Resident (R)26's grievances related to her ongoing dietary concerns. This deficient practice placed R26 at risk for decreased psychosocial wellbeing. Findings Included: - The Medical Diagnosis section within R26s Electronic Medical Records (EMR) included diagnoses of quadriplegia (inability to move the arms, legs and trunk of the body below the level of an associated injury to the spinal cord), major depressive disorder (major mood disorder), muscle weakness, abnormal posture, and multiple sclerosis (MS- progressive disease of the nerve fibers of the brain and spinal cord). R26's Quarterly Minimum Data Set (MDS) dated [DATE] noted a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The MDS noted she required set-up assistance from meals. The MDS noted no weight loss or swallowing disorders. R26's Nutritional Care Area Assessment (CAA) completed 01/26/23 indicated she was at risk for weight loss due to her medical diagnoses. The CAA indicated she required staff assistance with most of her activities of daily living (ADLs) including meal set-up. The CAA encouraged staff to provide assistance with meals when needed. R26's Care Plan initiated 01/20/21 noted she was at risk for an alteration in nutrition related to her medical diagnoses. The plan instructed staff to encourage and reinforce the importance of maintaining her ordered diet. The plan indicated she was able to feed herself. The plan indicated she was on a regular diet but directed no pork (01/20/21). R26's Physician's Orders revealed a dietary order dated 02/02/21 R26 was served a regular textured diet with thin liquids. The order specified no pork. A review of the facility's Grievance Logs indicated R26 had one grievance filed 07/06/23 related to her dietary concerns. The grievance log indicated Dietary Staff BB had resolved the grievance. The facility was unable to provide the grievance form related to the grievance for 07/06/23. On 11/15/23 at 11:05AM R26 stated she had complained to the facility and staff multiple times related to the facility serving her pork during mealtimes. She stated she voiced grievances month prior, but they continue to serve her pork. On 11/16/23 at 08:05AM R26 sat in her room and stated she was waiting on breakfast to arrive. At 08:10AM Certified Nurse's Aide (CNA) N entered the room with R26's meal tray. CNA N brought R26's plate to her bedside table and stated it was biscuits and gravy. R26 immediately refused the plate. An inspection of the plate revealed the gravy had pepper sausage. CNA N stated all the resident received the same meals for breakfast. An inspection of the meal ticket revealed the sausage gravy was scratched out. CNA N confirmed the sausage-based gravy was on the plate. On 11/16/23 at 10:30AM R26's representative stated the facility was not checking the dietary tickets before serving the meals. He stated he also complained to the facility about her dietary preferences on multiple occasions, but the occurrences didn't stop after complaining. On 11/16/23 at 01:45PM Social Service X stated all grievance were turned over to the designated department head for review. She stated the facility would ensure the grievances were resolved in a timely manner and the issues would not return. On 11/16/23 at 12:13PM Dietary staff BB stated each resident's diet and preferences were recorded in a binder kept in the kitchen. He stated staff reeducation had been provided to ensure each resident was provide the correct diet. He stated staff should be verifying with the cook in the kitchenette before serving meals to the residents. He stated the dietician and himself meet with the quality assurance to address concerns or other dietary needs the occur. He stated staff was to verify R26's meals before serving her. A review of the facility's Grievance policy revised 01/2023 indicated any resident or family member had the right to voice a grievance with the facility. The policy indicated grievances may be filed in writing, verbally, or anonymously. The policy indicated the grievance will be documented and addressed by the appropriate department. The policy indicated the facility will take prompt efforts to resolve he grievances and the record will be maintained for a period of no less than three years. The facility failed to adequately resolve R26's grievances related to her ongoing dietary concerns. This deficient practice placed R26 at risk for decreased psychosocial wellbeing.

