Every finding on record at Tonganoxie Terrace

Based on record review, and interview, the facility failed to provide appropriate treatment and care for Resident (R) 1's peripherally inserted central catheter (PICC-a thin, flexible tube that is inserted into a vein in the upper arm and threaded into a large vein above the heart) including monitoring the resident's status for complications, assessing PICC insertion site, performing PICC line flushes, and providing a sterile dressing change per the standards of care for a PICC line at least every seven days. Findings included:- R1's Electronic Medical Record (EMR) documented diagnoses of bacteremia (presence of bacteria in the blood), sepsis due to Serratia (a severe, life-threatening bloodstream infection often related to indwelling medical devices), multiple sclerosis (MS- progressive disease of the nerve fibers of the brain and spinal cord), and chronic combined systolic and diastolic heart failure (occurs when the heart muscle both fails to contract effectively and becomes too stiff to relax and fill properly). The admission / Medicare Minimum Data Set (MDS), dated 06/05/2026, for R1 documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS documented R1 required partial or moderate assistance for eating, oral hygiene, and personal hygiene. R1 required substantial or maximal assistance for showers, bathing, and dressing. R1 was dependent on staff for bed mobility and transfers. The Functional Abilities Care Area Assessment (CAA), dated 06/05/2026, documented R1 was non-ambulatory, transferred with Hoyer lift (total body mechanical lift), used a wheelchair for all mobility, and was propelled by staff. The CAA documented R1 required extensive assistance with bathing, dressing, and all bed mobility. R1's Care Plan lacked evidence R1 had a PICC line in place. R1's Care Plan lacked any documentation under the Focus, Goals or Interventions/Tasks sections related to R1's PICC line. R1's EMR, under the orders tab, lacked evidence of any orders for PICC line dressing changes, PICC line flushes, or PICC line site monitoring. Order review included all orders from admission on [DATE] to 06/10/2026 when R1 discharged to the hospital. R1's 06/01/2026 to 06/30/2026 Treatment Administration Record (TAR) lacked evidence staff had performed flushes, dressing changes, or site monitoring for R1's PICC line. R1's Nursing admission Screening, with a lock date of 06/02/2026, recorded under the drains and line section, R1 had a PICC line present in the right upper arm. The document recorded R1's PICC line had one lumen (an individual, separate channel or tube inside the main catheter). The document recorded the last dressing change date was 06/01/2026. An Encounter note, dated 06/03/2026, documented R1 had a PICC line but was not receiving intravenous (IV - administered directly into the bloodstream via a vein) antibiotics. The note recorded the provider would review outside Infectious Disease (ID) recommendations and plan for a PICC removal. A New PMR Consultation PCC note, dated 06/04/2026, recorded R1 had previously admitted to the hospital from [DATE] to 04/13/2026. The note recorded R1 was managed in the intensive care and step-down setting with high flow oxygen, weaned to two liters, and she received broad-spectrum IV antibiotics (medications that treat a wide variety of bacterial infections), later narrowed to ceftriaxone (antibiotic) via a newly placed PICC line. R1's EMR lacked any further progress notes related to R1's PICC line. Review of the facility's communication book from 05/31/2026 through 06/14/2026 revealed no documentation or orders related to R1's PICC line. R1's clinical record lacked evidence R1's PICC line dressing had been changed after 06/01/2026. R1's clinical record lacked evidence that R1's PICC insertion site was monitored or assessed after 06/01/2026. R1's clinical record lacked evidence R1's PICC line was flushed after 06/01/2026. R1's clinical record lacked evidence R1's PICC line hub (plastic connector at the very end of a PICC that serves as the main access point) had been capped by staff. On 06/23/2026 at 03:04 PM, Consultant GG stated she had taken care of R1 after R1 arrived at the hospital. She stated central lines needed to have a closing on the end to help prevent infections and R1's PICC line did not have any cap or covering on the hub when she arrived at the hospital from the facility. She stated R1's PICC dressing was not at all intact and the PICC did not have a proper dressing in place. She stated the line appeared to have come out a few centimeters. Consultant GG stated the PICC line did not look right and said there was no date or initials on any part of the PICC line dressing to identify when it was last changed. Consultant GG stated R1 had poor hygiene, and she was concerned about infection risk. She said R1 reported she had not bathed in 10 days. Consultant GG stated R1 had a new PICC line placed while she was in the hospital due to the condition her old PICC was in when she arrived. On 06/23/2026 at 04:02 PM, Licensed Nurse (LN) G stated R1 had a PICC line in place, but they were not running any treatments through it. She stated she did not know if there were any orders for dressing changes or flushes for R1's PICC line. She stated she had been flushing the PICC to keep the lines open. She stated PICC line needed to be flushed to keep them active. LN G stated she believed the facility had standing orders for PICC lines. She stated the facility had a book with all of the standing orders. She verified PICC lines should have caps placed on them and dressings should have been done every three days or every week. She further stated staff were supposed to assess the PICC line site. She said R1 had mentioned that she was concerned about the PICC line and R1 said she still needed it. LN G stated staff were not using it, so she was not sure what R1 still needed the PICC for. She stated orders should probably be in the EMR for staff to document against, or staff should have put in a progress note. LN G stated she spoke to the provider about R1's PICC line and was told to flush it to keep it active. She stated they have a doctor's communication book they write things in for the provider to review that are non-emergent. On 06/23/26 at 04:06 PM, Administrative Nurse D stated she had only been at the facility since 06/08/2026. She stated she was not that familiar with R1 and when she came in R1 had left shortly after. She stated if a resident had a PICC line, staff should still have obtained orders for flushes and dressing changes. She stated PICC lines should be capped and assessed daily. She stated all orders related to PICC line should have been in the resident's chart and care plan. She stated if staff noted something was wrong with the PICC line they should contact the provider for additional orders. Administrative Nurse D stated she was still learning about how the facility handled standing orders; however, she stated if there were standing orders for PICC line cares, they should still have been in the resident's chart. She stated if staff flushed a resident's PICC line they should have documented it so they get credit for what they did. She stated if it was not documented, then it did not happen. She stated any dressing changes need staff initials and the date it was changed. She stated it was a common practice to document the date on a dressing change otherwise it would have been difficult for staff to know when to change it again. She stated any orders that were entered in the communication book would still have needed to be placed in the chart. On 06/23/2026 at 04:20 PM, Administrative Nurse E stated she was unsure if R1 had a PICC line; however, staff should flush and cap PICC lines. She stated the expectation was for staff to complete dressing changes for PICC lines. Administrative Nurse E stated the facility did not have any standing orders for flushes or dressing changes related to PICC lines. She stated that was something she was working on today. She stated any dressing change should have had the date and staff initials. She stated assessments of the PICC should have been documented in R1's chart. Administrative Nurse E further stated there should have been orders in the chart so staff knew what to do in relation to the care for R1's PICC line. She stated if staff had completed any of the cares for R1's PICC line it should have been documented in the TAR or in a progress note that it had been completed. On 06/23/26 at 04:46 PM, Administrative Staff A stated she was not clinical; however, if a resident had a PICC line the expectation was for staff to contact the provider to get orders for PICC dressing changes, flushes, and assessments. She stated staff should have documented that those things were done. The facility's Peripherally Inserted Central Catheter Flushing, Locking, Removal policy with a revised date of 01/15/26, documented it is the policy of the facility to ensure that peripherally inserted central catheters (PICC) are flushed, locked, and removed consistent with current standards of practice. The frequency for flushing and locking central venous access catheter can vary depending upon type of catheter. If no IV therapy is being infused, the facility may follow these guidelines or as per facility/pharmacy protocol: a. Non-valved PICC every 24 hours; b. Valved PICC at least weekly. The facility's PICC/Midline/CVAD Dressing Change policy, with a revised date of January 2026, documented it is the policy of this facility to change peripherally inserted central catheter (PICC), midline or central venous access devices (CVAD) dressing weekly or if soiled, in a manner to decrease potential for infection and or cross contamination. Physician's orders will specify type of dressing and frequency of changes.

