Every finding on record at The Healthcare Resort of Topeka

The facility reported a census of 67 residents. Based on observation, interview, and record review, the facility failed to prepare food under sanitary conditions, related to the use of unsanitary pots and pans used to prepare food in the main kitchen, where all residents meals are prepared prior to distribution to two satellite kitchens, which include the east kitchenette that served the residents of the long-term care and skilled residents of the facility.Findings included: - On 12/15/2025 at 10:45 AM, observations during the main kitchen tour with Dietary Staff CC revealed the following concerns: Three pots had a black and brown substance built up on the outside and inside of the pots in areas that would come in contact with the food items prepared in the pots. Twenty-four sheet pans had a baked-on brown substance inside and outside of the pans and along the outer rim of the sheet pans. The sheet pans were stacked one on top of another. On 12/15/2025 at 10:45 AM, Dietary Staff CC verified the above findings and agreed the pots and sheet pans were not sanitary and were in need of cleaning and/or replacement to ensure a clean, sanitizable surface during food preparation. On 12/18/2025 at 10:23 AM, observation and interview during the follow-up tour of the kitchen with Dietary Staff CC revealed a four-quart and an eight-quart aluminum pot, both with pitted insides and discolored bottom in areas which would have direct contact with foods during preparation. Dietary Staff CC confirmed the inside surfaces of the two pots were not sanitary and in need of replacement. The facility policy Policy: Handling Soiled, Damaged, or Non-Restorable Pots and Pans, dated 01/06/2025 documentation included the policy purpose included to ensure food-contact cookware (pots and pans) used by Dietary Services maintained in a sanitary and safe condition, define removal from use, deep cleaning, discard criteria (including pitting) and procedures for replacements when items are beyond restoration.

The facility reported a census of 67 residents; there were 18 residents sampled, which included two residents selected for closed record review. Based on observation, interview, and record review, the facility failed to ensure nursing documentation in Resident (R) 27's health record met the professional standards of care when staff repeatedly documented application of a brace or splint even when they did not apply the device, inaccurately representing the provision of treatments.Findings included:- R27's Electronic Medical Record (EMR) documented diagnosis of hemiplegia and hemiparesis following cerebral infarction (stroke) affecting the left non-dominant side (weakness and paralysis on one side of the body), other lack of coordination (a neurological sign characterized by a loss of muscle control, leading to uncoordinated movements), and Parkinson's disease with dyskinesia (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness).R27's Annual Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The assessment documented R27 had impairment to one side and required set-up, supervision, or touching assistance with activities of daily living (ADL) such as oral and personal hygiene. He required partial to moderate assistance with toileting hygiene.The Activities of Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA), documented that R27 required ADL assistance for self-care or mobility activities.R27's Quarterly MDS, dated 11/25/19, documented a BIMS score of 15. The assessment documented R27 had impairment on one side and required set-up, supervision, or touching assistance with ADL, such as oral and personal hygiene, and he required partial to moderate assistance with toileting hygiene.R27's Care Plan recorded an intervention dated 01/31/24 that directed staff to assist the resident with wearing a splint on his left hand and middle finger during sleeping hours and removing it when he was up. Staff were to monitor his skin integrity as indicated. R27's Orders tab revealed a physician order, dated 08/12/24, which documented staff were to assist the resident with wearing a splint on his left hand, wrist, and finger during sleeping hours and remove it when up.R27's December 2025 Medication Administration Record/ Treatment Administration Record (MAR/TAR) reviewed from 12/01/25 through 12/17/25 documented R27's arm splint had been applied at 08:00 PM and removed at 08:00 AM each day, including the night of 12/17/25, with no refusals documented.During an observation on 12/15/25 at 11:39 AM, R27 was in bed with his left fingers contracted and swollen. He did not have a brace or splint on the left hand. There was a sign on the wall from the therapy staff that directed staff to make sure the brace straps were tight and also included instruction to assist the resident with applying his left WHFO [wrist hand finger orthotic] at nap time and remove after naps. R27 stated that it was his fault he did not wear the brace because he did not like calling the staff in to assist him. He further stated that he had just awakened from a nap and that he would usually awaken around 04:30 AM and then nap each day from 08:30 AM until lunch time.On 12/16/25 at 09:21 AM, R27 stated he never wore the arm brace at night because it made it difficult to do things.On 12/18/25 at 10:04 AM, Certified Nurse Aide (CNA) N stated that R27's arm brace had been applied before he got into bed, and that sleeping hours included any sleep during the day. She further stated that any refusal would have been reported to the nurse and marked as refused. CNA N said that R27 had refused the brace sometimes at night and that he was alert and oriented and would call the staff if he wanted it on.On 12/18/25 at 10:08 AM, CNA M stated that R27 did not wear his brace at all during the day and that when she arrived in the morning, he was already awake and had the brace off. She further stated that if he refused the brace, she would have marked it as refused and notified the nurse.On 12/18/25 at 10:16 AM, Licensed Nurse (LN) G stated that the CNAs completed the task of applying and removing the arm brace, but the nurses documented it as completed on the TAR. She also stated that if R27 refused the brace, it should be marked as refused and noted in the chart indicating the refusal.12/18/25 at 10:17 AM, Administrative Nurse D stated that the TAR was charted in real time and that refusals of any treatment, including braces, should be charted. Administrative Nurse D verified the CNA staff were allowed to assist with placement and removal of assistive braces, but said that any refusal was to be reported to the nurse, and it was expected that the nurse make a progress note in the chart about any refusal and provide the resident with education. Administrative Nurse D stated she expected the documentation in the resident's clinical record to be correct and accurately reflect the care provided. She said the record allowed staff to review for consistent patterns of refusal, so that the provider could be notified, and the care plan updated to reflect that the resident had potential for refusal. On 12/28/25 at 11:54 AM, R27 stated that he did not wear the brace the previous night and that the last time he wore it was the night of 12/15/25.On 12/18/25 at 11:54 AM, Consultant GG stated that R27 needed to wear the splint for an hour during the day, and that he had an alarm to remind him of when to wear it. On 12/18/25 at 11:55 AM, Consultant HH stated that R27 was able to apply the splint himself and that he had a reminder on his phone set for 09:00 AM. She further stated that he could not get the straps tight enough and required assistance. Consultant HH also stated that she had discussed with R27 that he did not always want to wear the brace or ask for help, and that was why the reminder was put in his phone, so that he was able to put the brace on himself.The facility policy Policy/Procedure-Nursing Clinical: Medication and Treatment, dated 01/2025, documented that all treatments, such as wound dressing, catheter care, urine output totals, application/removal of splint/brace/slings, etc., were to be completed on the TAR.