The facility had a census of 63 residents. The sample included 17 residents with five residents reviewed for accidents and/or hazards. Based on observation, record review, and interview, the facility failed to secure rooms containing hazardous materials out of reach of 17 cognitively impaired /independently mobile residents. This deficient practice placed the affected residents at risk for preventable injuries and accidents. Findings included: - On 11/13/23 at 07:08AM a walkthrough of the facility revealed two Spa rooms with doors propped open. Both rooms contained boxes of COVID-19 (highly contagious respiratory virus) testing kits in an unsecured closet. Both rooms had opened germicidal cylindrical containers of wipes stored on counter with the Keep out of reach from children warning. Certified Nurse's Aide (CNA) N secured the room. She reported the rooms should not be left open and unattended. On 11/16/23 at Licensed Nurse H stated cleaning solutions and hazardous chemicals should be locked in the cabinets when not in use or closely monitored. On 11/16/23 at 02:23PM Administrative Nurse D reported chemical solutions should not be stored in an area residents could access. She stated the doors were usually left propped open in the morning, but the COVID-19 test kits and cleaning solutions should be secured in a locked cabinet. A review of the facility's Accidents and Supervision 01/2023 indicated that the resident environment will remain of accident hazards (elements of the resident environment that have the potential to cause injury or illness). The policy noted that the facility will make reasonable efforts to identify the hazards and risks in the environment. The facility failed to secure chemicals in a safe, locked area, and out of reach of the 17 cognitively impaired independently mobile residents. This placed the affected residents at risk for accidents.

The facility identified a census of 63 residents. Based on observations, record review, and interviews, the facility failed to ensure proper infection control standards were followed related to catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) care, disinfecting shared equipment, and storage of oxygen tubing when not in use. This deficient practice placed the residents at risk for complications related to infectious diseases. Findings included: - On 11/13/23 at 09:26 AM Resident (R) 18 sat in his wheelchair in his room with a nasal cannula (a device that delivers extra oxygen through a tube and into your nose) on. In R18's bathroom, there was an oxygen concentrator (a device that provides supplemental oxygen) and the nasal cannula was lying on the floor. R18's continuous positive airway pressure (CPAP - a machine that used mild air pressure to keep breathing airways open while you sleep) mask was draped over the bedrail and not stored in a bag. Observation on 11/14/23 at 04:10 PM R15 laid on her bed. Her catheter bag laid directly on the floor. R15 stated her legs hurt, but the staff gave her something for the pain. Observation on 11/16/23 at 08:21 AM Certified Nurse Aide (CNA) M completed a Hoyer (total body mechanical lift) transfer for R23. CNA M pushed the Hoyer lift from the room and into the hallway without disinfecting the lift. CNA M then left the Hoyer lift in the hallway and entered another room. Observation on 11/16/23 at 01:27 PM R15 laid on her bed. CNA M asked R15 if she could provide catheter care. CNA M gathered the supplies to provide catheter care, then placed items on a clean barrier on the bedside table. CNA M washed her hands, donned gloves, unfastened R15's incontinence brief, doffed gloves, then donned a clean pair of gloves without performing hand hygiene. CNA M provided catheter care then doffed gloves and donned a new pair of gloves without performing hand hygiene and replaced the incontinent brief. CNA M doffed gloves washed her hands and donned new gloves. CNA M applied cream to R15 buttocks with her right hand. CNA M doffed her glove from her right hand and without performing hand hygiene, donned a new glove on her right hand. CNA M assisted the resident with repositioning her clothes. On 11/16/23 at 08:41 AM CNA M stated the mechanical lifts were disinfected on the night shift. On 11/16/23 at 01:14 PM Certified Nurse Aide (CNA) N stated that the nasal cannula and CPAP masks should be stored in a plastic bag when not being used. On 11/16/23 at 01:27 PM Licensed Nurse (LN) G stated oxygen tubing and the CPAP masks should be stored in a bag when not being used. On 11/16/23 at 02:30 PM Administrative Nurse E, the facility Infection Preventionist, stated she expected staff to perform hand hygiene between glove changes and catheter bags should never be placed on the floor. Administrative Nurse E stated R15 had a history of frequent UTIs. On 11/16/23 at 02:50 PM Administrative Nurse D stated she expected staff to ensure that nasal cannulas and CPAP masks should be stored in a plastic bag when not in use. Administrative Nurse D stated R18 had been educated numerous times about the proper storage of this cannula and mask. Administrative Nurse D stated catheter bags should never be placed on the floor and hand hygiene should be performed between glove changes. The facility's Cleaning and Disinfection of Resident-Care Equipment policy dated 01/01/23 documented resident-care equipment could be a source of indirect transmission of pathogens. Reusable resident-care equipment would be cleaned and disinfected in accordance with current Center of Disease Control recommendations in order to break the chain of infection. Disinfection refers to thermal or chemical destruction of pathogenic and other types of microorganisms. Staff would follow established infection control principles for cleaning and disinfecting reusable, non critical equipment. General guidelines include: Each user is responsible for routine cleaning and disinfection of multi-resident items after each use, particularly before use for another resident. The facility failed to ensure proper infection control standards were followed related to hand hygiene during catheter care, catheter bags resting on the floor, disinfecting of shared equipment, and storage of oxygen tubing when not in use. This deficient practice placed the residents at risk for complications related to infectious diseases.