Based on observation, record review, and interviews, the facility failed to provide Resident (R) 1 with the necessary behavioral health care and services, that included adequate supervision to prevent unwanted touching by R1 to other residents. Findings included:- R1 admitted to the facility on [DATE]. R1's Electronic Medical Record (EMR) documented a diagnosis of personal history of traumatic brain injury (TBI-an injury to the brain caused by external forces). The admission Minimum Data Set (MDS) dated 03/14/26 documented R1 had a Brief Interview for Mental Status (BIMS) score of four, which indicated severe cognitive impairment. R1 had no behaviors in the assessment period. The Cognitive Loss/Dementia Care Area Assessment (CAA) documented R1 had a TBI that affected her cognition. R1's 04/09/26 Care Plan documented she had a behavior problem related to sexual inappropriateness. The Care Plan documented an intervention, dated 04/09/26, that directed, if reasonable, staff to discuss R1's behavior and explained/reinforced why her behavior was inappropriate and/or unacceptable to R1. R1's 04/29/26 Care Plan documented she had a tendency to invade other people's personal space and interrupt conversations. The Care Plan documented the following interventions:- 04/29/26 Staff assisted R1 to develop more appropriate methods of interacting with others.- 04/29/26 Caregivers provided R1 opportunities for positive interaction and attention, including stopping to talk to her as they passed by.- 04/29/26 Staff intervened as necessary to protect the rights of others. Staff approached R1, spoke in a calm manner, diverted her attention, removed R1 from the situation, and took her to alternate locations as needed. R1's EMR documented the following: A Behavioral Note on 04/28/26 at 02:15 PM, documented R1 repeatedly self-propelled in her wheelchair toward a male resident who was engaged in a conversation with another resident. The male resident verbally requested that R1 maintained personal space and to not interrupt his conversation. R1 continued to approach the male resident despite the verbal redirection. Staff intervened, provided redirection, and guided R1 away from the area. R1 engaged in alternate activity. There was no physical contact. Staff continued to monitor for boundary awareness and provided redirection as needed. A Behavioral Note on 05/14/26 at 06:22 PM, documented R1 reached out to touch another resident. Staff immediately redirected R1. A Behavioral Note on 05/15/26 at 01:34 PM, linked to the note on 05/14/26 at 06:22 PM, documented the nurse did not witness the incident. Staff reported to the nurse that R1 attempted to touch another resident, but staff redirected her. R1 did not understand personal boundaries and had to be redirected at times. A Nurses Note on 05/17/26 at 03:11 PM, documented staff reported R1 was observed with her hand down the front of another resident's pants in the activity room. Staff separated the residents. R1 was unable to give a description of the event. Staff assessed R1 and found no new skin issues. Staff placed R1 on one-on-one supervision with staff. The facility notified R1's provider and representative of the incident. The facility's Investigation dated 05/22/26, documented on 05/17/26 at approximately 11:30 AM, R2 worked on a puzzle at a table in the North activity room with the back of his wheelchair facing the hallway camera. Housekeeper U walked past the activity room and saw R1 with her hands inside R1's pants. Review of the camera footage revealed at approximately 11:15 AM, R1 talked to another resident at the nurse's station, and at 11:22 AM she entered the activity room from the left side. The camera only showed the back wheels of R1's wheelchair behind R2's wheelchair. After a short time, R1's wheelchair could no longer be seen on camera as she moved further into the room. At approximately 11:31 AM, Housekeeper U walked past the activity room on the right side and looked inside to witness the interaction between R1 and R2. A short time later, R1 was seen on the right side of the activity room, and a Certified Nurse Aide (CNA) took her to the dining room for lunch. Administrative Staff A arrived at the facility at 12:06 PM to investigate the incident and R2 stated to her that a woman went up to him while he worked on his puzzle and touched his arm. The facility placed R1 on one-on-one supervision immediately after the situation until the psychiatric provider cleared her from the one-on-one and adjusted her medications to help with R1's behaviors. The facility substantiated the incident as abuse for inappropriate touching based on an eyewitness. Housekeeper U's notarized Witness Statement, dated 05/17/26, stated on 05/17/26 at approximately 11:30 AM, she walked by the North nurses station and entered the activity room. She witnessed R1 with her hand inside R2's pants. She stated she immediately informed a CNA. When the CNA arrived, R1 was already leaving the activity room. CNA M's notarized Witness Statement, dated 05/17/26, stated on 05/17/26, she was in the dining room when Housekeeper U told her R1 had her hands in R2's pants in the television (TV) room. She stated she immediately went to the TV room, and R1 wheeled herself out of the doorway. CNA M notified the nurse of the incident and placed R1 in the dining room for lunch. On 06/03/26 at 12:44 PM, R1 sat in her wheelchair at a dining room table. R4 sat at the table immediately to her left. On 06/03/26 at 12:57 PM, R1 self-propelled in her wheelchair in the dining room towards R5. CNA N and CNA O stood in the dining area facing the kitchen door, with their backs to the dining room. R5 stated to R1, no R1, no. R5 asked CNA O to save him. CNA N intervened and propelled R1 out of the dining room. On 06/03/26 at 01:00 PM, CNA N propelled R1 in her wheelchair down the hallway towards the nurse's station. R3 sat in his wheelchair in the area in front of the nurse's station. While CNA N propelled R1 past R3, R1 reached over to R3 and rubbed his right leg as she went by. CNA N did not react to the touching and continued to propel R1 to the front of the nurse's station. Licensed Nurse (LN) G sat behind the nurse's station. On 06/03/26 at 01:56 PM, R5 stated R1 went up to him all of the time, and she was handsy. He stated R1 tried to touch him inappropriately often, but he would run from her. R5 stated R1's behaviors made him feel uncomfortable. He stated that most of the time, there were staff around to tell R1 to stay in her personal space, but not all the time. R5 stated R1 tried to grab his private parts before. He stated he was afraid of having an allegation made against him because of R1's inappropriate behaviors towards him. On 06/03/26 at 12:36 PM, CNA M stated on 05/17/26, she was in the dining room when Housekeeper U stated R1's hands were in R2's pants. CNA M stated when she went to get R1, R1 was already going out of the door. She stated she had last seen R1 about 30 minutes prior at the nurse's station. CNA M stated R1's typical behaviors included touching staff and other residents. She stated R1 tried to wheel up to other residents, and staff redirected her away from the men. She stated she tried to keep an eye on R1 and tried to get her to do activities. CNA M stated she usually took R1 with her to the dining room or to activities or she asked another staff member to keep an eye on her if there were other residents in the area. She stated R1 was easily redirected and was open to activities. On 06/03/26 at 02:22 PM, CNA N stated it was her first day, but she did not get a report when she came in because she moved halls. She stated she thought the CNAs received papers about each resident, but she did not get one. CNA N stated she was not told anything about R1's behaviors. She stated she did see R1 touch R3's leg, but she was unaware of her inappropriate touching behaviors. She stated she did not tell anybody about the leg touch, but she probably should have. On 06/03/26 at 02:26 PM, CNA O stated she received a report sheet that listed the resident's transfer status, their preferred name, and assistance status. She stated the report sheet did not have a resident's behaviors on it unless they were an elopement risk. CNA O stated she knew R1's behaviors from working with her and knew she was very kind which CNA O thought was what made R1 handsy. She stated most residents did not appreciate R1 touching them. She stated R1 commonly tried to touch residents and staff redirected her, engaged her in activities, or sat her at the nurse's station, which almost always had staff there. On 06/03/26 at 02:50 PM, LN G stated he received a report sheet that gave alerts and cues about the residents. He stated R1 had inappropriate touching behaviors and staff provided cares in pairs and redirection. LN G stated there were usually staff at the nurses station to try and keep an eye on R1. On 06/03/26 at 02:55 PM, Administrative Nurse D stated staff protected other residents from R1's inappropriate touching behaviors by making sure they were kept at an arm's length apart from R1, redirecting R1, and keeping R1 in an area with eyes on her. She stated that all staff were instructed to keep eyes on R1 and try to redirect her. Administrative Nurse D stated staff should always have eyes on R1 while not necessarily having her on one-on-one supervision. She stated there should be a staff member at the nurse's station if R1 was in the area, and they made sure R1 was at an arm's length from other residents. Administrative Nurse D stated staff tried to keep staff around her and to try to not let her touch any other residents. She stated if R1 touched another resident, she expected staff to intervene. She stated R1 was able to inappropriately touch R2 because staff did not have eyes on her, and the facility was aware she had those behaviors, so staff should have kept eyes on her. The facility's Behavioral Health Services policy, dated 2026, directed the facility ensured the necessary behavioral health care services were person-centered and reflected the resident's goals for care, while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety. The facility provided behavioral health care and services in an environment conducive to mental and psychosocial well-being.

The facility had a census of 70 residents. The sample included 18 residents, with one reviewed for pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Based on observation, record review, and interview, the facility failed to initiate effective interventions to prevent the development of the left lateral (pertaining to the side, away from the middle) foot and left middle toe facility acquired pressure ulcers for Resident (R) 44.Findings included: - R44's diagnoses included metabolic encephalopathy (a condition in which brain function is disturbed either temporarily or permanently due to different diseases or toxins in the body), anemia (an inadequate number of healthy red blood cells to carry adequate oxygen to body tissues), fracture right femur (thigh bone), pneumonia (a lung infection that causes inflammation and fluid or pus to fill the air sacs of the lungs), and nicotine dependency. R44's admission Minimum Data Set (MDS) dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The MDS documented R44 was dependent on staff with activities of daily living (ADL), used a wheelchair for mobility, and required staff supervision in the facility. The MDS documented the resident had a pressure ulcer, was at risk for developing pressure ulcers, had one Stage 3 (full-thickness pressure injury extending through the skin into the tissue below) pressure ulcer that was present upon admission. The MDS documented R44 had a pressure reducing device for his chair received pressure ulcer/injury care with application of non-surgical dressings. R44's Activities of Daily Living Care Area Assessment (CAA) dated 12/22/25 documented the resident required substantial assistance with toileting, bathing, dressing, bed mobility, and transfers. The CAA documented the resident as non-ambulatory, required a wheelchair for all mobility and used stand pivot method for transfer. The CAA documented the residents was alert and oriented. R44's Pressure Ulcer CAA dated 12/22/25 documented the resident admitted with a Stage 3 pressure wound on his coccyx (area at the base of the spine), a surgical wound to his right hip, and an unstageable pressure wound on his right heel. R44's admission Braden (a clinical tool that assesses a resident's risk for developing pressure injuries) was 16. (a score of 16 indicated a mild risk to develop pressure ulcers) The resident had a pressure reduction mattress, which was changed to a low air loss mattress due to his wounds, and he required significant assistance of one staff for turning and repositioning. R44 had a cushion to his wheelchair and was to offload/shift weight while up in his chair. R44 would be followed by wound nurse practitioner until wounds are healed. R44's Care Plan dated 12/28/25 documented R44 had a cushion in his wheelchair and was able to shift his weight/offload while up in a chair. The care plan documented R44 had a pressure-reducing mattress and was able to turn and reposition with substantial assistance from staff. Staff would complete a Braden assessment upon admission, quarterly, and as needed to identify any risk for skin issues. Staff would complete a weekly skin assessment and would monitor R44's skin with all cares. R44's care plan documented the resident as non-ambulatory and used a wheelchair for all mobility. Staff would push the resident in his wheelchair for longer distances, and he could propel himself for shorter distances. The Braden Scale Assessment for predicting pressure ulcer risk dated 12/16/25 documented a score of 16.0, which indicated the resident had a risk of pressure injury development. The Braden Scale Assessment for predicting pressure ulcer risk dated 01/12/26 documented a score of 20.0, which indicated the resident did not have a risk of pressure injury development. The Weekly Skin Observation dated 12/16/25, documented R44 admitted to the facility with a right heel wound, coccyx wound, and surgical incision on the right thigh with no signs or symptoms of infection noted. The Wound Assessment Details Report dated 01/08/26 document R44 had an unstageable (depth of the wound is unknown due to the wound bed being covered by a thick layer of other tissue and pus) facility acquired, pressure injury on the left middle toe that measured 2.00 centimeters (cm) by 1.00 cm by 0.01 cm with hard necrotic (pertaining to the death of tissue in response to disease or injury) tissue present. The Wound Assessment Details Report dated 01/08/26 documented R44 had a facility acquired, deep tissue pressure injury to the left lateral outer foot that measured 4.00 cm by 5.00 cm by 1.00 cm. The Weekly Skin Observation dated 01/13/26 documented R44 had a coccyx wound, open area to his left knee, open area to the left inner, and the back of heel-but failed to document right or left and lacked any further description of the wound. The Physician Order dated 01/13/26 directed staff to send R44 to the emergency department for evaluation and treatment of the left lower leg wounds and swelling. The Wound Assessment Details Report dated 01/28/26 documented R44 had a facility acquired, unstageable pressure injury to the left middle toe that measured 2.00 cm by 1.00 cm by 0.01 cm, with hard necrotic tissue. The Wound Assessment Details Report dated 01/29/26 documented R44 had a facility acquired, pressure injury to the left lateral outer foot that measured 2.00 cm by 4.00 cm by 0.01 cm. After review of the medical records, it was revealed R44 only had two weekly skin observations since admission on [DATE] (six weeks ago). The Physician Order dated 01/12/26 documented staff would change the dressing to R44's left lateral foot, cleanse with wound cleanser, gently pat dry with gauze, Skin-prep (liquid skin protectant) around the peri wound (skin surrounding the wound), cut calcium alginate (highly absorbent dressing) to size, apply to wound bed, and cover with a 4 x 4 bordered foam dressing to the area, change once a day and as needed. The Physician Order dated 01/28/26 documented staff would change the dressing to R44's left middle toe, cleanse with wound cleanser, pat dry, apply calcium alginate to the wound bed only, cover with dry dressing, change daily, and/or as needed. On 01/28/26 at 01:05 PM, R44 laid in be on his back. License Nurse (LN) G cleansed the left middle toe with wound cleanser, dried the area with a gauze sponge, then applied calcium alginate to the wound bed and secured with a band-aid. The left middle toe had a black area approximately one-fourth of an inch by one-fourth of an inch on the distal (away from the farthest point of origin or attachment) side of the toe with a small amount of serous (thin, clear) drainage and the entire toe appeared swollen and red. R44 complained of discomfort with the dressing change. Continued observation revealed LN G cleansed the open area on R44's lateral left foot with wound cleanser. The wound appeared as a one-half inch round open area. LN G dried the area with a gauze sponge, then applied calcium alginate to the wound bed and secured with bordered foam dressing. The open area had a small amount of serous drainage with redness around the open wound. On 01/28/29 at 09:05 AM, Administrative Nurse E verified R44 developed the facility acquired, pressure ulcer on his left middle toe and left lateral foot approximately four weeks after admission to the facility. Administrative Nurse E verified R44 admitted to the facility with a coccyx wound and left heel wound. Administrative Nurse E verified the facility assessed the resident with a Braden Assessment, that documented the resident as at risk and the last one documented the resident as not at risk for pressure ulcer development. She stated they should have assessed the resident for being at risk of pressure ulcers. Administrative Nurse E verified the resident had a low air loss mattress but lacked any pressure relieving boots upon admission and stated he should have those to protect his skin. The Pressure Injury Prevention Guidelines, policy dated 01/02/26, documented the facility would prevent the formation of avoidable pressure injuries and promote healing of existing pressure injuries and it was the policy of the facility to implement evidenced-based interventions for all residents who are assessed at risk or who have a pressure injury present. The policy documented interventions would be implemented in accordance with physician orders, including the type of preventative devices to be used and, for tasks, the frequency for performing them. Preventative devices would be utilized in accordance with manufacturer recommendations, such as heel flotation devices, cushions, and mattresses. Interventions would be documented in the care plan and communicated to all staff. The effectiveness and interventions would be monitored through ongoing assessment of the resident and/or wound, and consideration for needed modification includes development of a new pressure injury, lack of progression towards healing or change in wound characteristics, and changes in the resident's goals and preferences, such as at end-of -life or in accordance with his/her rights.