The facility had a census of 70 residents. The sample included 19 residents. Based on observation, record review, and interview, the facility failed to measure and record food temperatures for pureed food items at mealtimes, placing the two residents who received a pureed diet at risk for foodborne illness. Findings included: - On 02/08/24 at 11:40 AM, during the preparation of the two pureed diets, observation revealed Dietary Staff (DS) CC prepared the pureed diet food items. DS CC placed the servings of each food item into bowls and then placed the uncovered bowls on the lid of a compartment on the steam table. At 12:20 PM, DS CC served the pureed diets to the residents without checking the food items' temperatures before serving them. The Weekly Steam Table Temperature Logs lacked documentation staff obtained pureed diet (meat, starch, and vegetables) food temperatures at mealtimes for the following days: 2023 10/01-10/17 - the East and [NAME] kitchenette pureed meal temperatures were not taken for all three meals. 10/08-10/14-the East kitchenette pureed meal temperatures were not taken for all three meals. The [NAME] Hall kitchenette was not taken one day for breakfast and five days for supper. 10/15-10/21- the East kitchenette pureed meal temperatures were not taken every day for all three meals. 10/22-10/28-the East kitchenette pureed meal temperatures were not taken for all three meals. 10/29-11/04-the East kitchenette pureed meal temperatures were not taken for all three meals. 11/5-11-the East kitchenette pureed meal temperatures were not taken for all three meals. 11/12-11/18- the East kitchenette pureed meal temperatures were not taken for all three meals. The [NAME] kitchenette was not taken for supper every day. 11/19-11/25- The East kitchenette pureed meal temperature was not taken for all three meals. The [NAME] kitchenette was not taken on one day for lunch and supper. 11/19-25-the East kitchenette pureed meal temperatures were not taken for all three meals. The [NAME] kitchenette was not taken for two days for breakfast and lunch and one day for supper. 11/26-12/2- the East kitchenette pureed meal temperatures were not taken every day for all three meals. The [NAME] kitchenette was not taken on one day for lunch and supper. 12/3-12/09- the East kitchenette pureed meal temperatures were not taken every day for all three meals. The East kitchenette was not taken one day for breakfast and two days for lunch and supper. 12/10-12/16-the East kitchenette pureed meal temperatures were not taken every day for all three meals. The [NAME] kitchenette was not taken for two days for lunch and every day for supper. 12/17-12/23-the East kitchenette pureed meal temperatures were not taken every day for all three meals. The [NAME] kitchenette temperatures were not taken for one day for lunch and four days for supper. 12/24-12/30- the East kitchenette pureed meal temperatures were not taken every day for all three meals. The [NAME] kitchenette temperatures were not taken six days for supper. 2024 01/01- 01/06- In the East kitchenette the pureed meal temperature was not taken every day for all three meals. 01/07-01/13-the East kitchenette pureed meal temperature was not taken every day for all three meals. The [NAME] kitchenette was not taken one day for breakfast, one day for lunch, and every day for supper. 01/14-01/20- the East kitchenette pureed meal temperature was not taken every day for all three meals. The [NAME] kitchenette temperatures were not taken two days for breakfast and lunch, and every day for supper. 01/21-01/27-the East kitchenette pureed meal temperature was not taken every day for all three meals. The [NAME] kitchenette temperatures were not taken two days for breakfast and lunch and every day for supper. 01/21-01/27- the East kitchenette pureed meal temperature was not taken every day for all three meals. 01/28-2/03- the East kitchenette pureed meal temperatures were not taken every day for all three meals. The [NAME] kitchenette meal temperatures were not taken five days for breakfast, six days for lunch and supper. 02/04-02/10-the East kitchenette pureed meal temperatures were not taken every day for all three meals. The [NAME] kitchenette pureed meal temperatures were not taken for two days for lunch. On 02/08/24 at 12:30 PM DS CC verified he had not checked the pureed diet food items before serving to the residents and stated he should have. On 02/08/24 at 12:45 PM, DS BB verified the lack of pureed food temperatures on the above dates and stated staff should check them before serving them to the residents. On 02/12/24 at 01:52 PM, Registered Dietician (RD) GG stated staff should measure the pureed food item temperatures before they served them to the residents. The facility's Guidelines for Food Temperatures Policy, revised 10/23, documented that food temperatures would be taken and recorded before each meal service. Food would be reheated/cooled to ensure proper serving temperatures before meal service. If there were two meal services, food temperatures would be taken before each meal service. The facility failed to obtain meal temperatures for pureed food items before meal service. This placed the residents who received pureed diets at risk for food-borne illness.

The facility had a census of 70 residents. The sample included 19 residents with five residents reviewed for immunizations to include pneumococcal (a disease that refers to a range of illnesses that affect various parts of the body and are caused by infection) vaccinations. Based on record review and interview, the facility failed to follow the latest guidance from the Centers for Disease Control and Prevention (CDC) when they failed to offer, obtain an informed declination, or a physician-documented contraindication for pneumococcal PCV20 vaccination. This deficient practice placed the residents at risk of acquiring, spreading, and experiencing complications from the pneumococcal disease. Findings included: - Review of Resident (R) 20, R17, R33, R42, and R51's clinical medical records lacked evidence of consent, informed declination, or physician-documented contraindication for the current pneumococcal vaccine PCV20. On 02/08/24 at 08:42 AM, Administrative Nurse E stated she had offered the flu and Prevnar 13 and 23 vaccines but not the PCV20. Administrative Nurse E stated the facility had not discussed the vaccine with the physician and was told by the pharmacy it was unavailable On 02/08/24 at 02:24 PM, Administration Staff A stated he discussed the PCV20 with the Medical Director and that the facility would start talking with residents and providing consent forms to families about the new vaccine. Administration Staff A further stated the vaccine would be available within the next two weeks. The facility's Prevention of infection, Immunization, Influenza, and Pneumococcal policy, dated 1/2024, documented the immunizations are to minimize the risk of residents acquiring, transmitting, or experiencing complications from influenza and pneumonia by assuring that each resident was informed about the benefits and risks of immunizations, had the opportunity to receive, unless medically contraindicated or refused or already immunized, influenza and pneumococcal vaccine. The policy further documented, that each resident was offered a pneumococcal immunization unless the immunization was medically contraindicated, or the resident had already been immunized. Before vaccination, the resident and/or resident representative would be provided information and education regarding the benefits and potential side effects of influenza and/or pneumococcal immunization, the resident and/or resident representative would be allowed to refuse immunizations, if the resident and/or resident representative consented to the vaccine the facility obtained a physician order for the resident. For residents who receive vaccination, the following information will be documented in the resident's electronic health record. if declined document the reason why the resident did not receive the influenza and/or pneumococcal immunization, administration of the influenza and/or pneumococcal vaccination would be made in accordance with current CDC recommendations at the time of vaccination. The facility failed to offer the pneumococcal PCV20 vaccinations per CDC recommendations. This deficient practice placed the residents at risk of acquiring, spreading, and experiencing complications from pneumococcal disease.

- On 02/07/24 at 12:05 PM, observation of the [NAME] dining room revealed residents sat at the dining room tables and ate lunch. Continued observation revealed Dietary Staff BB asked the surveyor to relocate to a different table in the dining room because the staff needed the feeders to sit at that table so staff could assist them with their meals. Dietary Staff BB again stated the other table where the feeders normally sat was filled up, so staff needed to use the table. On 02/13/24 at 09:30 AM, Administrative Nurse D verified staff were to not call residents feeders, the term was unacceptable. Administrative Nurse D said she would speak with the staff regarding the issue. The facility's undated Resident Rights policy, dated 10/04/23, documented the residents have the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. Residents have the right to exercise their rights without interference, coercion, discrimination, or reprisal from the facility as a resident of the facility. Residents have the right to be treated with respect and dignity. The facility failed to promote care in a manner that maintained and enhanced dignity and respect, when staff called the residents that required assistance with eating feeders. This placed the residents at risk for an undignified dining and living experience. 32360 The facility had a census of 70 residents. The sample included 19 residents, with one reviewed for dignity. Based on observation, record review, and interview, the facility failed to promote care in a manner to maintain and enhance dignity and respect when staff obtained Resident (R) 41's blood sugar (measures the glucose levels in the blood) and administered insulin (a hormone that lowers the level of glucose in the blood) by the dining room, with five other residents in full view. The facility further failed to address residents with respect and dignity when staff called residents who required meal assistance feeders. This placed the residents at risk for undignified experiences and impaired psychosocial well-being. Findings included: - The Electronic Medical Record (EMR) for R41 documented diagnoses of diabetes mellitus (DM-when the body cannot use glucose, not enough sepsis made. or the body cannot respond to the insulin) type 2, dysphagia (dysphagia (swallowing difficulty), hypertension (high blood pressure), and cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R41 had moderately impaired cognition and was dependent upon staff for dressing, personal hygiene, and transfers. R41 received insulin daily. R41's Care Plan, dated 12/29/23, initiated on 02/13/23, directed staff to administer diabetic medication as ordered by the physician and monitor for side effects and effectiveness. The update dated 08/01/23 directed staff to obtain blood sugar checks as ordered; monitor, document, and report to the physician signs and symptoms of hypoglycemia (less than normal amount of sugar in the blood) and hyperglycemia (greater than normal amount of glucose in the blood). The Physician's Order, dated 05/11/23, directed staff to obtain a blood glucose check before meals and at bedtime, and if less than 70 milligrams per deciliter (mg/dl), hold the insulin and notify the physician. If the blood glucose was greater than 400 mg/dl, administer ordered insulin and notify the physician for diabetes mellitus. The Physician's Order, dated 12/18/23, directed staff to administer Novolog (rapid-acting insulin), four units with meals, and hold for blood glucose less than 120 mg/dl or if not eating. On 02/12/24 at 12:15 PM, observation revealed R41, sat in her wheelchair by the dining room as Licensed Nurse (LN) G obtained her blood sugar. LN G then administered R41's insulin within view of the five residents present. On 02/12/24 at 12:15 PM, LN G stated she always checked the resident's blood sugar and administered insulin by the dining room. On 02/13/24 at 11:10 PM, Administrative Nurse D stated blood sugar checks and insulin administration should be done in the resident's room unless it was an emergency. The facility's Dignity and Respect policy, dated 10/2015, documented it was the policy of the facility that all residents would be treated with kindness, dignity, and respect and treated in a manner that maintained the privacy of their bodies. The facility failed to promote care in a manner to maintain and enhance dignity and respect when staff obtained R41's blood sugar and administered insulin in the dining room, with five other residents in full view. This placed the resident at risk for undignified care and services.