The facility identified a census of 53 residents. The sample included three residents, with three residents reviewed for accidents. Based on observations, record review, and interviews, the facility failed to ensure Resident (R) 1 remained free of accidents when facility staff failed to use a gait belt (belt used to help transfer a person from one place to another) during a transfer in the bathroom, which resulted in a fall. This deficient practice resulted in a fracture of R1's right femur (thigh bone). Findings included: - The Diagnoses tab of R1's Electronic Medical Record (EMR) documented diagnoses of displaced fracture of base of neck of right femur subsequent encounter for closed fracture with routine healing, difficulty in walking, generalized weakness, [CONDITION(S)] (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain) without behavioral disturbance, and history of falling. The Annual Minimum Data Set (MDS) dated [DATE], documented R1 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated intact cognition. R1 required extensive physical assistance with two staff for bed mobility and walking; extensive physical assistance with one staff for transfers, locomotion, dressing, toileting, and personal hygiene. R1 had no falls since the last assessment. The Quarterly MDS dated [DATE], documented a BIMS was not assessed for R1. R1 required extensive physical assistance with one staff for bed mobility, locomotion, and dressing; limited physical assistance with one staff for personal hygiene; extensive physical assistance with two staff for transfers and toileting. R1 had a fall with fracture in the last six months. The Activities of Daily Living (ADL) Functional/Rehabilitation Potential Care Area Assessment (CAA) dated 05/06/22, documented R1 required assistance of staff with all ADLs. The Falls CAA dated 05/06/22, documented R1 was at risk for injury/falls related to diagnoses and required assistance with ADLs. The Care Plan dated 03/30/18, directed R1 had ADL self-care performance deficit and documented an intervention, last revised 12/03/18, which documented that R1 required one staff participation to use toilet. The Care Plan documented an intervention, revised on 08/20/18, which noted that R1 required one staff assistance with transfers. The Care Plan was revised on 06/15/22 with an intervention that noted R1 required two staff assistance with transfers with a gait belt. The Notes tab of R1's EMR revealed the following: A Nursing Note on 05/26/22 at 10:00 AM documented Certified Nurse Aide (CNA) M informed a nurse that R1 had a non-injury fall during transfer from the toilet to her wheelchair. R1 attempted to sit down before the wheelchair was under her and R1 fell on her buttocks. Assessment completed, with no complaints of pain. The nurse and CNA M assisted R1 back to the wheelchair. A Nursing Note on 05/26/22 at 12:46 PM documented R1 complained of pain to her right knee. Consultant G was notified and ordered two to three view x-rays to the resident's right knee. A Nurse Practitioner (NP)/Physician Assistant (PA) Progress Note on 05/26/22 at 03:16 PM documented non-face-to-face completed. Nursing staff called to notify of a witnessed fall in the bathroom. R1 complained of right lower extremity pain and requested x-rays. In further discussion with the nurse, Consultant G needed the nurse to narrow down area of pain. After the nurse's assessment, it was determined that R1's main pain was in her right knee. X-ray ordered for two to three views of the resident's knee. A Nursing Note on 05/26/22 at 11:15 PM documented x-ray results of the right knee, two view study, showed no fracture, dislocation, or bony erosion, soft tissue swelling noted. A NP/PA Progress Note on 05/27/22 at 03:09 PM documented R1 was seen and examined following a recent fall. Yesterday she had a witnessed fall in the bathroom and complained of right leg pain. Upon further assessment form the nurse, R1's main pain was in her knee. X-ray of the knee ordered, which was within normal limits. Today upon assessment of R1, she complained of pain in her right groin and was unable to bear weight. Hip x-ray to be obtained. A Nursing Note on 05/28/22 at 05:32 AM documented R1 had a right hip x-ray done. Results came back indicating R1 had an impacted slightly displaced sub-capital (femoral neck) fracture of the right femur. NP gave an order to send R1 to hospital. A Fall Committee Interdisciplinary Team (IDT) Note on 05/28/22 at 01:58 PM documented IDT reviewed witnessed fall with fracture on 05/26/22 at 10:00 AM. R1 was assisted by CNA M off of toilet and into wheelchair. CNA