The facility had a census of 70 residents. The sample included 18 residents. Based on observation, interview, and record review, the facility failed to inform the residents of the posting of the Ombudsman (an independent, neutral official who investigates, reports on, and helps resolve complaints) and State Agency contact numbers.Findings included:- On 01/27/26 at 01:15 PM, the State Agency and Ombudsman information posters were located in the front portion of the building lobby/hallway area. The resident council minute review from 01/2025 through 01/2026 lacked information regarding the Ombudsman and State Agency posting.On 01/28/26 at 03:29 PM, the Resident Council President, Resident (R) 12, reported that the council had not been informed of the Ombudsman and State Agency contact information.On 01/29/26 at 11:45 AM, Activity Staff Z reported sharing information regarding the Ombudsman and State Agency reporting during the resident council meetings, but had not recorded this information in the resident council meeting minutes.On 01/29/26 at 01:45 PM, Administrative Staff A stated the information should be reviewed with the council at least annually.The facility's undated Posting of Ombudsman and State Agency policy documented that the facility shall prominently post all required Ombudsman and state agency notices in locations that are readily accessible and visible to residents, resident representatives, and the public. Posting shall be reviewed at least annually and whenever there is a change in contact information or regulatory requirements.

The facility had a census of 70 residents. The sample included 18 residents. Based on observation, interview, and record review, the facility failed to inform the resident council of the state inspection report.Findings included:- On 01/27/26 at 01:15 PM, the State Agency inspection book was located in the front lobby. The resident council minutes' review from 01/2025 through 01/2026 lacked information regarding the location of state inspection results.On 01/28/26 at 03:29 PM, the Resident Council President, Resident (R) 12, reported that the council had not been informed of the location of the state inspection results.On 01/29/26 at 11:45 AM, Activity Staff Z reported she had not included the location of the State Agency's inspection report. Activity Staff Z reported sharing information regarding the Ombudsman and State Agency reporting during the resident council meetings, but had not recorded this information in the resident council meeting minutes.On 01/29/26 at 01:45 PM, Administrative Staff A stated the information should be reviewed with the council at least annually.The facility's undated Resident Rights policy document the facility informed the residents both orally and in writing, in a language that the resident understands, of his or her rights and all rules and regulations governing resident conduct and responsibilities during their stay in the facility. The resident has a right to examine the results of the most recent survey of the facility conducted by Federal or State surveyors and any plan of corrections in effect with respect to the facility.

The facility had a census of 70 residents. Based on observation, interview, and record review, the facility failed to conduct a thorough facility-wide assessment to determine necessary care for residents competently during both day-to-day operations and emergencies.Findings included:- On 01/28/26 at 09:00 AM, Administrative Staff A reported looking for the assessment but had not located it when the facility assessment was requested a second time.On 01/29/26 at 10:00 AM, Administrative Staff A reported that she could not locate the facility assessment, which she had completed and provided for the survey process on 01/27/26, along with a Quality Assurance Assessment (QAA) committee to be reviewed on 02/18/26.The facility's Facility Assessment policy, dated 04/01/25, documented that the facility conducts and documents a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations (including nights and weekends) and emergencies. The purpose of the policy is to establish responsibilities and procedures for the facility assessment process. The facility assessment would be reviewed and updated as necessary and at least annually, or whenever there is, or the facility plans for, any change that would require a substantial modification to any part of the assessment.

The facility had a census of 70 residents. The sample included 18 residents. Based on observation, interview, and record review, the facility failed to place an open date on the Lantus (long acting insulin) pen (disposable, prefilled injection pen) in one of two nurse medication carts. The facility failed to consistently record refrigerator temperatures in the medication room. The facility further failed to lock an emergency (ER) cart, which had medications accessible to residents, with an expired Narcan (a medication that readily reverses an opioid, a narcotic pain medication).Findings included:- On [DATE] at 08:30 AM, observation revealed, in the 400 hall nurse medication cart, Resident (R) 58's Lantus pen lacked an open date. On [DATE] at 08:30 AM, Licensed Nurse (LN) K verified the Lantus pen was open, and stated staff should date a Lantus pen when they open it. On [DATE] at 02:00 PM, Administrative Nurse D stated staff should date insulin pens when they open them The facility's Medication Storage Policy, revised 2025, documented the facility would ensure all medications housed on its premises would be stored in the pharmacy and /or medication rooms according to the manufacturer's recommendations. - On [DATE] at 08:30 AM, during an initial tour of the facility's south medication room, the medication refrigerator temperature log had only been posted for [DATE] to 26th, had only recorded temperature on [DATE]st, 2nd, 3rd, 4th, 12th, and 20th. Licensed Nurse (LN) G reported that the refrigerator temperature readings were to be checked by the night shift nurses each night. On [DATE] at 08:53 AM, during an initial tour of the facility, a treatment cart located in the middle hall between the north and south sides of the building was found unlocked. The top drawer stored Naloxone HCL Nasal Spray (a medicine that rapidly reverses an opioid overdose) with an expiration date of 06/2025. The second drawer contained a container of Liquid Skin (topical skin treatment) and Derma Clenz (wound cleaner) with instructions to keep out of reach of children. During inspection of the cart, Administrative Staff A verified that the label of Naloxone HCL Spray had expired, and the Liquid Skin and Derma Clez had instructions to keep out of reach of children. Administrative Staff A stated that the treatment care should be locked. Administrative Staff A locked the cart at that time. On [DATE] at 02:30 PM, Administrative Nurse E verified that the medication room refrigerators should be checked and recorded daily by the night shift nurses, and the treatment cart should be locked when not in use. The facility's undated Medication Storage policy documented that all drugs and biologicals will be stored in locked compartments (i.e. medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls. Only authorized personnel will have access to the keys to locked compartments. During a medication pass, medications must be under direct observation of the person administering medications or locked in the medication storage area/cart. Temperatures are maintained within 36-46 degrees Fahrenheit. Charts are kept on each refrigerator, and temperature levels are recorded daily by the charge nurse or other designee.

The facility had a census of 70 residents. Based on observation, interview, and record review, the facility failed to prepare and serve food in a sanitary manner when dietary staff did not complete hair coverage with the hairnet and beard cover. This deficient practice placed the residents of the facility who received meals from the facility at risk for food borne illness. Findings included: - On 01/27/26 at 08:00 AM, observation revealed dietary staff in the facility kitchen preparing and serving breakfast to the residents. Dietary Staff (DS) CC had a beard and mustache and lacked a beard or facial cover while preparing drinks for the residents. On 01/28/26 at 11:00 AM, observation revealed DS DD had a beard and mustache and wore a beard cover but did not cover his mustache and was washing the dishes and preparing salads for lunch. On 01/28/26 at 11:40 AM, observation revealed DS EE walked through the dining room door to the back of the kitchen and grabbed a hair net then proceeded to walk through the kitchen where the staff were preparing the lunch meal and rolled her mid length hair in a low bun then put her hair in the hair net. On 01/28/26 at 11:45 AM, DS BB stated DS EE waked through the kitchen before she wore a hair net and stated staff were to wear hairnets while in the kitchen. DS BB verified DSCC lacked a beard and moustache cover and should cover beards, and have thorough hair coverage including mustaches with a beard/facial cover. The facility's Food Safety and Sanitization policy, undated, documented food would be stored, prepared, distributed and served in accordance with professional standards for food service safety. Food safety practices would be followed throughout the facility's entire food handling process. The process begins when the food is received from the vendor and ends with delivery of the food to the residents. During food preparation staff will take precautions in critical control points in the food preparation process to prevent, reduce, or eliminate potential hazards. Staff shall adhere to safe hygienic practices to prevent contamination of foods from hands or physical objects, dietary staff must wear hair restraints including hairnets, hat, and/or beard restraint to prevent hair from contacting food.

The facility had a census of 70 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility's Quality Assessment and Assurance (QAA) program failed to provide good faith efforts to identify multiple issues of concern for 33 residents residing in the facility.Findings included:-The facility failed to document the review of resident rights with the resident council. Refer to F 574.The facility failed to inform the resident council where the survey result book or contact the ombudsman and the state agency was kept. Refer to F577.The facility failed to prevent the misappropriation of R16's Morphine. Refer to F600.The facility failed to provide R2, R4, and R74 a bed hold notification and failed to notify the ombudsman when they were transferred to the hospital. Refer to F628.The facility failed to update R3's Care Plan when R3 received a leg injury to prevent further leg injuries. The facility failed to update R44's care plan with a smoking section. Refer to F657.The facility failed to consistently provide R69 and R20 bathing as per their preferences. Refer to F677.The facility failed to provide R6 with treatment when his blood sugar was in the 30's. The facility further failed to document the condition of R20 before ER/hospitalization. The facility further failed to provide documentation regarding R3, who was transferred to the ER, resulting in 17 sutures to his leg. Refer to F684.The facility failed to provide interventions to prevent R44's middle toe and left lateral foot pressure ulcer. Refer to F686.The facility further failed to provide R44 with a smoking assessment. Refer to F 689.The facility failed to have a system to prevent the diversion of liquid morphine. Refer to F755.The facility failed to label a Lantus pen with an open date. The facility further failed to lock an ER cart, which had Narcan expired 06/25 and liquid skin and derma cleanse accessible to residents. The facility further failed to consistently document refrigerator temperatures in one of two medication rooms. Refer to F761.The facility failed to procure, store, prepare, and keep the kitchen sanitary when one dietary aide lacked a beard cover, one lacked a mustache cover, and two dietary aides had stocking caps as hair covers. Refer to F812.The facility failed to establish a facility assessment. Refer to F 838.The facility had multiple system failures. Refer to F865.The facility failed to provide EBP for multiple devices, multiple residents, and failed to establish a legionella program. The facility further failed to prevent the spread of infection when staff walked down the hall with a glucometer machine, with a bloody strip in it, to dispose of it at the nurse's station. Refer to F 880.The facility failed to have a system in place to determine which residents were eligible for the Prevnar 20 vaccination. Refer to F883.