The facility had a census of 70 residents. The sample included 19 residents. Based on record review and interview, the facility failed to provide Resident (R)16 and R12 or their representative, the completed Centers for Medicare and Medicaid (CMS) Skilled Nursing Facility Advanced Beneficiary Notices (ABN) Form 10055. This placed the resident at risk of uninformed decisions and costs about their skilled services. Findings included: - The Medicare ABN form 10055 informed the beneficiary that Medicare may not pay for future skilled therapy services. The form included an option for the beneficiary to receive specific services listed, and bill Medicare for an official decision on payment. The form stated 1) I understand if Medicare does not pay, I will be responsible for payment but can make an appeal to Medicare, (2) receive therapy listed, but do not bill Medicare, I am responsible for payment for services, (3) I do not want the listed services. A review of the ABN provided to R16 revealed the form lacked the estimated cost of continued service and R16 received the wrong form. R16 received the CMS-R-131 instead of CMS Form 10055. The resident's skilled services ended on 12/06/23. A review of the provided to R12 revealed the form lacked the estimated cost of continued service and R12 received the wrong form. R12 received CMS -R-131 instead of CMS Form 10055. The resident's skilled services ended on 11/27/23. On 02/13/24 at 09:30 AM, Social Services X verified she provided R16 and R12, and/or their representative, the CMS-R-131 form and failed to provide the 10055 form. Social Service X verified the form provided to the residents lacked the estimated amount of money it would cost the residents for continued services. On 02/13/24 at 09:45 AM, Administrative Nurse D verified the facility provided the CMS-R-131 form to R16 or R12, and/or their representative, and failed to provide the 10055 with the estimated amount it would cost the resident if they wished to continue services. The facility's Advance Beneficiary Notices policy, dated September 2020, recorded the facility would ensure a liability notice to Medicare beneficiaries before the Skilled Nursing Facility provides an item or service that is usually paid by Medicare, but may not be paid for in this instance because it is not medically reasonable and necessary, or custodial care. Failure to provide the ABN may result in the facility being unable to bill the beneficiary directly for the subject services. The ABN of noncoverage is used for beneficiaries in original Medicare when the facility believes that Medicare is not likely to cover the services described in the ABN. The Form CMS 10055 is used to satisfy the SNF Part A, ABN requirement. The facility failed to provide R16 and R12 or their representatives, the correct 10055 form which included an estimated cost of continued services when discharged from skilled care. This placed the residents at risk of uninformed decisions and costs about their services and the continuation of their skilled services.

The facility had a census of 70 residents. The sample included 19 residents. Based on record review and interview, the facility staff failed to identify an unwitnessed fall that resulted in serious injury as a potential allegation of neglect or abuse and report immediately to the State Survey Agency (SA), when Resident (R) 172, a cognitively impaired resident, had an unwitnessed fall with injuries. This placed the resident at risk for further injury and unidentified abuse or neglect. Findings included: - R172's Electronic Medical Record (EMR) documented R 172 had diagnoses of displaced posterior arch fracture of the first cervical vertebra (broken neck), fracture of part of the neck of the left femur (thigh bone) just below the ball of the joint (at the hip), reduced mobility, and weakness, R172's Admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview of Mental Status (BIMS) of eight which indicated moderate cognitive impairment. The MDS documented R172 required substantial/maximal staff assistance with most activities of daily living (ADLs) The Care Area Assessment (CAA) dated 12/10/23 documented R172 had a reduction in ADLS and needed minimal assistance from one staff and occasionally two staff. The CAA documented R172 had an increased risk for falls but had no reported falls as of that assessment. R172 reported falls before admission while at home. R172's Care Plan, revised 12/04/23, documented R172 had a fracture of her left femur and cervical spine (neck). The care plan instructed staff to anticipate and meet R172's needs, make sure her call light was within her reach, and respond promptly when it was activated. The plan directed staff to encourage the use of supportive devices (neck collar) and follow physician orders for weight-bearing status and the therapy treatment plan. The care plan instructed staff to monitor R172 for fatigue and educate her family and caregivers on the safety measures necessary to reduce the risk of falls. The care plan instructed staff to keep R172's routine consistent and try to provide consistent caregivers as much as possible to decrease confusion and report to the nurse any changes in R172's cognitive function. The facility's Incident Note, dated 12/27/23 at 01:15 PM, documented that staff heard R172 yelling. Upon entering the room staff observed R172 lying on the floor of her bathroom on her left side with the top half of her body on the floor of the shower and her lower body on the floor of the bathroom. Her back was against the wall of the shower. The note documented R172 had a shirt on and had thrown away her pants. R172 did not have her wheelchair or walker in the bathroom. The note documented R172 complained of extreme pain in her bilateral lower legs and rated the pain the highest rating using the cognitively impaired scale. The note documented R172 had swelling of her left lower leg and bruising of her left chest and left ankle. The note documented staff stabilized R172's head and neck. The facility investigation related to the fall included Fall Witness Statements from staff which documented R172 was toileted at 11:00 AM on the day of the fall and then last observed in the Dining room at 12:40 PM. The investigation did not include a resident statement or root cause analysis. The investigation lacked documentation regarding how the facility ruled out abuse and/or neglect. The Hospital Note, dated 12/27/23, documented R172 arrived at the hospital after she sustained a fall, apparently unwitnessed, when she was tried to the bathroom. R172 immediately complained of left hip pain and pelvic pain, and R172 was unable to provide a specific history due to her cognition. The note documented that R172 had an acute left femoral neck fracture. On 02/12/24 at 01:50 PM, Administrative Staff A verified the facility had not reported R172's unwitnessed fall with injuries to the SA due to the fact he interviewed the three certified nurse aides present at the time of the fall, and no staff were in the room when R172 fell . Administrative Staff A stated R172 was alert and oriented and was able to tell staff what happened. The facility's Abuse Prevention Policy, revised 06/23, documented that all alleged violations, including injuries of unknown sources and misappropriation of resident property, would be reported immediately to the administrator of the facility and to the officials in accordance with state law through established procedures. The policy documented all alleged violations would be reported to the administrator/designee immediately and thoroughly investigated. all alleged incidents of abuse, mistreatment, or neglect would be reported to the state licensing agency immediately or within 24 hours. once the incident is fully investigated the administrator or designee would notify the person making the report of the conclusions and any corrective actions implemented based on investigative findings. The facility staff failed to report R172's unwitnessed fall with injuries to the SA as required, placing her at risk for further injury and unidentified abuse or neglect.