M was attempting to get pants pulled up while R1 was attempting to sit down. CNA M was unable to get wheelchair underneath R1 and she fell to her bottom. Fall was witnessed, care plan was being followed at time of fall. The facility's Investigation dated 06/06/22, documented R1 had a witnessed fall on 05/26/22. The fall occurred during a transfer by CNA M in the restroom. Immediate education was given to CNA M regarding transfers. On 05/26/22, x-rays were completed of R1's knee, in which they resulted negative on 05/27/22. R1 complained of further pain, in which, additional x-rays were taking in the evening on 05/27/22 of R1's right hip. The x-rays noted on 05/28/22 at 05:20 AM that R1 had a right side impacted slightly displaced right sub-capital fracture. R1 was transported to the hospital for further follow-up and surgery. Upon further investigation into the fall, it was found that CNA M failed to use a gait belt. Prior to the fall, R1 was an assist of one staff with gait belt. In a Fall Witness Statement on 05/26/22 at 09:58 AM, CNA M stated R1 just finished using the restroom and when CNA M was pulling up her pants, R1 hurried up, and tried to sit down before CNA M told her to and she fell on her bottom. On 06/23/22 at 01:56 PM, R1 sat in her wheelchair in her room and watched television. R1 was hard of hearing but was able to communicate with surveyor. R1's feet rested on foot pedals, shoes were worn, and call light was within reach. R1 appeared comfortable and without signs of distress or discomfort. On 06/23/22 at 01:56 PM, R1 stated she had a fall and broke her hip. She stated an aide was helping her transfer, did not lock the brakes to her wheelchair, and she fell . On 06/23/22 at 02:03 PM, CNA N stated residents were transferred using a gait belt or a mechanical lift, whichever was applicable for the resident. She stated falls were prevented by ensuring resident wore nonskid shoes/socks, staff answered call lights in a timely manner, and staff used a gait belt with transfers. On 06/23/22 at 02:06 PM, Licensed Nurse (LN) G stated depending on the resident, they were transferred with one or two staff using a gait belt. She stated falls were prevented by ensuring the resident wore the correct socks/shoes, advising resident to get their bearings before standing, staff anticipating resident needs, ensuring proper lighting in room, ensuring call light was within reach, and staff used a gait belt with transfers. LN G stated on 05/26/22, CNA M was taking R1 to the bathroom and R1 fell while CNA M was in the bathroom. CNA M informed LN G R1 had a witnessed fall and LN G entered the room. LN G stated when she entered R1's bathroom, R1's wheelchair was to her side and R1 sat on her buttocks facing the toilet. She stated R1 did not complain of pain at the time, but later that day she complained of pain and an x-ray was obtained of her knee, it was negative. LN G stated CNA M informed her R1 sat down before the wheelchair was behind her. On 06/23/22 at 02:22 PM, Administrative Nurse D stated R1 fell on [DATE] during a transfer. R1 had complained of knee pain and an x-ray was obtained, it was negative. R1 continued to complain of pain and after an assessment was completed, the NP ordered a hip x-ray. Administrative Nurse D stated the hip x-ray was positive and R1 was sent to the hospital for evaluation. She stated she expected staff to follow the care plan for fall preventions and any resident that was unsteady or had a change in condition should have a gait belt utilized during transfers at a minimum. On 06/23/22 at 02:35 PM, Administrative Staff A stated R1's family informed her that staff had not been using a gait belt with R1. Once R1 returned from the hospital, R1's family requested she become a two person assist with gait belt for transfers. Administrative Staff A stated on 05/26/22, R1 was in the bathroom and stood up to transfer off the toilet, R1 became weak, and staff did not have anywhere to grab onto R1 to prevent the fall. The facility's Transfer/Gait Belt policy, last revised September 2021, directed gait belt transfers required one or two-person transfers depending on the residents' ability to cooperate with the procedure and bear weight. The policy directed staff placed a gait belt around resident's waist and during the transfer, four fingers were held up under the gait belt with thumbs in a downward position. The facility failed to ensure R1 remained free of accidents when facility staff failed to use a gait belt transfer in the bathroom which resulted in a fall. This deficient practice resulted in a fracture of R1's right femur.