The facility had a census of 70 residents. The sample included 18 residents. Based on record review and interviews, the facility failed to conduct a risk assessment to identify risks and implement a water management program to mitigate the risk of Legionella disease (Legionella is a bacterium spread through mist, such as from air-conditioning units for large buildings. Adults over the age of 50 and people with weak immune systems, chronic lung disease, or heavy tobacco use are most at risk of developing pneumonia caused by Legionella) and other waterborne pathogens. The facility failed to adhere to infection control procedures with wound care for Resident (R) 1 who had an open abdominal wound and a gastrostomy tube (G-tube surgically placed through an artificial opening into the stomach) and staff administered medications through the tube who had enhanced barrier precautions (EBP -an infection control intervention designated to reduce transmission of resistant organisms that employs targeted gown and glove used during high contact resident care activities), failed to adhere to infection control procedures and failed to adhere to adhere to personal cares for R3, R20, and R35 who all had an indwelling catheter (a tube inserted into the bladder to drain urine into a collection bag). The facility further failed to maintain infection control procedures when staff carried a bloody glucometer strip down the hallway versus dispensing it in the nearest sharps container.Findings included:- On 01/29/26 at 11:35 AM, Administrative Staff A verified the facility did not have a system to check for standing water in unoccupied rooms or to mitigate potential Legionella growth inside the facility. Administrative Staff A verified she was not aware of any routine facility water management checks, and they would have to initiate a program to complete the checks for Legionella's. The facility's Water Management Plan policy, dated 01/01/24, documented the facility would establish and maintain an infection prevention and control program designs to provide a safe, sanitary, and comfortable environment and help to prevent the development of and transmission of communicable disease. The policy documented the facility would establish a water management team, identify risks and implement control measures and control limits describing the water systems and flow diagrams. The flow charts would summarize the risks associated with the multiplication of the Legionella bacteria, given varying temperature ranges and common control points. Legionella grows best between 77 to 108 degrees Fahrenheit (scale of temperature on which water freezes at 32 degrees and boils at 212 degrees under standard conditions). The growth of Legionella bacteria is at risk where water is stagnant, and water flow is limited. As such, the use of flushing as a control measure is only for control points where flow is suspended for periods of time. Any determined on-going treatment and testing requirements determined by the management team would be recorded via a TELS task for that specific facility. The completion of TELS tasks is monitored by the water management team. The water Management Plan would be reviewed and updated as applicable annually, confirmed by the TELS task and annual Legionella training for the Maintenance Director. - On 01/27/26 at 08:30 AM, observation revealed Licensed Nurse (LN) G donned gloves and cleaned R1's wound on the right side of his abdomen with wound cleanser. Observation revealed greenish drainage, then LN G applied a 4 by 4 gauze pad and secured with border foam dressing. LN G discarded his gloves in a trash can in the resident's room. On 01/28/26 at 07:35 AM, observation revealed Certified Nurse Assistant (CNA) M and CNA N donned gloves and assisted R2 to reposition in bed and noted the resident has oxygen per nasal cannula and a Foley catheter bag attached to the right side of her bed. CNA M unclamped the catheter bag, wiped the spigot with an alcohol wipe,drained the urine in a plastic graduate,cleansed the spigot with an alcohol wipe, reattached the spigot in the bag,hooked it on the side of the bed then covered the urinary drainage bag with the protective cover, then emptied the graduate containing urine in the toilet. Observation revealed the CNAs wore gloves but lacked gowns or personal protective equipment with cares. CNA M and CNA N discarded their gloves in a trash can in the resident's room. On 01/28/26 at 08:55 AM, observation of LN G donned gloves and unhooked R1's feeding G-tube and administered 10 milliliters (ml) of water followed by liquid Tylenol (pain relief medication) 1000 milligrams (mg)/30 ml followed by and liquid Iron (iron supplement) 300 mg/5 ml medication then flushed with 10 ml of water, reattached the G-tube to the nutritional supplement -continuous feeding. LN G discarded his gloves in a trash can provided in the resident's room. On 01/28/26 at 01:05 PM, R44 laid in be on his back. LN G donned gloves and cleansed the left middle toe with wound cleanser, dried the area with a gauze sponge, then applied calcium alginate to the wound bed and secured with a band-aid. The left middle toe has a black area approximately 1/4 of an inch by 1/4 of an inch on the distal side of the toe with a small amount of serous (thin, clear) drainage, and the entire toe appears swollen and red. R44 complained of discomfort with the dressing change. LN G discarded his gloves in a trash can in the resident's room. Continued, observation revealed LN G cleansed the open area on R44's lateral left foot with wound cleanser. The wound appeared to be a one-half-inch round open area. LN G dried the area with a gauze sponge, then applied calcium alginate to the wound bed and secured it with bordered foam dressing. The open area had a small amount of serous drainage with redness around the open wound. LN G discarded his gloves in a trash can in the resident's room. On 01/29/25 at 01:05 PM, interview with Administrative Nurse E verified R21, R2, and R44 should be on EBP with signage on the door to the room with PPE supplies available for each resident care. Administrative Nurse E verified she would provide PPE for the residents who required it and inform staff of the proper care of the residents. The facility's Enhanced Barrier Precautions policy, dated 01/01/25, documented the facility would implement enhanced barrier precautions for the prevention of transmission of Multidrug-resistant organisms. The facility would train staff on hire of high-risk activities and common organisms that require EBP. The facility will have the discretion on how to communicate to staff which residents require the use of EBP, as long as staff are aware of which residents require the use of EBP prior to providing high contact care activities. An order for EBP would be obtained for the residents with the following: chronic wounds such as pressure ulcers diabetic foot ulcers, unhealed surgical wounds, chronic venous stasis ulcers, catheters, peripheral IV's insulin pumps, ostomies. The facility would have available gowns, and gloves immediately near or outside of the resident's room, and face protection may also be needed if performing activity with risk of splash or spray, PPE for EBP is only necessary when performing high contact care activities and may not need to be done prior to entering the resident's room. Ensure access to alcohol-based hand rub in every resident room and position a trash can inside the resident's room and near the exit for discarding PPE after removal, prior to exit of the room or before providing care for another resident in the same room. The Infection Preventionist would incorporate periodic monitoring and assessment of adherence to determine the need for additional training and education. Provide education to residents and visitors, High contact care areas include dressing, bathing, transferring, providing hygiene, changing linens changing briefs or assisting with toileting, device care or use of central lines, urinary catheters, feeding tubes, catheters, wound care and nay skin opening that required a dressing. Therapies should use gown and gloves when working with residents on EBP the therapy gym or in the resident's room if they anticipate prolonged, close body contact where MDRO transmission is possible. - Resident (R) 3 Electronic Medical Record (EMR) recorded diagnoses of adult failure to thrive (includes not doing well, feeling poorly, weight loss, and poor self-care that could be seen in elderly individuals), congestive heart failure (CHF -a condition with low heart output and the body becomes congested with fluid), spinal stenosis (degenerative condition of the spine that could cause weakness and loss of use of extremities), severe protein-calorie malnutrition, lymphedema (swelling caused by accumulation of lymph), muscle weakness, unsteadiness on feet, 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). R3's Quarterly Minimum Data Set (MDS) dated [DATE] documented had intact cognition, exhibited no behavioral symptoms, had a functional range of motion of both sides of the lower extremities, used a walker and wheelchair for mobility. R3 required substantial to maximal assistance with upper and lower body dressing, putting on and taking off footwear, bed mobility, sit to lying, lying to sitting, sit to standing, chair/bed to chair transfers, and walking ten feet. R3 had skin tears, nutritional/hydration interventions to manage skin problems, application of nonsurgical dressing, and application of ointment/medication other than to the feet. The MDS further documented that R3 received an antidepressant (a class of medications used to treat mood disorders), an anticoagulant (slows down the process of blood clotting), an antibiotic (a class of medications used to treat infections), and an opioid (medication used to treat pain). R3's Care Plan dated 07/13/25 documented R3 had an indwelling catheter related to BPH (BPH -non-cancerous enlargement of the prostate, which can lead to interference with urine flow, urinary frequency, and urinary tract infections), urinary retention. The Care Plan directed staff to position the catheter bag and tubing below the level of the bladder, change the catheter monthly, and monitor/record/report to the physician signs and symptoms of urinary tract infection (UTI -an infection in any part of the urinary system). The Physician Order dated 06/17/25 instructed staff to change the catheter and tubing monthly and as needed. The Physician Order also instructed R3 to be on Enhanced Barrier Precaution and must don personal protective equipment (PPE- gowns, face shields, and/or eyeglasses/goggles, and gloves) for all high contact care. The Practitioner Progress Note dated 01/27/26 at 09:50 AM documented that R3 was at high risk for UTI, recommended appropriate catheter care, and urine was yellow with sediment. The note also documented that R3 had a dressing on the left lower leg. On 01/29/26 at 09:05 AM, Licensed Nurse (LN) H provided left lower leg wound care. During the procedure, LN H wore gloves but did not wear a gown. LN H leaned over the bed while doing wound care with her uniform coming into contact with the catheter tubing. On 01/29/26 at 10:30 AM, Certified Nurse Aide (CNA) O and CNA P reported R3 declined the surveyors' request to observe catheter care. Both CNA O and CNA P verified that the room lacked EBP signage or had gowns stored in the room or outside the door. Both staff members also reported that they had not worn gowns when providing catheter care for the residents. On 01/29/25 at 02:24 PM, Administrative Nurse E verified R3's room lacked EBP signage, and that staff providing care of the catheter and wound should wear both gloves and gowns. Administrative Nurse E stated gowns should be stored inside and/or outside the room for direct care usage. The facility's Enhanced Barrier Precautions policy, dated 01/01/25, documents that it is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. Enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high-contact resident care activities. An order for enhanced barrier precautions will be obtained for residents with any of the following: wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous statis ulcers) and/or indwelling medical devices (e.g., central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes, hemodialysis catheters, PICC lines, midline catheters) even if the resident is not known to be infected or colonized with a MDRO. Implementation of EBPs: make gowns and gloves available immediately near or outside of the resident's room. PPE for enhanced barrier precautions is only necessary when performing high-contact care activities and may need to be donned prior to entering the resident's room. Ensure access to alcohol-based hand rub in every resident room. Position a trash can inside the resident room and near the exit for discarding PPE after removal, prior to exit of room, or before providing care for another resident in the same room. - Resident (R) 20's Electronic Medical Record (EMR) documented diagnoses of diabetes mellitus (DM -when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), 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), patient's noncompliance with other medical treatment and regimen, dementia (a progressive mental disorder characterized by failing memory and confusion), schizophrenia (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought), presence of urogenital implant (medical devices used to support or restore function in the urinary system), urinary tract infection (UTI -an infection in any part of the urinary system), and hydronephrosis (swelling of one or both kidneys, caused by back up of urine). R20's Annual Minimum Data Set (MDS) dated [DATE] documented that R20 had moderately impaired cognition, exhibited no behaviors, and had functional range of motion impairment of both lower extremities. R20 was dependent on staff for toileting, bathing, lower body dressing, and substantial/maximum assistance with bed mobility and transfers. R20 had an indwelling catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) and was always incontinent of bowel. The MDS further documented that R20 received insulin (a hormone that lowers the level of glucose in the blood) injections, an antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality), and antibiotic (a class of medications to treat infections). The Urinary Incontinence and Indwelling Care Area Assessment (CAA) dated 12/10/25 documented R20 had a diagnosis of neurogenic bladder and had a permanent catheter to dependent drainage. The catheter was changed monthly, and a history of urinary tract infections, and catheter care was performed totally by the staff. R20's Care Plan revised 12/14/25 documented R20 was at risk for urinary tract infection related to the indwelling catheter and neurogenic bladder. The Care Plan directed staff to evaluate urine characteristics, monitor for any changes in urine, and nursing may perform a urine dipstick if a UTI was suspected, and nursing to complete catheter care each shift. The Physician Order dated 01/06/26 directed staff that R20 was on Enhanced Barrier Precaution and staff must don personal protective equipment (PPE- gowns, face shields, and/or eyeglasses/goggles, and gloves) for all high contact care two times a day for the catheter. The Practitioner Progress Note dated 01/15/25 at 10:31 AM, documented R20 denied issues with his catheter or bowels, and that R20 had been back and forth from the emergency room (ER) multiple times over the last few months for catheter issues and infections. On 01/28/26 at 11:21 AM, R20 remained in bed. The bed was in a low position, and the catheter drainage bag was attached to the bed frame, which was not visible from the doorway. The urine in the tubing was yellow with sediment. On 01/29/26 at 10:30 AM, Certified Nurse Aide (CNA) O and CNA P reported R20 declined the surveyors' request to observe catheter care. Both CNA O and CNA P verified that the room lacked EBP signage or had gowns stored in the room or outside the door. Both staff members also reported that they did not wear gowns when providing catheter care for the residents. On 01/29/25 at 02:24 PM, Administrative Nurse E verified R20's room lacked EBP signage, and that staff providing care of the catheter and wound should wear both gloves and gowns. Administrative Nurse E stated gowns should be stored inside and/or outside the room for direct care usage. The facility's Enhanced Barrier Precautions policy, dated 01/01/25, documents that it is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. Enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high-contact resident care activities. An order for enhanced barrier precautions will be obtained for residents with any of the following: wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous statis ulcers) and/or indwelling medical devices (e.g., central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes, hemodialysis catheters, PICC lines, midline catheters) even if the resident is not known to be infected or colonized with a MDRO. Implementation of EBPs: make gowns and gloves available immediately near or outside of the resident's room. PPE for enhanced barrier precautions is only necessary when performing high-contact care activities and may need to be donned prior to entering the resident's room. Ensure access to alcohol-based hand rub in every resident room. Position a trash can inside the resident room and near the exit for discarding PPE after removal, prior to exit of room, or before providing care for another resident in the same room. - R35's Electronic Medical Record (EMR) documented diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) disorder, chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), diabetes mellitus (DM -when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), paraplegia (paralysis characterized by motor or sensory loss in the lower limbs and trunk), 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), heart failure, acute kidney failure, and urinary tract infection (UTI -an infection in any part of the urinary system). R35's 5-Day Minimum Data Set (MDS) dated [DATE] documented R35 had intact cognition, functional range of motion impairment of both lower extremities, was dependent on staff for toileting, bathing, upper and lower body dressing, bed mobility, and transfers. R35 had an indwelling catheter and was always incontinent of bowel. The MDS further documented that R35 had insulin (a hormone that lowers the level of glucose in the blood) injections, received an antidepressant (a class of medications used to treat mood disorders), an antibiotic (a class of medications used to treat infections), a diuretic (a medication to promote the formation and excretion of urine), and an opioid (medication used to treat pain). R35's Care Plan, revised 08/23/25, documented that R35 had an indwelling catheter due to a neurogenic bladder. The Care Plan directed staff to change the catheter monthly, monitor/record/report to the physician signs and symptoms of a UTI, and provide catheter care every shift. The Physician Order dated 08/29/25 directed staff to change the catheter monthly. The Physician Orders did not contain directions for Enhanced Barrier Precaution (EBP) personal protective equipment (PPE- gowns, face shields, and/or eyeglasses/goggles, and gloves) for all high contact care two times a day for the catheter. The Progress Note dated 01/18/26 at 05:40 AM documented a change in condition of abdominal pain and altered mental status. The note further documented that the primary care provider recommended R35 to be sent to the hospital. The Progress Note dated 01/22/26 at 04:00 PM documented that R35 had returned to the facility, had a UTI, and was on an antibiotic. On 01/28/26 at 11:22 AM, R35 was in bed. R35 was alert and reported she had recently been in the hospital for a UTI and was taking an antibiotic. R35 reported that the staff took care of all her catheter care. The catheter bag was attached to the bed frame and not visible from the doorway. On 01/29/26 at 11:00 AM, Certified Nurse Aide (CNA) Q verified R35's room lacked signage for EBP, and she had not worn a gown while caring for the catheter. On 01/29/25 at 02:24 PM, Administrative Nurse E verified R35's room lacked EBP signage, and that staff providing care of the catheter and wound should wear both gloves and gowns. Administrative Nurse E stated gowns should be stored inside and/or outside the room for direct care usage. The facility's Enhanced Barrier Precautions policy, dated 01/01/25, documents that it is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. Enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high-contact resident care activities. An order for enhanced barrier precautions will be obtained for residents with any of the following: wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous statis ulcers) and/or indwelling medical devices (e.g., central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes, hemodialysis catheters, PICC lines, midline catheters) even if the resident is not known to be infected or colonized with a MDRO. Implementation of EBPs: make gowns and gloves available immediately near or outside of the resident's room. PPE for enhanced barrier precautions is only necessary when performing high-contact care activities and may need to be donned prior to entering the resident's room. Ensure access to alcohol-based hand rub in every resident room. Position a trash can inside the resident room and near the exit for discarding PPE after removal, prior to exit of room, or before providing care for another resident in the same room. - On 01/27/26 at 04:00 PM, observation revealed Licensed Nurse (LN) G exited R8's room, carrying a glucometer machine with a bloody strip in it. LN G went down the hall to the nurse's cart and discarded it in a sharps container on the cart. On 01/27/26 at 04:26 PM, LN G verified he had walked down the hall, carried a glucometer machine with a bloody strip in it, and stated he probably should have brought the cart down the hall outside R8's room. On 01/28/26 at 08:45 AM, Administrative Nurse D stated staff should dispose of a glucometer strip with blood on it in a resident's room in a sharps container. The facility's Infection Prevention and Control Program, revised 01/01/25, documented that the facility had established and maintained an infection prevention and control program designed to provide a safe, sanitary environment, and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines.