The facility had a census of 70 residents. The sample included 19 residents. Based on record review, and interview, the facility failed to identify an unwitnessed fall that resulted in serious injury as a potential allegation of neglect or abuse and conduct a thorough investigation, when Resident (R) 172, a cognitively impaired resident, had an unwitnessed fall with serious injuries. This placed the resident at risk for further injury and unidentified abuse or neglect. Findings included: - R172's Electronic Medical Record (EMR) documented R 172 had diagnoses of displaced posterior arch fracture of the first cervical vertebra (broken neck), fracture of part of the neck of the left femur (thigh bone) just below the ball of the joint (at the hip), reduced mobility, and weakness, R172's Admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview of Mental Status (BIMS) of eight which indicated moderate cognitive impairment. The MDS documented R172 required substantial/maximal staff assistance with most activities of daily living (ADLs) The Care Area Assessment (CAA) dated 12/10/23 documented R172 had a reduction in ADLS and needed minimal assistance from one staff and occasionally two staff. The CAA documented R172 had an increased risk for falls but had no reported falls as of that assessment. R172 reported falls before admission while at home. R172's Care Plan, revised 12/04/23, documented R172 had a fracture of her left femur and cervical spine (neck). The care plan instructed staff to anticipate and meet R172's needs, make sure her call light was within her reach, and respond promptly when it was activated. The plan directed staff to encourage the use of supportive devices (neck collar) and follow physician orders for weight-bearing status and the therapy treatment plan. The care plan instructed staff to monitor R172 for fatigue and educate her family and caregivers on the safety measures necessary to reduce the risk of falls. The care plan instructed staff to keep R172's routine consistent and try to provide consistent caregivers as much as possible to decrease confusion and report to the nurse any changes in R172's cognitive function. The facility's Incident Note, dated 12/27/23 at 01:15 PM, documented that staff heard R172 yelling. Upon entering the room staff observed R172 lying on the floor of her bathroom on her left side with the top half of her body on the floor of the shower and her lower body on the floor of the bathroom. Her back was against the wall of the shower. The note documented R172 had a shirt on and had thrown away her pants. R172 did not have her wheelchair or walker in the bathroom. The note documented R172 complained of extreme pain in her bilateral lower legs and rated the pain the highest rating using the cognitively impaired scale. The note documented R172 had swelling of her left lower leg and bruising of her left chest and left ankle. The note documented staff stabilized R172's head and neck. The facility investigation related to the fall included Fall Witness Statements from staff which documented R172 was toileted at 11:00 AM on the day of the fall and then last observed in the Dining room at 12:40 PM. The investigation did not include a resident statement or root cause analysis. The investigation lacked documentation regarding how the facility ruled out abuse and/or neglect. The Hospital Note, dated 12/27/23, documented R172 arrived at the hospital after she sustained a fall, apparently unwitnessed, when she was tried to the bathroom. R172 immediately complained of left hip pain and pelvic pain, and R172 was unable to provide a specific history due to her cognition. The note documented that R172 had an acute left femoral neck fracture. On 02/12/24 at 01:50 PM, Administrative Staff A verified the facility had not reported R172's unwitnessed fall with injuries to the SA due to the fact he interviewed the three certified nurse aides present at the time of the fall, and no staff were in the room when R172 fell . Administrative Staff A stated R172 was alert and oriented and was able to tell staff what happened. The facility's Abuse Prevention Policy, revised 06/23, documented all alleged violations, including injuries of unknown sources and misappropriation of resident property would be reported immediately to the administrator of the facility and to the officials in accordance with state law through established procedures. The policy documented all alleged violations would be reported to the administrator/designee immediately and thoroughly investigated. all alleged incidents of abuse, mistreatment, or neglect would be reported to the state licensing agency immediately or within 24 hours. once the incident is fully investigated the administrator or designee would notify the person making the report of the conclusions and any corrective actions implemented based on investigative findings. The facility failed to thoroughly investigate potential abuse or neglect when R172, a cognitively impaired resident, had an unwitnessed fall with serious injuries placing her at risk for further injury and unidentified abuse or mistreatment.

The facility had a census of 70 residents. The sample included 19 residents, with one reviewed for catheters (a tube inserted into the bladder to drain urine into a collection bag). Based on observation, record review, and interview, the facility failed to notify the physician when Resident (R) 10's urine output was less than 360 milliliters (ml) in 12 hours as ordered. This placed the resident at risk for physical decline. Findings included: - The Electronic Medical Record (EMR) R10 documented diagnoses of neuromuscular dysfunction of the bladder (the muscles that control the flow of urine out of the body do not relax and prevent the bladder from fully emptying), multiple sclerosis (MS- progressive disease of the nerve fibers of the brain and spinal cord), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear) and depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R10 had intact cognition and was dependent upon staff for toileting, showers, dressing, transfers, and personal hygiene. The MDS further documented R10 had a catheter. R10's Care Plan, dated 11/21/23, initiated on 09/24/20, directed staff to irrigate (flush) the catheter with acetic acid (vinegar) and sterile water per orders. The update, dated 04/30/21, directed staff to change the suprapubic (surgically created connection between the urinary bladder and the skin used to drain urine from the bladder) catheter as ordered. The update, dated 06/15/21, directed staff to monitor, record, and report to the physician any signs of infections; and check the catheter anchor (secures and stabilizes a catheter to keep it in place). The plan directed to monitor and document intake and output per facility policy. An update, dated 03/26/23, directed staff to monitor R10's urine output and report any concerns to the physician. The Physician's Order, dated 03/28/23, directed staff to detach the catheter bag and irrigate R10's catheter every morning with five milliliters (ml) of acetic acid 0.25%, and 60 ml of sterile water. Instill into the catheter and allow to drain freely, reattach the catheter bag, and the procedure was to be done by the nurse. The physician further directed staff to clean around the catheter, apply a drainage sponge, secure it with tape, change it daily, and report any changes to the physician. The order directed staff to document urine output every shift and notify the physician if the urine output was less than 360 ml in 12 hours. R10's Treatment Administration Record (TAR), dated February 2024, documented the following outputs. 02/09/24 dayshift-70 ml 02/09/24 nightshift-70 ml The EMR lacked evidence the physician was notified of less than 360 ml of urine output that was outside of the ordered parameters. On 02/12/24 at 11:30 AM, observation revealed R10 sat in his room watching television. Further observation revealed R10 declined any survey observations of his catheter care. On 02/12/24 at 11:15 AM, Licensed Nurse (LN) G verified the urine output below 360 ml and stated the physician should have been notified as ordered. On 02/13/24 at 09:00 AM, Administrative Nurse D stated the 70 ml urine output was very low for the resident and staff should have contacted the physician. The facility's Notification, Physician or Responsible Party, policy, dated 09/18, directed staff to promptly notify the resident's physician, and//or responsible party of changes in the resident's condition and/or status. The policy further directed staff to notify the physician when there was a need to alter the resident's treatment significantly and he/she would be notified when deemed necessary or appropriate. The facility failed to notify the physician as ordered when R10's urine was out of the parameters as set by the physician. This placed the resident at risk for physical decline.

The facility had a census of 70 residents. The sample included 19 residents. Based on observation, interview, and record review, the facility failed to date Resident(R)20's insulin (a hormone which allows cells throughout the body to uptake glucose) flex pen when opened and failed to discard R11 and R12 insulin flex pen when outdated. This deficient practice placed the affected resident at risk for ineffective medications. Findings included: - On [DATE] at 08:40 AM, observation of the facility's [NAME] Hall treatment cart revealed the following: R20's Humulin aspart (rapid-acting insulin) flex pen lacked an open date and discard date. R11 Lantus (long-acting insulin) date opened [DATE] (expired on [DATE], 28 days.) R12 Humalog (fast-acting insulin) date opened [DATE] (expired on [DATE], 28 days) On [DATE] at 08:45 AM, Licensed Nurse (LN) I verified the nurses were to date the insulin pens when opened and discard the expired insulin. On [DATE] at 09:30 AM, Administrative Nurse D verified the nurses should label and date the insulin pens with the resident's name and discard expired pens. Medlineplus.gov directs open, unrefrigerated Lantus, insulin lispro (Humalog) and Humulin aspart pens can be used within 28 days; after that time, they must be discarded. The facility lacked a Storage of Medication policy, dated ,d+[DATE], documented it is the policy of the facility to store all drugs and biologicals in locked compartments under proper temperature control. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. The policy documented insulin pens are labeled with name and date opened and stored in the cart. The facility failed to label, and date the resident's flex pen, with the date opened and expiration date placing the residents at risk for ineffective medication.