The facility reported a census of 52 residents. The sample included three residents reviewed for elopement (when a cognitive impaired resident with little or poor safety awareness exits the facility without staff knowledge). Based on observation, record review, and interview, the facility failed to ensure Resident (R)1 received adequate supervision with audible door and Wander Guard alarms to prevent elopement. R1, who was on the West unit, exited the facility without staff knowledge and supervision on 07/14/21 between approximately 04:30 PM and 04:40 PM. R1 exited through the fire exit door on the South side of the building. R1 pushed on the door for approximately 15 seconds and then exited the facility. R1 then wheeled her wheelchair approximately a half block to a nonsecure, unsupervised location. R1 was then found by staff seated in her wheelchair in the parking lot of another facility. R1 was found in an [NAME] metropolitan area with four lanes of traffic, changing speeds up to 35 miles per hour, and significant hazards, such as changing elevations and cross streets. The temperature was 87 degrees Fahrenheit (F) and R1 wore light blue pants, a short-sleeved shirt, socks, and shoes. This deficient practice placed this resident and four other residents at risk for elopement in immediate jeopardy . Findings included: - R1's electronic medical record (EMR), under the Diagnoses tab recorded diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear) disorder, and muscle weakness. The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of three which indicated severely impaired cognition. R1 had no behaviors of wandering exhibited during the look back period. R1 self-propelled in a wheelchair with supervision and set up help only. The Cognitive Loss/Dementia Care Area Assessment (CAA) dated 01/15/21 documented R1 as pleasantly confused and she liked to wander throughout the facility in her wheelchair that she self-propelled. The Behavioral Symptoms CAA dated 01/15/21 did not trigger. The Quarterly MDS dated [DATE] documented R1 had short- and long-term memory problems with no behaviors of wandering exhibited during the look back period. R1 required supervision of one staff member for locomotion on the unit, and supervision with set up help only off the unit. The Elopement/Wandering Evaluation dated 05/02/21 documented R1 had a score of 12 which indicated high risk for elopement. The Care Plan revised 05/29/19 for cognitive issues related to dementia directed staff if R1 wandered around the facility in her wheelchair staff were to notify the nurse if exit seeking behaviors occurred. The Care Plan created 05/13/21 for elopement risk/wandering related to history of attempts to leave the facility unattended directed staff to document wandering behaviors, attempt diversional interventions, and monitor Wander Guard placement and function every shift. Review of the Progress Note dated 07/13/21 at 06:30 PM documented the following: the door alarm was sounding and when the nurse entered the hallway another resident stated that someone had went out the door. [R1] had exited the facility out of the long hall exit door on Hallbrock and staff immediately responded. The charge nurse assessed [R1] with no injuries noted, when [R1] was asked how she was she stated hot and accepted water to drink. The Primary Care Physician and family were notified. The Primary Care Physician ordered urinary analysis and blood work related to elopement. [R1] was placed on one on one with a staff member. Review of the progress note dated 07/14/21 at 10:57 AM documented [R1] had normally been seeking exits and the behavior continued over the past months but had never actually exited and the severity was done under radar. The Facility Investigation documented staff assisted residents in the dining room and did not hear the door alarm. The Certified Nurse Aid went to the door and looked outside to the parking lot and saw no one. [R1] was located half a block away in the parking lot of an independent living facility south of the facility. Certified Nurse Aid (CNA) M's 07/13/21 Witness Statement documented after helping another resident, she and CNA N exited that resident's room and heard both the Wander Guard alarm and the door alarm going off. CNA M documented CNA N went to the road but could not see R1. Staff then dispersed throughout the facility to look for R1. CNA M's statement lacked a timeline of events. Licensed Nurse (LN) G's 07/13/21 Witness Statement documented LN G returned to the hall after R2 stated she saw R1 exit the building. LN G ran down the hall and then heard the door alarm as she got further down the hall. LN G exited the facility. R1 was not in sight at that time. R1 was found at 05:06 PM after exiting the facility at 04:45 PM. R1 returned to the facility and assessed with no injuries, her only complaint was that she was hot. LN G had not witnessed R1 attempting to elope that day, but she was found seated by the door earlier that day and the alarm had sounded. Certified Medication Aide (CMA) R's 07/13/21 Witness Statement documented CMA R and LN H walked outside to take a