The facility had a census of 70 residents. The sample included 18 residents, with five residents reviewed for immunizations, Resident (R) 16, R31, R43, R55, and R56, 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 interviews, the facility failed to offer, obtain an informed declination, or a physician documented contraindication for the pneumococcal PCV20 vaccination per the latest guidance from the Centers for Disease Control and Prevention (CDC).Findings included:- Review of the clinical medical records lacked evidence the facility or the resident representative received or signed a consent to receive or informed declination for the pneumococcal vaccine PCV20 for the following residents.Review of R16's Electronic Medical Record (EMR) revealed the resident was admitted to the facility on [DATE]. R16 had not been offered or received a pneumococcal PCV20 vaccine since admission.Review of R31's EMR revealed the resident was admitted to the facility on [DATE]. R31 had not been offered or received a pneumococcal PCV20 vaccine since admission.Review of R43's EMR revealed the resident was admitted to the facility on [DATE]. R43 had not been offered or received a pneumococcal PVC20 vaccine since admission.Review of R55's EMR revealed the resident was admitted to the facility on [DATE]. R55 had not been offered or received a pneumococcal PCV20vaccine since admission.Review of R56's EMR revealed the resident was admitted to the facility on [DATE]. R56 had not been offered or received a pneumococcal PCV20 vaccine since admission.On 01/28/26 at 11:00 AM, Administrative Nurse E stated residents were offered the pneumonia vaccines on admission and as indicated. Administrative Nurse E said the resident or resident representative would sign a consent or declination for receiving the vaccine. Administrative Nurse E verified that every resident in the building had not been reviewed to determine if they were eligible to receive the PVC20 vaccine or not. Administrative Nurse E verified they did not have a definitive system in place to determine who was eligible, or if they were eligible, if they had been offered or declined the vaccinations, and verified this was something they had recently been working on.The facility's Pneumococcal Vaccine policy, dated 10/01/25, documented each resident would be assessed for pneumococcal immunization upon admission. Self-report of immunization shall be accepted. Any additional effort to obtain information shall be documented, including efforts to determine the date of immunization or the type of vaccine received. Each resident would be offered a pneumococcal immunization unless it is medically contraindicated or the resident has already been immunized. Following assessment for any medical contraindications, the immunization may be administered in accordance with physician-approved standing orders. The resident or the resident's representative retains the right to refuse the immunization. The facility would document in the clinical record the reason for refusal or the medical contraindication of the immunization. The consent shall be signed prior to the administration of the vaccine and filed in the individual's medical record. The type of pneumococcal vaccine (PCV15, PCV20, PCV21, or PPSV23) would be offered depending on the residents' age, having certain risk conditions, and previously received pneumococcal vaccines, in advance according to current CDC guidelines and recommendations.