The facility had a census of 70 residents. The sample included 19 residents, with two reviewed for choices. Based on observation, record review, and interview, the facility failed to offer Resident (R) 163 a choice of showers instead of sponge baths. This placed R163 at risk for decreased self-determination and impaired psychosocial well-being. Findings included: - The Electronic Medical Record (EMR) for R163 documented diagnoses of fracture around the internal prosthetic right knee joint (a break in the bone around the knee implant), need for assistance with personal care, weakness, heart failure, and hypertension (high blood pressure). The Admission Medicare 5-Day Minimum Data Set (MDS), dated [DATE], documented R163 had severely impaired cognition and was dependent upon staff for lower body dressing, and substantial to maximum assistance with toileting, upper body dressing, mobility, and bathing. The MDS further documented it was very important for R163 to choose between a tub bath, shower, bed bath, or sponge bath. R163's Care Plan, dated 01/31/24, documented R163 required assistance with bathing and/or showering and all hygiene. The facility's Bathing Record, for January and February 2024, documented R163 received two baths per week, on dayshift Wednesday and Sunday. On 02/07/24 at 10:23 AM, R163's family member stated R163 preferred showers and did not understand why she had only received sponge baths since her admission. On 02/12/24 at 10:45 AM R163 stated staff brought in a bucket with water so she could wash herself off and further said she would like to have a shower next time. On 02/12/24 at 12:56 PM, Licensed Nurse (LN) H stated that R163 required the use of a full mechanical lift and that it was hard to get the lift into the shower room, so staff decided to give R163 sponge baths. LN H further stated R163 no longer used the full lift, but R163 continued to receive sponge baths. On 02/13/24 at 09:40 AM, Certified Nurse Aide (CNA) M verified she had never offered a shower to R163. On 02/13/24 at 09:00 AM, Administrative Nurse D stated that R163 should be asked what her preference was with bathing. Administrative Nurse D said the facility had other means to provide showers to residents who required full lifts for transfers. The facility's Bath, Shower policy, dated 05/23, documented it was the policy of the facility that residents would be able to choose when they wanted to bathe and what style of bathing the resident preferred. The facility failed to offer a choice of bathing to R163. This placed R163 at risk for decreased self-determination and impaired psychosocial well-being.

The facility identified a census of 63 residents. The sample included 18 residents with one resident reviewed for self-administration of medications. Based on observations, interviews, and record reviews, the facility failed to assess Resident (R)116 for the ability to safely self-administrator medications. This deficient practice placed R116 at risk for medication errors and unnecessary side effects. Findings Included: - A review of R116's Electronic Medical record (EMR) revealed that she was admitted to the facility on [DATE]. The Medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of R116's EMR indicated that her Minimum Data Set (MDS) information was not available for review. A review of R116's Assessments revealed a Brief Interview for Mental Status (BIMS) score of 10 completed on 08/29/22 indicating moderate cognitive impairment. A review of R116's EMR lacked evidence an assessment was completed related to self-administration of medication for R116. R116's Care Plan created 08/27/22 noted that R116 was at risk for impaired cognitive thought processes related to impaired decision making. The plan instructed staff to keep her routine consistent and try to provide consistent care givers as much as possible to decrease confusion. A review of R116's Medication Administration Report (MAR) indicated that her morning medications on 08/29/22 had been administered. On 08/29/22 at 10:48 PM observation revealed a plastic medication cup with four white pills inside sat on R116's bedside table. On 08/29/22 at 10:48 AM R116 reported that nursing staff left her medication on the bedside table but further said she would not take the medication because she did not know what it was or what the medication did. R116's representative reported that she was not sure why the medications were left in the room or if staff expected R116 to take the medication's herself. On 08/31/22 at 01:40 PM in interview with Licensed Nurse (LN) H, she stated that medications should never be left in the resident's room unsupervised. She stated that some residents could self-administer medications but required a risk assessment to be completed for their safety. On 08/31/22 at 03:40 PM in an interview with Administrative Nurse D, she stated that if a resident desired to self-administer medications, an assessment must be completed to ensure they were safe to administer the medications themselves. She stated that R116 was not safe for self-administration of medications and that the medications should not have been left in the room. A review of the facility's Medication Administration Policy revised 01/2022 stated that all medications given will be documented in the Medication Administration Report as the medications are given only by a licensed nurse or certified medication aide. The facility failed to assess R116 for the ability to self-administrator medications safely. This deficient practice placed R116 at risk for medication errors and unnecessary side effects.

The facility identified a census of 63 residents. The sample included 18 residents with one resident reviewed for physician notification. Based on observations, interviews, and record reviews, the facility failed to notify Resident (R)18's physician of R18's face/head injuries obtained during an accident while being transferred with a Hoyer lift (total body mechanical lift used to transfer residents). This deficient practice placed R18 at risk for complications related to accidents and injuries. Findings Included: - The Medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R18's Quarterly Minimum Data Set (MDS) dated [DATE] noted a Brief Interview for Mental Status (BIMS) assessment could not be completed due to severe cognitive impairment. The MDS noted that she required extensive assistance from two staff for all transfers and bed mobility. A review of R18's Dementia Care Area Assessment (CAA) dated 12/17/21 noted a BIMS score of three at the time of assessment with a dementia diagnosis. A review of R18's Communication CAA dated 12/17/21 she had an impaired ability to make herself understood and to express ideas and wants with others. R18's Care Plan created 01/03/20 noted that she had a self-care deficit related to her activities of daily living (ADL's). The plan noted that she required two staff to transfer her with the Hoyer lift. The care plan noted that she had a risk for impaired skin integrity noted. The plan instructed staff to use caution during transfers and bed mobility to prevent injuries from sharp or hard surfaces. The care plan indicated that R18 was taking [MEDICATION(S)] (medication used to prevent blood from clotting) and was at risk for [CONDITION(S)] (disorder where blood does not clot leading to excessive bleeding). A review of a Witness Statement completed on 08/25/22 by Certified Medication Aid (CMA) R indicated that R18 was struck on the left cheekbone by the sling attachment point (metal swivel bar) during a Hoyer transfer from R18's bed to her wheelchair on 08/25/22 at 08:00 AM. The statement noted Certified Nurse Aid (CNA) M notified the charge nurse immediately of the incident. A review of a Witness Statement completed 08/25/22 by CNA M noted that while transferring R18, the Hoyer lift's arm struck R18 in the face. R18's clinical record lacked evidence the physician was notified regarding the accident related injury. On 08/30/22 at 12:05PM R18 ate her lunch in the dining area. R18's left cheek had a circular quarter sized dark blue bruise under her left eye. R18 was unable to communicate how her injury happened. On 08/31/22 at 01:20 PM Licensed Nurse (LN) G stated that she notified the nurse practitioner and the family but did not document the notifications. LN G stated that the resident's representative was contacted about the accident. On 08/31/22 at 03:54 PM Administrative Nurse D stated that both the physician and the resident representative had been notified at the time, but LN G wasn't able to document the information. She stated that she also had intended to update the information but was out those days due to an illness. A review of the facility's Notification to Physician and Responsible Party policy revised 08/2022 noted that the facility is required to promptly notify the resident, attending physician, and resident representative of any change in conditions or status. The facility failed to ensure that R18's attending physician was notified of face/head injuries from an accident during a Hoyer lift transfer. This deficient practice placed R18 at risk for complications related to accidents and injuries.

The facility identified a census of 63 residents. The sample included 18 residents with 18 residents reviewed for development of comprehensive care plans. Based on observation, record review, and interviews, the facility failed to develop a person-centered comprehensive care plans for Resident (R) 43, related to an individualized toileting program and/or bladder retraining. This deficient practice placed the resident at risk of not achieving and/or maintaining her highest practicable physical, mental, and psychosocial well-being due to unmet or uncommunicated care needs. Findings included: - R43's Electronic Medical Record (EMR) from the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 13 which indicated intact cognition. The MDS documented that R43 required extensive assistance of one staff member for toileting and bed mobility, limited assistance of one staff member for transfers and dressing and limited assistance of two staff members for personal hygiene. R43's Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA) dated 08/12/22 documented R43 was incontinent of bladder and bowels and required assistance with toileting. Review of the EMR under Assessments tab revealed a Bowel and Bladder Evaluation dated 08/09/22 which documented R43was a likely candidate for bowel and bladder retraining. R43's Care Plan dated 08/10/22 documented staff was to offer restroom frequently. The Care Plan lacked resident -specific toileting schedule or interventions related to bladder retraining. R43's clinical record lacked evidence a bladder retraining program was attempted or implemented. On 08/30/22 at 12:21 PM R43 was assisted into the bathroom, R43 was not incontinent of urine. One staff member assisted her into the bathroom. On 08/29/22 at 11:23 AM R43 stated she was aware of the urge to void and had a few episodes of incontinence when she was unable to get to the bathroom in time. On 08/31/22 at 01:19 PM Licensed Nurse (LN) H stated the Bowel and Bladder Evaluation was completed by LN I and was not sure what information was reviewed for that evaluation. LN H stated she had access to the care plan and was able to make changes to the care plan if needed or would notify the director of nursing or the assistant director of nursing to make the changes to the care plan. On 08/31/22 at 01:30 PM Certified Medication Aide (CMA) R stated R43 was continent of urine most of the times she had assisted her to the bathroom. CMA R stated she was not aware of an individualized toileting schedule for R43. CMA R stated she would check R43 every two hours. CMA R stated she had access to review the resident's care plan and care information was found on the Kardex (a medical information system used by nursing staff to communicate important information on their patients. It is a quick summary of individual patient needs that is updated at every shift change). On 08/31/22 at 02:47 PM Administrative Nurse D stated LN I completed the Bowel and Bladder Evaluation three days after a resident's admission to the facility. Administrative Nurse D stated LN I reviewed the documentation under the Tasks tab in the EMR for bowel and bladder. Administrative Nurse D stated that LN I would make a note in the progress notes and update the resident's care plan. Administrative Nurse D stated she was unable to located LN I progress note for the current evaluation for R43. The facility Comprehensive Person-Centered Care Plan policy, last revised January 2022 documented the resident's comprehensive care plan would be review and revised after each assessment. The facility failed to develop a person-centered comprehensive care plans for R43 related to an individualized toileting program and/or bladder retraining. This deficient practice placed the resident at risk of unmet or uncommunicated care needs.