breath before dinner began. When CMA R and LN H returned to the back doors they ran into R1 as she tried to get out the golf course doors. CMA R turned off the alarm and redirected R1. CNA N's 07/13/21 Witness Statement documented at about 04:45 PM she heard the Wander Guard and door alarm sounding. CNA N looked outside for R1 and did not see her. Upon coming in the facility CNA N and CNA M checked rooms, dining room, and R1's room and could not locate R1. CNA N documented everyone went outside to look for R1, who was eventually located by management staff all the way down a busy street, at another building. CNA O's 07/13/21 Witness Statement documented CNA O walked towards the busy four lane road adjacent to the facility grounds , noted co-workers at the intersection, so CNA O headed south. CNA O turned into the parking lot south of the facility. CNA O noted two unidentified older women looking to their right, looking at something in the distance. CNA O saw R1 in her wheelchair to the right of the building sitting straight ahead of the turn into the parking lot. CNA O approached R1 and asked if R1 needed help. R1 reported she was looking for her house. CNA O stated she could help, and wheeled R1 back to the facility. On 07/19/21 at 10:40 AM R1 laid in her bed on her right side with blankets pulled up over her shoulder. Staff sat in a chair in R1's room for one on one observation. Observation on 07/19/21 at 11:40 AM revealed the locked door on the back of Brickwood hallway was noted to alarm after pressure was applied for 15 seconds. After 15 seconds, the door opened, and the alarm shut off while the door was open. When the door was pulled shut, the door alarm began to sound, no staff responded. Housekeeper U, located three rooms away from the door, stated it took a badge to shut the alarm off. Upon recognition that it was not a staff member at the door, Housekeeper U came to shut the alarm off. On 07/19/21 at 11:42 AM Housekeeper U stated she thought the alarm did not always work. She stated there were people in to work on the alarms last week because something did not work right. On 07/19/21 at 12:00 PM Maintenance Staff C stated staff from the alarm company came to look at the alarm because it was not working right and Administrative Staff C felt a technician should look at it. The door alarms only sound at the door that has been opened and not anywhere else in the building. On 07/19/21 at 12:40 PM an unidentified staff member stated the alarms could not be heard in the dining room when staff were serving the residents. She further stated staff could hardly hear the alarm at the nurse's station located in the middle of the hallway. On 07/19/21 at 12:41 PM LN H stated the alarm was very hard to hear at the nurse's station. LN H further revealed that the elopement occurred during meal time. On 07/19/21 at 01:35 PM Administrative Nurse D stated she felt that once R1 was missing, the staff responded appropriately. Administrative Nurse D revealed that she felt that R1 should have been handled differently prior to the elopement and it may have been prevented. She further stated when R1 was found attempting to exit the building, staff should have kept her in eyesight. On 07/19/21 at 01:45 PM Administrative Staff B stated that when the elopement first happened, R2 stated R1 went that way and pointed to the door at the back of the hallway. She further revealed that when a response team comes out the facility to investigate the incident, the facility will look at getting a louder door alarm. Administrative Staff B revealed when staff were interviewed, it was found they reported they could not hear the door alarm until they were further down on the hallway . The facility's policy Quality of Care: Elopement/Unsafe Wandering reviewed 02/2021 documented staff assisted each resident in attaining or maintaining their highest practicable level of function through providing the resident adequate supervision and diversional programs to prevent unsafe wandering while maintaining the least restrictive environment for those at risk for elopement. The facility failed to ensure Resident (R)1 received adequate supervision and failed to ensure audible door and Wander Guard alarms to prevent elopement. This placed all five residents at risk for elopement, including R1, in immediate jeopardy. The facility abated the immediate jeopardy on 07/20/2021 at 04:50 PM by implementing the following: One to one observation of R1 15-minute checks on the four other residents who were at risk for elopement. One staff member designated only to those four residents. Staff member move from resident to resident and document activity and location. Activities will be involved with the residents to keep them busy and engaged. Louder alarms have been ordered for all eight exits with an expected completion date of Wednesday, July 21, 2021.Temporary alarms with very shrill sounds will be placed until the permanent door alarms are received. The scope and severity of the deficient practice remained at the level of an E to represent the risk to all five residents known to wander and at risk for elopement.