The facility had a census of 70 residents. The sample included 18 residents, with three residents reviewed for discharge. Based on observation, record review, and interview, the facility failed to provide Resident (R) 20 and R2 with written information regarding the facility's bed hold policy when the residents were transferred to the hospital and failed to notify the State Long Term Care Ombudsman (LTCO) of their facility-initiated discharge to the hospital.Findings include: - Resident (R) 20's Electronic Medical Record (EMR) documented diagnoses of diabetes mellitus (DM -when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), 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), patient's noncompliance with other medical treatment and regimen, dementia (a progressive mental disorder characterized by failing memory and confusion), schizophrenia (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought), presence of urogenital implant (medical devices used to support or restore function in the urinary system), urinary tract infection (UTI -an infection in any part of the urinary system), and hydronephrosis (swelling of one or both kidneys, caused by back up of urine). R20's Minimum Data Set (MDS) recorded: On 07/02/25, a Discharge Return Anticipated. On 07/07/25, an Entry into the facility. On 07/17/25, a Discharge Return Anticipated. On 07/22/25, an Entry into the facility. On 10/27/25, a Discharge Return Anticipated. On 10/30/25, an Entry into the facility. On 11/29/25, a Discharge Return Anticipated. On 12/03/25, an Entry into the facility. The Progress Note dated 07/02/25 at 08:11 AM, documented R20 had a change in condition, responsive and talking, and initially combative and resistant to care. R20 refused oxygen saturation, blood glucose check, and the administration of insulin (a hormone that lowers the level of glucose in the blood). R20 had light green emesis (vomit) with food particles and ongoing gurgling. Staff attempted to assist R20 multiple times, but was limited due to aggression and attempts to hit and kick staff. The note further documented a blood sugar reading of 333, oxygen saturation of 92 percent (%), and a temperature of 104.8 Fahrenheit (F). Staff called 911 at 12:24 AM, and upon arrival, R20 had projectile vomiting, oxygen saturation dropped to 74%, and oxygen was applied. R20 was sent to the hospital. Staff obtained the physician's order to send to the hospital, and R20's family member was notified. The note lacked mention of whether bed hold consent had been given or obtained. The Progress Note dated 07/15/25 at 08:24 AM documented that R20 had increased penile pain. The area was assessed and intact, with the lack of a catheter secure (device to anchor the catheter to the leg), as R20 would often remove it. The catheter secure was placed, and barrier cream was applied. The catheter remained in place and was draining cloudy yellow urine. R20 was educated on the importance of not pulling on the catheter and leaving the catheter secure in place. This note was the last entry. The MDS recorded a Discharge Return Anticipated on 07/17/25. The Progress Notes lacked R20's discharge assessment or mention of a bed hold to R20 or R20's representative notification. The Progress Note dated 07/22/25 at 03:52 PM documented R20 returned to the facility on a stretcher with two attendants. R20's had stable and within normal vital signs. R20 was to receive an antibiotic (a classification of medication used to treat infections) through a peripheral line (a short, flexible tube inserted into a small vein to deliver fluids and medications into the bloodstream) in the left forearm. The Progress Note dated 10/27/25 at 09:00 AM documented a change of condition with abnormal vital signs for R20. The note documented R20 had an altered mental status decline, shortness of breath, was tired, weak, and confused. The primary care provider was notified of the condition and responded by sending R20 to the hospital for possible sepsis (a life-threatening systemic reaction that develops due to infections that cause inflammation throughout the entire body). The Progress Notes lacked R20's discharge assessment or mention of a bed hold to R20 or R20's representative notification. The Progress Note dated 11/29/25 at 04:56 PM documented R20 had increasing confusion, needed additional assistance with activities of daily living, had cloudy urine with sediment, and a non-productive cough. R20's representative was at the bedside and requested that R20 be sent to the emergency room for evaluation. The Progress Notes lacked R20's discharge assessment or mention of a bed hold to R20 or R20's representative notification. The Progress Note dated 12/03/25 at 05:17 PM documented that R20 had returned to the facility. On 01/28/26 at 12:14 PM, R20 was in the dining room and was assisted to eat his meal. R20's hair was not combed, and R20 had facial hair stubble on his face. On 01/28/26 at 01:38 PM, upon review of the Ombudsman's monthly notification list, the review revealed R20 had not been included in the discharge notifications. Social Service X reported the discharge list pulled from the facility's computerized system did not include R20's discharges and, therefore, was not sent to the Ombudsman. On 01/28/26 at 01:04 PM, Administrative Staff A reported the facility could not locate the bed holds for R20's discharges to the hospital. Administrative Staff A stated the nursing staff who discharged residents to the hospital was responsible for getting the resident or representative the bed hold paperwork. The facility's Bed Hold Notice policy, dated 04/01/25, documents that it is the policy of the facility to provide written information to the resident and/or the resident representative regarding bed hold practices both well in advance and at the time of a transfer for hospitalization or therapeutic leave. The facility's undated Transfer and Discharge policy documented that it is the policy of the facility to permit each resident to remain in the facility and not transfer or discharge the resident from the facility, except in limited circumstances. The facility will maintain evidence that the notice was sent to the Ombudsman. Emergency transfers to acute care, the Social Service Director, or designee, would provide copies of notice for emergency transfers to the Ombudsman, but they may be sent when practicable, such as in a list of residents on a monthly basis, as long as the list meets all requirements for content of such notices. - R2's Electronic Medical Record (EMR) recorded diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), chronic kidney disease Stage 3 (kidneys are moderately damaged and filter waste and fluid less effectively), dysphagia (swallowing difficulty), and chronic obstructive pulmonary disease (COPD -a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). The Nurse's Note dated 08/25/25 at 10:50 PM documented an order was received to send R2 to the emergency room, and she left the faciity on a stretcher due to retching (the sound and movement of vomiting) with black/brown emesis. The Nurse's Note dated 09/03/25 at 01:27 PM documented the resident arrived at the facility per emergency medical transport. R2's clinical record lacked a bed hold policy and a resident or resident representative signature. R2's clinical record lacked documentation staff notified the LTCO of R2's discharge from the facility to the hospital. On 01/29/26 at 1:00 PM, Administrative Staff A verified the facility was unable to provide written evidence upon request. They had a bed hold policy for R2 and stated the nurse who discharges the resident should have the resident or family sign the bed hold policy. On 01/29/26 at 01:38 PM, Social Service X verified the facility lacked evidence that the LTCO was notified of R2's discharge to the hospital. Social Service X verified she sent monthly discharged resident information to the LTCO office, but R2 was not included in the monthly report. The facility's Bed Hold Notice policy, dated 01/28/26, documented the facility would provide written information to the resident and/or the resident's representative regarding bed hold practices both well in advance and at the time of transfer for hospitalization and therapeutic leave. As part of the admission packet and at the time of a transfer to the hospital or therapeutic leave, the facility would provide the resident and/or the resident's representative with written information that specifies: The duration of the State bed hold policy, if any, during which the resident is permitted to return and resume residence in the nursing facility. The reserve bed hold payment policy in the state plan policy, if any. The facility policies regarding bed-hold periods include allowing a resident to return to the next available bed. Conditions upon which the residents would return to the facility. The resident required the services which the facility provides The resident was eligible for Medicare skilled nursing facility services or Medicaid nursing facility services. In the event of an emergency transfer of a resident, the facility would provide written notice of the facility's bed hold policies to the resident and/or the resident's representative within 24 hours. The facility would document multiple attempts to reach the resident's representative within 24 hours. The facility would document multiple attempts to reach the resident's representative in cases where the facility was unable to notify the representative. The facility would keep a signed and dated copy of the bed hold notice information given to the resident and/or resident representative in the resident's file and/or medical record. The facility's Ombudsman and State Agency Notices policy, undated, documented to ensure residents, residents' representatives, visitors, and staff have clear, continuous access to information regarding resident rights, advocacy services, and complaint processes through the proper posting of required notices, in accordance with federal and state requirements. The posting of the office of the Ombudsman included notice of Transfers and Discharge rights related to transfer, discharge, and requirements that copies of transfer/discharge notices are provided to the Ombudsman.