The facility identified a census of 63 residents. The sample included 18 residents with two residents sampled for respiratory care. Based on observation, record review and interview, the facility failed to ensure that a comprehensive person-centered care plan was implemented for R58's oxygen (O2) therapy/use. This deficient practice placed R58 at risk uncommunicated care needs related to O2 therapy. Findings included: - The electronic medical record (EMR) for R58 documented diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Significant Change Minimum Data Set (MDS) dated [DATE] documented R58 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. R58 required extensive assistance of two staff for all her activities of daily living (ADLs). R58 required O2 therapy. The ADL Care Area Assessment (CAA) dated 08/22/22 documented R58 admitted for [CONDITION(S)] and was on hospice. R58 needed staff assistance with ADLs. R58 was noted with O2 use. R58's Care Plan lacked directives or intervention related to O2 use/care. Under the Orders tab, R58 had an order dated 07/22/22 to titrate (to continuously measure and adjust the balance of) O2 to keep saturation level between 88 to 92 percent (%). Under the Orders tab R58 had an order dated 07/22/22 to change O2 tubing and humidifier bottle weekly every Wednesday night shift. An initial observation on 08/29/22 at 01:56 PM revealed R58 had O2 on per nasal cannula (NC-tube which delivers oxygen through the nostrils). The tubing lacked a date to indicate when the tubing was last changed. On 08/31/22 at 10:46 AM R58 laid in bed with her O2 on. On 08/31/22 at 01:00 PM Certified Nurse Aide (CNA) M stated that the care plan for the residents should show the cares needed for the O2 therapy. The care plan was updated by the nurses. On 08/31/22 at 01:08 PM Licensed Nurse (LN) G stated that the care plan was initiated at admission and the interdisciplinary team (IDT) would update the care plan as needed. LN G was not aware that R58 lacked a care plan area for her O2. On 08/31/22 at 02:47 PM Administrative Nurse D stated that the initial care plan was completed by herself or Administrative Nurse E and was updated as needed by nursing staff. Administrative Nurse D said R58 should have a care area in her care plan for the O2 therapy but it appeared that it had been omitted. The facility policy Comprehensive Person-Centered Care Planning revised 01/22 documented: the facility interdisciplinary team (IDT) shall develop a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, mental and psychological needs that were identified in the comprehensive assessment. The facility failed to ensure that R58's comprehensive care plan included interventions and directives for O2 therapy/care. This deficient practiced placed R58 at risk for unmet care needs related to O2 therapy.

The facility identified a census of 63 residents. The sample included 18 residents with three residents reviewed for accidents. Based on observations, interviews, and record reviews, the facility failed to ensure a safe environment free from preventable accidents when staff hit Resident (R)18 in the face with the Hoyer lift (total body mechanical lift used to transfer residents) swivel bar during a transfer. This deficient practice placed R18 at risk for complications related to accidents and injuries. Findings Included: -The Medical Diagnosis section within R18's Electronic Medical Records (EMR) included diagnoses of [CONDITION(S)] (paralysis of one side of the body), major depressive disorder(major mood disorder), dementia (progressive mental disorder characterized by failing memory, confusion), muscle weakness, [CONDITION(S)] (severely overweight), and anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). R18's Quarterly Minimum Data Set (MDS) dated [DATE] noted a Brief Interview for Mental Status (BIMS) assessment could not be completed due to severe cognitive impairment. The MDS noted that she required extensive assistance from two staff for all transfers and bed mobility. A review of R18's Dementia Care Area Assessment (CAA) dated 12/17/21 noted a BIMS score of three at the time of assessment with a dementia diagnosis. A review of R18's Communication CAA dated 12/17/21 she had an impaired ability to make herself understood and to express ideas and wants with others. R18's Care Plan created 01/03/20 noted that she had a self-care deficit related to her activities of daily living (ADL's). The plan noted that she required two staff to transfer her with the Hoyer lift. The care plan noted that she had a risk for impaired skin integrity noted. The plan instructed staff to use caution during transfers and bed mobility to prevent injuries from sharp or hard surfaces. The care plan indicated that R18 was taking [MEDICATION(S)] (medication used to prevent blood from clotting) and was at risk for [CONDITION(S)] (disorder where blood does not clot leading to excessive bleeding.) A review of a Witness Statement completed on 08/25/22 by Certified Medication Aid (CMA) R indicated that R18 was struck on the left cheekbone by the sling attachment point (metal swivel bar) during a Hoyer transfer from R18's bed to her wheelchair on 08/25/22 at 08:00 AM. The statement noted Certified Nurse Aid (CNA) M notified the charge nurse immediately of the incident. A review of a Witness Statement completed 08/25/22 by CNA M noted that while transferring R18, the Hoyer lift's arm struck R18 in the face. A review of the facility's In-Service training logs revealed that the facility recently held a Skills Fair held in 04/17/22 that included resident accidents, lifting transfers, and resident injuries. The review revealed staff involved completed the skills check-off training and received monthly online training on topics related to accident prevention, transfers, and basic care skills. On 08/30/22 at 12:05 PM R18 was observed eating her lunch in the dining area. R18's left cheek had a circular quarter sized dark blue bruise under her eye. R18 was unable to communicate how her injury happened. On 08/30/22 at 02:00 PM Certified Nurses Aide (CNA) M stated that she assisted Certified Medication Aide (CMA) R with transferring R18 to her wheelchair when the metal sling arm came forward and struck R18 in the left cheek. She stated neither staff held the sling arm while moving the machine and the arm where the sling connected struck R18 in the face while the lift was moved backwards. On 08/30/22 at 02:45 PM CMA R stated that the momentum of the sling being unhooked caused the Hoyer lift arm to swivel forward and strike R18 in the face. She stated that it was an accident and the nurse was immediately notified. She stated that staff offered a cold compress pack (ice pack) but R18 would not allow them to assist her. On 08/31/22 at 01:20 PM Licensed Nurse (LN) G stated when she arrived in R18's room the accident had already occurred and R18 was crying and refusing cares from the staff. She stated that she assessed R18 and notified Administrative Nurse D, the nurse practitioner, and R18's representative. She stated that she did enter note to monitor R18's left cheek but no documentation was completed related to R18's assessment, physician/guardian notification, or injury documentation. LN G stated that she had left work early due to being stressed out from the incident and was not able to complete the documentation. On 08/31/22 at 02:00 LN H stated that all Hoyer lift transfers required two staff members to safely move a resident between positions. She stated that if an injury occurred, she would immediately assess the resident's health and safety, notify the physician, administrative nurses, and the resident's representative. She stated that the assessments should have been documented in the EMR and an incident note created to show what happened. On 08/31/22 at 03:54PM Administrative Nurse D reported that all injuries were to be assessed and documented. She stated that all transfer with the Hoyer lift required two staff members present to ensure the resident was safely moved. She stated that all staff had recently received in-services related to transfers, accident management, and patient safety. A review of the facility's Hoyer Lift 03/2022 stated that it is the facility's responsibility to ensure all resident's that required transfers using a mechanical device by safely transferred. The policy indicated that two staff members are required to be assisting for the safety of the resident in the event of a device failure or emergency. The facility failed to safely transfer R18 from her bed to her wheelchair resulting in an injury during a Hoyer lift transfer. This deficient practice placed R18 at risk for complications related to accidents and injuries.