The facility presented a census of 60 residents. The sample included one resident (#1) reviewed for medication administration. Based on record review and interview the facility failed to ensure staff correctly transcribed physician's MEDICATION ORDERS FOR [REDACTED]. Staff administered the incorrect dose of this medication for 6 days necessitating an acute care hospitalization . Findings included: - The closed electronic medical record (EMR) for resident #1 included the following Diagnoses: [REDACTED]. by hardening of the arteries), Cerebral Infarction (stroke); Aortic aneurysm (the wall of the main artery in the body, balloons out and becomes weak) The medication order dated 02/01/18 read [MEDICATION NAME] (a medication used to treat [MEDICAL CONDITION] Arthritis - inflammation of joints) 25 Mg IM (into the muscle) every 10 days. The order on the Medication Administration Record [REDACTED]. The start date was 2/4/18. The MAR indicated [REDACTED]. Nursing staff discovered the error on 2/10/18, after the resident received 6 doses totaling 150 mg in 5 days. According to Federal Drug Administration (FDA.gov) the maximum dose of [MEDICATION NAME] for treatment of [REDACTED]. This resident received 7.5 times the normal dose for a week. The FDA lists the following black box warnings for this medication: closely monitor for bone marrow, liver, lung, and kidney toxicities. Side effects of the medication included leukopenia (decreased white blood cell count), pancreatitis (inflammation of the pancreas-the gland in the body that stores and releases insulin to regulate blood sugar); and [MEDICAL CONDITION] (when the body does not make enough platelets), and liver damage. Admission records to the acute care hospital indicated the resident was admitted with acute pancreatitis. The lab work drawn at the facility when staff discovered the error on 2/10/18 indicated a white blood count (WBC) level of 1500 (normal range was 4000- ). Previously drawn level on 2/6/18 was 5000. A platelet count of 59,000 (normal range 140,000-440,000). Previously drawn level on 2/6/18 was 214,000. Additional lab work drawn on 2/10/18 were AST (indicate liver damage) result: 91 (normal range 13-39) and ALT (also indicated liver damage) result: 55 (normal range 7-52). Both these tests had been in the normal range on 1/25/18. On 08/13/18 Consultant Staff GG stated the abnormal elevated lab values could be directly related to the overdose of the medication. He/she also stated in his/her estimation, the resident had started to decline before the medication was given. He/she stated staff G asked him/her to clarify the order on 2/1/18.He/she stated the order he/she verified was written as [MEDICATION NAME] 25 mg IM once every 10 days. The resident had been on the medication at home in oral form, same dosing schedule, and the family wanted to switch it to IM. On 08/13/18 at 11:30 AM Consultant staff HH stated the abnormal lab values could be related to the overdose of the medication. Additionally, HH stated acute pancreatitis can be one of the untoward effects of the medication. On 8/13/18 at 11:45 AM staff G stated the error was found during a pharmacy review. The facility failed to ensure staff correctly transcribed a medication order, which resulted in a significant medication error and hospitalization for this resident who depended on the staff for medication management. This deficiency was assigned a scope and severity of G and was deemed past non-compliance when on 2/12/18 the facility implemented a QAPI (Quality Assurance Performance Improvement) plan to verify all telephone orders written by the previous shift and every 24 hours. The assistant director of nursing (ADON) and director of nursing DON would develop a 24 hour summary report to verify that all orders had been input into the EMR correctly .