The facility had a census of 70 residents. The sample included 18 residents. Based on observation, interview, and record review, the facility failed to identify and implement interventions to prevent further injuries to the lower extremities of Resident (R) 3 and R44's smoking activity.Findings included:- R3's Electronic Medical Record (EMR) recorded diagnoses of adult failure to thrive (includes not doing well, feeling poorly, weight loss, and poor self-care that could be seen in elderly individuals), congestive heart failure (CHF -a condition with low heart output and the body becomes congested with fluid), spinal stenosis (degenerative condition of the spine that could cause weakness and loss of use of extremities), severe protein-calorie malnutrition, lymphedema (swelling caused by accumulation of lymph), muscle weakness, unsteadiness on feet, 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). R3's Quarterly Minimum Data Set (MDS) dated [DATE] documented R3 had intact cognition, exhibited no behavioral symptoms, had a functional range of motion of both sides of the lower extremities, and used a walker and wheelchair for mobility. R3 required substantial to maximal assistance with upper and lower body dressing, putting on and taking off footwear, bed mobility, sit to lying, lying to sitting, sit to standing, chair/bed to chair transfers, and walking ten feet. R3 had skin tears, nutritional/hydration interventions to manage skin problems, application of nonsurgical dressing, and application of ointment/medication other than to the feet. The MDS further documented that R3 received an antidepressant (a class of medications used to treat mood disorders), an anticoagulant (a class of medication used to thin blood), an antibiotic (a class of medications used to treat infections), and an opioid (a medication used to treat pain). R3's Care Plan dated 05/13/25 documented R3 had a potential for impaired skin integrity related to impaired mobility and incontinence. The Care Plan directed staff to assess and record changes in skin status. R3's needed for substantial assistance from one to two staff with turning/repositioning, and nursing would complete a weekly skin assessment and would monitor skin with all care. The Care Plan also documented that R3 had an activity of daily living (ADL) performance deficit related to Parkinson's disease and spinal stenosis, and required extensive assistance of one to two staff with transfers using the stand pivot method. The Care Plan lacked interventions to prevent injuries to R3's lower extremities from a laceration obtained from the bedframe during a transfer on 11/13/25. The Physician Order dated 01/05/26 directed staff to cleanse the left lateral (pertaining to the side, away from the middle) calf with normal saline (NS -saline water solution for medical use), pad dry with gauze, wet kerlix (stretchy gauze bandage) with normal saline, pack wound, cover with non-adherent pad, cover with abdominal pad, then wrap with Coban (a self-adhesion wrap) once a day. The Progress Note dated 11/14/25 at 03:09 AM documented that the nurse and nurse manager assessed R3's wound. The wound had blood on Kerlix. The Kerlix was removed, and sutures were intact; a nonadherent dressing and Kerlix were applied. The Progress notes before 11/14/25 lacked any mention of wound cause or incident related to the wound. The Progress Note dated 11/14/25 at 04:16 AM documented that the nurse assessed R3's left leg wound. The dressing was clean and intact. No issues with the dressing at that time. The Infection Type Progress Note dated 11/17/25 at 05:11 PM documented fungal/skin infection (unspecific) receiving antibiotic therapy for wound infection to the left lower leg, cefpodoxime 200 milligrams (mg) by mouth two times a day. The resident returned to the facility with 17 sutures due to a leg laceration. Prophylactic (prevention) antibiotics began due to an extensive wound. On 01/29/26 at 08:21 AM, R3 stated the leg wound happened when a Certified Nurse Aide (CNA) was assisting him to bed for the night. R3 stated that his leg hit something on the bed frame. He was sent to the ER and received 17 stitches, with a measurement of five inches long. On 01/29/26 at 09:05 AM, Licensed Nurse (LN) H reported she was unsure of what caused the laceration, stating she was a new employee to the facility. On 01/29/26 at 02:45 PM, Administrative Nurse E reported she and the head of the housekeeping department looked at the bedframe and wheelchair and could not locate any sharp edges that would have caused the laceration. Administered Nurse E verified that the care plan lacked interventions to prevent further injury. The facility's Comprehensive Care Plan policy, dated 01/01/25, documented it was the policy of the facility to develop and implement a comprehensive person-center care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, an mental and psychosocial needs and all services that are identified in the resident's comprehensive assessment and professional standards of quality. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. Qualified staff responsible for carrying out interventions specific to the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made. - R44's diagnoses included metabolic encephalopathy (a condition in which brain function is disturbed either temporarily or permanently due to different diseases or toxins in the body), anemia (an inadequate number of healthy red blood cells to carry adequate oxygen to body tissues), fracture right femur (thigh bone), pneumonia (a lung infection that causes inflammation and fluid or pus to fill the air sacs of the lungs), and nicotine dependency. R44's admission Minimum Data Set (MDS) dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The MDS documented R44 was dependent on staff with activities of daily living (ADL), used a wheelchair for mobility, and required staff supervision in the facility. The MDS documented R44 did not use tobacco. R44's Activities of Daily Living Care Area Assessment (CAA) dated 12/22/25 documented the resident required substantial assistance with toileting, bathing, dressing, bed mobility, and transfers. The CAA documented that the resident was non-ambulatory and used a wheelchair for all mobility and used a stand pivot transfer. The CAA documented that the resident was alert and oriented. R44's Care Plan, dated 12/28/25, directed staff to assist R44 with a stand pivot transfer. The care plan recorded R44 used a wheelchair and did not ambulate. R44 lacked a smoking Care Plan. R44's Smoking Safety Risk Assessment, dated 12/22/25, documented R44 did not currently smoke or use electronic smoking devices. On 01/06/26, Encounter Notes documented R44 smoked half a pack of cigarettes a day. On 01/28/26 at 08:35 AM, observation revealed R44 seated on the side of his bed, and Certified Medication Aide R administered R44's morning medications. On 01/27/26 at 04:05 PM, Administrative Staff A verified R44 was admitted to the facility, and a Safe Smoking Assessment was completed, but failed to document that the resident did smoke. Administrative Staff A verified the staff should have filled out the smoking assessment to see if the resident was able to smoke safely or what was required to assist him to smoke safely. Administrative Staff A stated the staff would complete a Smoking Assessment for R44 soon. The Smoking Assessment policy, dated 01/02/26, documented that the facility would promote resident-centered care by providing a safe smoking area for the residents who request to smoke and are capable of safe smoking behaviors either independently or with supervision, unless the facility is a designated nonsmoking facility. The policy documented e-cigarettes and vaporizers would be treated as a traditional cigarette, and residents would be assessed by the interdisciplinary team (IDT) and designated as dependent or independent. The policy documented smoking assessments for the residents who requested to smoke would be completed on admission, quarterly, and with any change in condition. Assessment for independent or supervised smoking would be determined by the IDT team to assess the level of cognition for safe smoking, the level of dexterity to manage smoking and smoking materials, assessment of ability to understand and comply with the policy, and assessment of ability to smoke safely. Smokers would be permitted to smoke only in designated smoking areas on the South patio, and outside smoking may be prohibited by the Executive Director if weather conditions are determined to be a risk to resident safety. Facility staff would secure smoking materials in a locked area when not in use by the residents for both independent and supervised smokers. The facility would document resident and family education in the medical records for acknowledgement of the Resident Smoking policy. The Comprehensive Care Plan policy, dated 01/01/25, documented the facility would develop and implement a comprehensive care plan for each resident consistent with resident rights, which includes measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs and all services that are identified in the resident's comprehensive assessment and meet professional standards of quality. The care planning process would include an assessment of the resident's strengths, needs, and would incorporate the resident's personal and cultural preferences in developing goals of care. All services provided or arranged by the facility, as outlined by the comprehensive care plan, must meet professional standards of quality and incorporate culturally competent and trauma-informed care as indicated. The comprehensive care plan would be developed within 7 days after completion of the comprehensive MDS assessment. All CAAS triggered by the MDS would be considered in developing the care plan. Other factors identified by the IDT, or in accordance with the resident's preferences, would also be addressed in the plan of care. The facility's rationale for deciding whether to proceed with care planning would be evidenced in the clinical record. The comprehensive care plan would describe, at a minimum, the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Any services that would otherwise be furnished but are not provided due to the resident's exercise of his or her right to refuse treatment. The comprehensive care plan would be reviewed and revised by the IDT after each comprehensive and quarterly MDS.

The facility had a census of 70 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility staff failed to provide necessary services for two of six residents reviewed for activities of daily living (ADL): Resident (R) 69 and R20.Findings included:- R69's Electronic Medical Record (EMR) documented R69 had diagnoses of vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain) and sequelae of cerebral infarction (commonly known as a stroke, when blood flow to the brain is blocked or a blood vessel inside or on the surface of the brain bursts). R69's Quarterly Minimum Data Set (MDS) dated [DATE] documented R69 had a Brief Interview for Mental Status (BIMS) score of eight, which indicated moderately impaired cognition. The MDS documented R69 required substantial, maximal staff assistance with showering. R69's Care Plan, revised 12/25/25, documented R69 required substantial staff assistance with bathing and instructed staff to provide a sponge bath when a full bath or shower could not be tolerated by R69. The Skin Monitoring Comprehensive CNA Shower Review Sheets revealed R69 had a bath on the following dates: November 2025- 0. December 2025- refused on 12 and 21. January 2026- 4, 8, and 18. R69s' clinical record did not specify the dates the resident was scheduled to have a bath. On 01/29/25 at 03:00 PM, Administrative Nurse E stated that if a resident refused a bath, staff should document it on the skin monitoring sheet. Administrative Nurse E stated that staff should document on the skin monitoring sheet when a resident receives a bath, and if they have not received one after two days of their scheduled bathing day, the nurse should be notified. Administrative Nurse E stated that if the resident refused, the staff were to offer different methods for bathing, like bed baths and bathing wipes. The facility's Resident Showers Policy, revised, documented it was the practice of this facility to assist residents with bathing to maintain proper hygiene, stimulate circulation, and help prevent skin issues as per current standards of practice. Residents would be provided with showers as per request or as per facility schedule protocols and based upon safety. - R20's Electronic Medical Record (EMR) documented diagnoses of diabetes mellitus (DM -when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), 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), patient's noncompliance with other medical treatment and regimen, dementia (a progressive mental disorder characterized by failing memory and confusion), schizophrenia (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought), presence of urogenital implant (medical devices used to support or restore function in the urinary system), urinary tract infection (UTI -an infection in any part of the urinary system), and hydronephrosis (swelling of one or both kidneys, caused by back up of urine). R20's Annual Minimum Data Sheet (MDS) dated [DATE] documented that R20 had moderately impaired cognition and exhibited no behaviors. R20 was dependent on staff for toileting, bathing, and lower-body dressing. The MDS further documented that R20 had an indwelling catheter and was always incontinent of bowel. R20's Functional Abilities Care Area Assessment (CAA) dated 12/10/25 documented that R20 had multiple comorbidities, neurogenic bladder, frequent UTI, and frequent hospitalizations. The CAA further documented that R20 required total assistance from one to two staff for toileting and bathing. R20's Care Plan, revised 12/14/25, documented that R20 had a functional ability deficit related to impaired balance, generalized weakness, and a history of a cerebrovascular accident (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) with cognitive impairment. The Care Plan documented R20 required extensive assistance with bathing, and if he was resistant with ADLs, to reassure the resident, leave and return in five to ten minutes, and try again. Upon review of the bathing task and Shower and Skin Monitoring sheets from 10/31/25 to 01/28/26, revealed that R20 had received eight showers out of 23 opportunities. This review revealed R20 received two showers in 11/2025 and 12/2025, and four showers in 01/2026. On 01/28/26 at 12:14 PM, R20 was sitting in the dining room, being assisted by staff to eat. R20's hair was not combed, and he had facial hair from several days' growth. On 01/29/25 at 03:00 PM, Administrative Nurse E stated that if a resident refused a bath, staff should document it on the skin monitoring sheet. Administrative Nurse E stated that staff should document on the skin monitoring sheet when a resident receives a bath, and if they have not received one after two days of their scheduled bathing day, the nurse should be notified. Administrative Nurse E stated that if the resident refused, the staff were to offer different methods for bathing, like bed baths and bathing wipes. The facility's undated Resident Showers Policy documented that it was the practice of this facility to assist residents with bathing to maintain proper hygiene, stimulate circulation, and help prevent skin issues as per current standards of practice. Residents would be provided with showers as per request or as per facility schedule protocols and based upon safety.