The facility identified a census of 63 residents. The sample included 18 residents. Based on observation, record review, and interviews, the facility failed to provide an individualized toileting program for Resident (R) 43 to promote continence. This placed her at risk for increased incontinence and impaired dignity and well-being. Findings included: - R43's Electronic Medical Record (EMR) from the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 13 which indicated intact cognition. The MDS documented that R43 required extensive assistance of one staff member for toileting and bed mobility, limited assistance of one staff member for transfers and dressing and limited assistance of two staff members for personal hygiene. R43's Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA) dated 08/12/22 documented R43 was incontinent of bladder and bowels and required assistance with toileting. Review of the EMR under Assessments tab revealed a Bowel and Bladder Evaluation dated 08/09/22 which documented R43 was a likely candidate for bowel and bladder retraining. R43's Care Plan dated 08/10/22 documented staff was to offer restroom frequently. The Care Plan lacked resident -specific toileting schedule or interventions related to bladder retraining. R43's clinical record lacked evidence a bladder retraining program was attempted or implemented. On 08/30/22 at 12:21 PM R43 was assisted into the bathroom, R43 was not incontinent of urine. One staff member assisted her into the bathroom. On 08/29/22 at 11:23 AM R43 stated she was aware of the urge to void and had a few episodes of incontinence when she was unable to get to the bathroom in time. On 08/31/22 at 01:19 PM Licensed Nurse (LN) H stated the Bowel and Bladder Evaluation was completed by LN I and she was not sure what information was reviewed for that evaluation. LN H stated she had access to the care plan and was able to make changes to the care plan if needed or would notify the director of nursing or the assistant director of nursing to make the changes to the care plan. On 08/31/22 at 01:30 PM Certified Medication Aide (CMA) R stated R43 was continent of urine most of the times she had assisted her to the bathroom. CMA R stated she was not aware of an individualized toileting schedule for R43. CMA R stated she would check R43 every two hours. CMA R stated she had access to review the resident's care plan and care information was found on the Kardex (a medical information system used by nursing staff to communicate important information on their patients. It is a quick summary of individual patient needs that is updated at every shift change). On 08/31/22 at 02:47 PM Administrative Nurse D stated LN I completed the Bowel and Bladder Evaluation three days after a resident's admission to the facility. Administrative Nurse D stated LN I reviewed the documentation under the Tasks tab in the EMR for bowel and bladder. Administrative Nurse D stated that LN I would make a note in the progress notes and update the resident's care plan. Administrative Nurse D stated she was unable to locate LN I's progress note for the current evaluation for R43. The facility Bladder and Bowel Assessment and Policy policy dated February 2022 documented the assessment would be completed quarterly, and with significant change and annually with each MDS. The care plan would be updated to reflect toileting schedule or other measures employed to reduce/prevent incontinence. The facility failed to provide an individualized toileting program and/or bladder retraining for R43 to promote continence. This placed her at risk for increased incontinence and impaired dignity and well-being.

The facility identified a census of 63 residents. The sample included 18 residents with 18 residents reviewed for competent nurse staffing. Based on observations, interviews, and record reviews, the facility failed to ensure that staff possessed the knowledge and skills necessary to ensure Resident (R)18 was assessed after an accident with a Hoyer lift (total body mechanical lift used to transfer residents) transfer. The facility additionally failed to complete follow-up assessments for R18's injury. This deficient practice placed R18 at risk for complications from accident related injuries. Findings Included: - The Medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R18's Quarterly Minimum Data Set (MDS) dated [DATE] noted a Brief Interview for Mental Status (BIMS) assessment could not be completed due to severe cognitive impairment. The MDS noted that she required extensive assistance from two staff for all transfers and bed mobility. A review of R18's Dementia Care Area Assessment (CAA) dated 12/17/21 noted a BIMS score of three at the time of assessment with a dementia diagnosis. A review of R18's Communication CAA dated 12/17/21 she had an impaired ability to make herself understood and to express ideas and wants with others. R18's Care Plan created 01/03/20 noted that she had a self-care deficit related to her activities of daily living (ADL's). The plan noted that she required two staff to transfer her with the Hoyer lift. The care plan noted that she had a risk for impaired skin integrity noted. The plan instructed staff to use caution during transfers and bed mobility to prevent injuries from sharp or hard surfaces. The care plan indicated that R18 was taking [MEDICATION(S)] (medication used to prevent blood from clotting) and was at risk for [CONDITION(S)] (disorder where blood does not clot leading to excessive bleeding). A review of a Witness Statement completed on 08/25/22 by Certified Medication Aid (CMA) R indicated that R18 was struck on the left cheekbone by the sling attachment point (metal swivel bar) during a Hoyer transfer from R18's bed to her wheelchair on 08/25/22 at 08:00 AM. The statement noted Certified Nurse Aid (CNA) M notified the charge nurse immediately of the incident. A review of a Witness Statement completed 08/25/22 by CNA M noted that while transferring R18, the Hoyer lift's arm struck R18 in the face. A review of R18's clinical record revealed the last nursing assessments completed were on 08/22/22. The record lacked evidence an assessment was completed immediately after R18 was hit in the face with the Hoyer. The record further lacked evidence nursing staff assessed and monitored R18 neurological status and skin for latent injury or adverse outcomes related to the accident. R18's clinical record lacked evidence the physician was notified regarding the accident related injury. On 08/30/22 at 12:05 PM R18 ate her lunch in the dining area. R18's left cheek had a circular quarter sized dark blue bruise under her left eye. R18 was unable to communicate how her injury happened. On 08/31/22 at 01:20 PM Licensed Nurse (LN) G stated that when she arrived in R18's room the accident had already occurred and R18 was crying and refusing cares from the staff. She stated that she assessed R18 and notified Administrative Nurse D, the nurse practitioner, and R18's representative. She stated that she did enter note to monitor R18's left cheek but no documentation was completed related to R18's assessment, physician/guardian notification, or injury documentation. LN G stated that she had left work early due to being stressed out from the incident and was not able to complete the documentation. On 08/31/22 at 12:54PM Administrative Nurse D reported that upon reviewing R18's EMR, she noted that no assessment or documentation had been completed since the incident occurred on 08/25/22 but stated that the physician had been notified and they monitored R18 closely for her injuries. A review of the facility's Incident reporting and Investigations policy revised 03/2022 reported that the facility must investigate all injuries and assess residents after accidents for safety and identify interventions to prevent future interventions for safety. The policy noted all injuries must be assessed by a licensed nurse and reported to the physician. The facility failed to ensure staff assessed for injuries from an accident during a Hoyer lift transfer. The facility additionally failed to staff monitored R18's injury. This deficient practice placed R18 at risk for complications related to accidents and injuries.

The facility identified a census of 61 residents. The sample included 19 residents. Based on observations, record reviews, and interviews, the facility failed to ensure safe and appropriate self-administration of medication for Resident (R) 18. Findings included: - R18 admitted to facility 09/30/17. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual Minimum Data Set (MDS) dated [DATE] documented R18 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. R18 required extensive physical assistance with two staff with bed mobility and transfers; extensive physical assistance with one staff with dressing and personal hygiene. R18 received opioid (pain reducing medications) medications seven days of the seven-day lookback period. The Quarterly MDS dated [DATE] documented R18 had a BIMS score of 15 which indicated intact cognition. R18 required extensive physical assistance with two staff with bed mobility and transfers; extensive physical assistance with one staff with dressing and personal hygiene. R18 received opioid medications seven days of the seven-day lookback period. The Activities of Daily Living (ADL)/Rehabilitation Potential Care Area Assessment (CAA) dated 09/07/20 lacked an analysis of findings. The Discomfort Care Plan dated 10/01/17 documented R18 had discomfort related to RA and old left shoulder injury and documented an intervention dated 03/25/19 that R18 received [MEDICATION(S)] (diclofenac- topical [the surface of a part of the body] gel used to treat pain) gel for pain management. The ADLS Care Plan dated 10/01/17 documented R18 could not care for herself like she used to and she needed help to do daily cares and documented an intervention dated 01/17/20 that R18 received Refresh (eye drops used to treat dry eye symptoms) per orders. The Orders tab of R18's EMR documented an order with an order date of 02/08/21 for [MEDICATION(S)] gel two grams transdermally (application of medication through the skin) four times a day for should and neck pain related to [CONDITION(S)] and an order with a start date of 02/08/21 for Refresh [MEDICATION(S)] Advanced Solution one drop in both eyes every four hours as needed for dry eyes. The EMR lacked an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The Assessments tab of R18's EMR documented an Initial Admission Record assessment on 09/30/17, 01/14/19, 02/27/20, and 02/08/21 that documented R18 had no desire for self-administration of drugs. The Treatment Administration Record documented R18 received [MEDICATION(S)] gel four times a day scheduled. In an observation on 05/26/21 at 09:15 AM, [MEDICATION(S)] gel tube and Refresh eye drops bottle noted on R18's tray table. In an observation on 05/27/21 at 09:11 AM, [MEDICATION(S)] gel tube and Refresh eye drops bottle noted on R18's tray table. In an observation on 05/27/21 at 04:44 PM, [MEDICATION(S)] gel tube and Refresh eye drops bottle noted on R18's tray table. In an observation on 06/01/21 at 01:56 PM, [MEDICATION(S)] gel tube on bathroom vanity and Refresh eye drops bottle on R18's tray table. R18 sat in her recliner and watched television, she appeared comfortable and without signs of distress. In an interview on 05/27/21 at 09:11 AM, R18 stated it was difficult to put the [MEDICATION(S)] gel on herself and she did not think she had been assessed on whether she could have administered [MEDICATION(S)] gel and eye drops herself. In an interview on 06/02/21 at 01:40 PM, Administrative Nurse D stated R18 did not have a self-administration of medication assessment in EMR. In an interview on 06/02/21 at 02:02 PM, Licensed Nurse (LN) G stated residents could self-administer medications if there was a doctor's order to leave at bedside and the director of nursing approved it after a self-administration of medication assessment was completed. In an interview on 06/02/21 at 02:41 PM, Administrative Nurse D stated residents could self-administer medications with a doctor's order. She stated a self-administration of medication assessment was completed by the interdisciplinary team (IDT) and care planned accordingly. She stated she was not aware of the [MEDICATION(S)] and Refresh eye drops in R18's room. The facility did not provide a policy for self-administration of medications. The facility failed to ensure self-administration of medications was safe and appropriate for R18. This had the risk for unnecessary medication side effects, in effective administration and self-administration errors.

The facility identified a census of 61 residents. The sample included 19 residents. Based on observations, interviews, and record reviews, the facility failed to ensure accurate assessment and documentation on the Minimum Data Set (MDS) for race/ethnicity for R37 and documentation of anticoagulant (medication used to prevent blood from thickening or clotting) use for R44 and R48. Findings included: - The Admission MDS dated [DATE] documented R37's race/ethnicity as white. The Miscellaneous (Misc) tab of R37's electronic medical record revealed a History and Physical (H&P) progress note by physician on 03/19/21. The H&P documented R37 was a black gentleman. An observation on 05/27/21 at 01:14 PM revealed R37 was a black man and sat in his wheelchair in his room. R37 did not appear to be in distress and was hopeful to be discharged from facility soon. The Admission MDS dated [DATE] documented R44 received anticoagulant medications six days in the seven-day lookback period. The Orders tab of R44's electronic medical record (EMR) documented an order with a start date of 05/08/21 for [MEDICATION(S)] (antiplatelet- medication that prevented or inhibited platelets [component of blood involved in clotting] from adhering to each other and reduced the risk of blood clot formation) 75 milligrams (mg) in the morning for history of [CONDITION(S)] (CVA [stroke] - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain). The Admission MDS dated [DATE] documented R48 received anticoagulant medications six days in the seven-day lookback period. The Orders tab of R48's electronic medical record (EMR) documented an order with start date of 05/21/21 for aspirin (medication that stopped the production of certain natural substances that caused fever, pain, swelling, and blood clots) 81 milligrams (mg) in the morning for clot prevention and an order with a start date of 05/21/21 for [MEDICATION(S)] (antiplatelet- medication that prevented or inhibited platelets [component of blood involved in clotting] from adhering to each other and reduced the risk of blood clot formation) 75 milligrams (mg) in the morning for coronary artery disease (abnormal condition that may affect the flow of oxygen to the heart). In an interview on 06/02/21 at 01:18 PM, Administrative Nurse E stated admissions department documented the race/ethnicity in the MDS but she visited the residents after admission and reviewed the demographics. She stated aspirin and [MEDICATION(S)] were not anticoagulant medications. The facility's Resident Assessment policy, last revised 07/2018, directed the facility completed a comprehensive assessment of the resident's needs and the resident assessment was completed as directed by the state. The policy directed the nursing administration of the facility assured the completion of the resident assessment process enabled the development of an individualized comprehensive care plan for the resident. The facility failed to ensure accurate assessment and documentation of race/ethnicity for R37 and anticoagulant medications for R44 and R48. This had the risk for misidentification/miscommunication with regards to resident care and care planning needs.

The facility identified a census of 51 residents. The sample included 3 residents reviewed for medication administration. Based on record review and interview, the facility failed to ensure staff correctly transcribed physician MEDICATION ORDERS FOR [REDACTED]. Staff administered the incorrect dose of this medication for 5 days, causing repeated hypoglycemic events that contributed to the decline of the resident and ultimately resulted in hospitalization . Findings included: - The closed electronic medical record (EMR) for resident #1 included [DIAGNOSES REDACTED]. The 5-day Minimum Data Set ((MDS) dated [DATE] documented staff assessed the resident's long and short-term memory as intact, with good awareness. The resident required extensive assistance of 2 staff for Activities of Daily Living (ADLs). The physician's orders [REDACTED]. The electronic Medication Administration Record [REDACTED]. The EMR documented the resident's blood sugar as 61 milligrams per deciliter (mg/dl) on 12/30/17, 54 mg/dl on 12/31/17, 67 mg/dl on 1/2/18 at 7:00 AM, and 59 mg/dl on 1/2/18 at 6:56 PM. The American Diabetes Association classified a low blood sugar as a reading below 70 mg/dl. According to fda.gov, a low blood sugar reading was listed as an effect of too much insulin. The nurse's note dated 1/2/18 at 8:48 AM documented the resident asked the nurse how to increase his/her blood sugar. The nurse explained orange juice would increase the blood sugar and proteins would maintain the blood sugar. The MAR indicated [REDACTED]. The nurse's note dated 1/2/18 at 11:34 AM documented staff checked the resident's blood sugar and obtained a low reading. Staff notified medical provider GG and received orders to administer 2 [MEDICATION NAME] tablets over a one hour period. The resident's blood sugar continued to be low at 65 gm/dl. Staff notified medical provider HH and received an order for [REDACTED]. The nurse's note dated 1/2/18 at 6:56 PM documented staff reported to the nurse the resident's blood sugar was 59 mg/dl and the resident's daughter requested the resident to be transferred to the hospital. On 1/8/18 at 5:00 PM, licensed nurse G stated he/she discovered the medication error when he/she entered the resident's room on 1/1/18 in the evening and told the resident he/she was going to administer 19 U of [MEDICATION NAME]. Staff G stated the resident's family member, who visited the resident at the time, stated he/she thought the dose was incorrect. Staff G further stated he/she checked the admission orders [REDACTED]. On 1/12/18 at 3:00 PM, administrative nursing staff D confirmed administrative nursing staff E incorrectly transcribed the medication order and confirmed that the staff administered the wrong dose for 5 days. On 1/12/18 at 3:45 PM, administrative nursing staff E acknowledged he/she had transcribed the order incorrectly. He/she verified the dosage on the original order was for 9 U. On 1/12/18 at 4:45 PM medical provider HH stated staff made him/her aware of the medication error, and stated the low blood sugar, which resulted from the overdose of [MEDICATION NAME] had a direct impact on the resident's decline and subsequent hospitalization . The facility's policy Transcribing Medication Orders, revised 5/17, failed to document a double check system to ensure accurate transcription of medication orders. 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 staff for medication management.