The facility had a census of 70 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility staff failed to provide care and treatment in accordance with professional standards of practice when the staff failed to provide Resident (R) 6 treatment for low blood sugar before transferring to the hospital. The facility failed to provide documentation related to R3's and R20's transfer to the hospital. Findings included:- R6's Electronic Medical Record, (EMR) documented R6 had a diagnosis of Type 2 Diabetes Mellitus (DM -when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin). R6's Quarterly Minimum Data Set (MDS) dated [DATE] documented R6 had a Brief Interview for Mental Status (BIMS) score of eight, which indicated moderate cognitive impairment. The MDS documented that R6 received insulin (a hormone that lowers the level of glucose in the blood) for seven days during the look-back period. R6's Care Plan revised 12/25/25 documented R6 had Diabetes Mellitus and instructed staff to monitor him for signs or symptoms of hypoglycemia (less than normal amount of sugar in the blood). Review of R6's October Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed a lack of documentation that the facility staff administered glucagon (a medication to treat severe hypoglycemia) to R6 on 10/28/25 at the time of the incident. R6's Clinical Record lacked a progress note with documentation regarding the incident on 10/28/25. The Emergency Medical Technician (EMT) Report, dated 10/28/25 at 05:18 AM, documented that the EMT arrived at the facility to find R6 lying semi-Fowler's (a standard patient position in which the patient is seated in a semi-sitting position (45–60 degrees) and may have knees either bent or straight) in bed, eyes closed. A physical assessment was conducted. R6 was physically responsive to pain but not verbally responsive. EMT checked R6's blood sugar level (the amount of simple sugar moving through your body at any given time), and it was 31. The facility staff were frantically fanning R6, agitated, and immediately demanded that the EMT staff administer glucagon. EMT replied by protocol that they would try for an intravenous (IV-administered directly into the bloodstream via a vein) first for D10 (normal saline (10% dextrose in normal saline providing 10 grams of dextrose per 100 mL along with 0.9% sodium chloride) administration. The report documented that EMT was unsuccessful with the attempt for IV establishment, so they prepared glucagon and administered it in R6's right anterolateral thigh, and R6's blood glucose went up to 45. The facility staff reported that when they went into R6's room this morning, his eyes were open, and he was breathing but was unresponsive. The report documented staff stated she did not check his oxygen saturation, but she placed him on 3 liters of oxygen. The report documented that facility staff stated R6's normal was not normally on oxygen, but she felt airway was key. The facility staff stated she checked R6's blood sugar, and it was 31. The facility staff stated she gave him glucose gel, but could not give a specific dose. The facility staff member stated that she knew R6 took insulin (a hormone that lowers the level of glucose in the blood) and got his regular dose, but did not know how much or when, other than that it was the previous night. The facility staff did not know if R6 had taken it with a meal or when he last ate. The facility staff stated that tonight was her first time working at the facility, and she did not know much about R6 or his baseline presentation. On 01/27/26 at 03:20 PM, observation revealed R6 rested in bed with eyes open and visited politely with staff. On 01/27/26 at 11:23 AM, Certified Nurse Aide (CNA) MM stated she was working the night shift on the 400 hall on the south side of the facility on 10/28/25. CNA MM stated R6's blood sugar plummeted to the 30's (according to Medicine Net.com, normal blood sugar levels range from 70-130). CNA MM stated Licensed Nurse (LN) J could not find the glucose shot. Emergency Medical Service (EMS) came to the facility, and R6 was transferred to the hospital by ambulance. On 01/27/26 at 11:27 AM, LN I stated she had no recollection regarding R6's transfer to the hospital on [DATE]. LN I stated she did know R6 was a brittle diabetic, and at some point, R6 had been transferred to the hospital for low blood sugar. On 01/28/26 at 01:40 PM, Administrative Nurse E stated she would expect staff to administer glucose gel when R6's blood glucose dropped into the 30's. Administrative Nurse E stated the glucose gel is kept in the nurse medication cart, and R6 also had one in the Pyxis machine (an automated medication dispensing system that securely stores, manages, and tracks medications at the point of care). The facility's Blood Glucose Monitoring Policy, revised 2023, documented that the policy of the facility was to perform blood glucose monitoring for diabetic residents as the physician ordered. - R3's Electronic Medical Record (EMR) recorded diagnoses of adult failure to thrive (includes not doing well, feeling poorly, weight loss, and poor self-care that could be seen in elderly individuals), congestive heart failure (CHF -a condition with low heart output and the body becomes congested with fluid), spinal stenosis (degenerative condition of the spine that could cause weakness and loss of use of extremities), severe protein-calorie malnutrition, lymphedema (swelling caused by accumulation of lymph), muscle weakness, unsteadiness on feet, 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). R3's Quarterly Minimum Data Set (MDS) dated [DATE] documented R3 had intact cognition, exhibited no behavioral symptoms, had a functional range of motion of both sides of the lower extremities, used a walker and wheelchair for mobility. R3 required substantial to maximal assistance with upper and lower body dressing, putting on and taking off footwear, bed mobility, sit to lying, lying to sitting, sitting to standing, chair/bed to chair transfers, and walking ten feet. R3 had skin tears, nutritional/hydration interventions to manage skin problems, application of nonsurgical dressing, and application of ointment/medication other than to the feet. The MDS further documented that R3 received an antidepressant (a class of medications used to treat mood disorders), an anticoagulant (slows down the process of blood clotting), an antibiotic (a class of medications used to treat infections), and an opioid (medication used to treat pain). R3's Care Plan dated 05/13/25 documented R3 had a potential for impaired skin integrity related to impaired mobility and incontinence. The Care Plan directed staff to assess and record changes in skin status. R3's needed for substantial assistance from one to two staff with turning/repositioning, and nursing would complete a weekly skin assessment and would monitor skin with all care. The Care Plan also documented that R3 had an Activity of Daily Living (ADL) performance deficit related to Parkinson's disease and spinal stenosis and required extensive assistance of one to two staff with transfers using the stand pivot method. The Care Plan lacked interventions to prevent injuries to R3's lower extremities from a laceration obtained from the bedframe during a transfer on 11/13/25. The Physician Order dated 01/05/26 directed staff to cleanse the left lateral (pertaining to the side, away from the middle) calf with normal saline (NS -saline water solution for medical use), pad dry with gauze, wet kerlix (stretchy gauze bandage) with normal saline, pack wound, cover with non-adherent pad, cover with abdominal pad, then wrap with Coban (a self-adhesion wrap) once a day. The Progress Note dated 11/14/25 at 03:09 AM documented that the nurse and nurse manager assessed R3's wound. The wound had blood on Kerlix. The Kerlix was removed, and sutures were intact; a nonadherent dressing and Kerlix were applied. The Progress notes before 11/14/25 lacked any mention of the wound cause or incident related to the wound. The Progress Note dated 11/14/25 at 04:16 AM documented that the nurse assessed R3's left leg wound. The dressing was clean and intact. No issues with the dressing at that time. The medical record lacked a nursing assessment of R3's condition before being sent to the hospital for evaluation on 11/13/25. The Infection Type Progress Note dated 11/17/25 at 05:11 PM documented fungal/skin infection (unspecific) receiving antibiotic therapy for wound infection to the left lower leg, cefpodoxime (an antibiotic) 200 milligrams (mgs) by mouth two times a day. The resident returned to the facility with 17 sutures due to a leg laceration. Prophylactic (prevention) antibiotics began due to an extensive wound. The Practitioner Acute Follow Up Progress Note dated 11/18/25 documented the nature of the presenting problem on laceration. The resident was seen today at the request of nursing for increased swelling and redness to the lower left extremity and had an emergency room (ER) visit and sutures placed. The resident reported that the laceration occurred last week, but the chart shows the laceration on 11/13/25. R3 reported pain in the leg since, but no increase in pain. Nursing present reported they were not sure if the swelling or redness was new or not. The resident was started on Keflex (an antibiotic) at the ER when the sutures were placed, to cover for Methicillin-resistant Staphylococcus aureus (MRSA -a type of bacteria resistant to many antibiotics), and would start Bactrim (an antibiotic) twice a day, and the resident agreed with the plan. The plan for the laceration with foreign body, left lower leg on 11/13/25, when R3 was initially sent to ER and had 17 sutures placed and started on Keflex with warmth/swelling and fluctuating mass, unclear if abscess (cavity containing pus and surrounded by inflamed tissue) or hematoma (collection of blood trapped in the tissues of the skin or in an organ, resulting from trauma), although it seems to more likely represent hematoma, will add Bactrim twice a day for seven days. The Progress Note dated 11/19/25 at 08:45 PM documented that R3 had returned from the hospital at 08:26 PM. R3 had been sent out for provider evaluation of a laceration to the left lateral calf. Upon return, R3 had new orders for cephalexin (an antibiotic) and doxycycline (an antibiotic). R3 was diagnosed with cellulitis (skin infection caused by bacteria). The previous Bactrim was placed on hold, and further clarification was needed regarding the antibiotic regimen. The medical record lacked a nursing assessment of R3's condition prior to being sent to the hospital for evaluation. On 01/29/26 at 08:21 AM, R3 stated the leg wound happened when a Certified Nurse Aide (CNA) was assisting him to bed for the night. R3 stated that his leg hit something on the bed frame. He was sent to the ER and received 17 stitches, with a measurement of five inches long. On 01/29/26 at 09:05 AM, Licensed Nurse (LN) H provided wound care to R3's lower legs. The left leg laceration had a thin scab line of five inches in length. LN H utilized gloves but did not wear a gown throughout the procedure. LN H reported she was unsure of what caused the laceration, stating she was a new employee to the facility. On 01/29/26 at 02:45 PM, Administrative Nurse E reported that the nurse should complete a narrative of the resident's condition related to the need to be sent to the ER or hospital. The facility's undated Comprehensive Nursing Assessment Policy documented that the facility shall complete a comprehensive nursing assessment for every resident upon admission, upon return from a hospital stay, upon a significant change in physical or mental condition, and upon discharge, as part of the required recapitulation of stay and discharge documentation. Assessments shall be completed by a licensed nurse, documented in the medical record, and used to inform care planning, physician notification, and interdisciplinary interventions. Discharge assessments shall be documented using the facility's form and shall reflect the resident's status at the time of discharge. Failure to complete or document assessment in accordance with this policy may result in corrective action and may place the facility at risk for regulatory noncompliance. - R20's Electronic Medical Record (EMR) documented diagnoses of diabetes mellitus (DM -when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), 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), patient's noncompliance with other medical treatment and regimen, dementia (a progressive mental disorder characterized by failing memory and confusion), schizophrenia (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought), presence of urogenital implant (medical devices used to support or restore function in the urinary system), urinary tract infection (UTI -an infection in any part of the urinary system), and hydronephrosis (swelling of one or both kidneys, caused by back up of urine). The Progress Note dated 07/15/25 at 08:24 AM documented that R20 had increased penile pain. The area was assessed and intact, with the lack of a catheter secure (device to anchor the catheter to the leg), as R20 would often remove it. The catheter secure was placed, and barrier cream was applied. The catheter remained in place and was draining cloudy yellow urine. R20 was educated on the importance of not pulling on the catheter and leaving the catheter secure in place. This note was the last entry. The MDS recorded a Discharge Return Anticipated on 07/17/25. The Progress Notes lacked R20's discharge assessment. The medical record lacked a nursing assessment of R20's condition before being sent to the hospital for evaluation. The Progress Note dated 07/22/25 at 03:52 PM documented R20 returned to the facility on a stretcher with two attendants. R20's had stable and within normal vital signs. R20 was to receive an antibiotic (a classification of medication used to treat infections) through a peripheral line (a short, flexible tube inserted into a small vein to deliver fluids and medications into the bloodstream) in the left forearm. On 01/28/26 at 12:14 PM, R20 was in the dining room and being assisted with eating his meal. R20's hair was not combed, and R20 had facial hair stubble on his face. On 01/29/26 at 02:45 PM, Administrative Nurse E reported that the nurse should complete a narrative of the resident's condition related to the need to be sent to the emergency room or hospital. The facility's undated Comprehensive Nursing Assessment Policy documented that the facility shall complete a comprehensive nursing assessment for every resident upon admission, upon return from a hospital stay, upon a significant change in physical or mental condition, and upon discharge, as part of the required recapitulation of stay and discharge documentation. Assessments shall be completed by a licensed nurse, documented in the medical record, and used to inform care planning, physician notification, and interdisciplinary interventions. Discharge assessments shall be documented using the facility's form and shall reflect the resident's status at the time of discharge. Failure to complete or document assessment in accordance with this policy may result in corrective action and may place the facility at risk for regulatory noncompliance.

The facility had a census of 70 residents. The sample included 18 residents. Based on observation, record review, and interviews, the facility failed to fully investigate Resident (R) 25's unwitnessed fall to identify causative factors and implement interventions to prevent further falls. The facility further failed to accurately identify R44's tobacco use and assess his ability to safely smoke independently. Findings included: - R25's Electronic Medical Record (EMR) documented the resident had diagnoses Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness), hypoxia (inadequate supply of oxygen), hypertension (HTN -elevated blood pressure), and muscle weakness. R25's admission Minimum Data Set (MDS) dated [DATE] recorded the resident had a Brief Interview for Mental Status (BIMS) of 00, indicating severely impaired cognition. The MDS recorded the resident was dependent on staff for most activities of daily living (ADL). The MDS recorded R25 required substantial to maximum staff assistance with all transfers and used a wheelchair for mobility. R25's Care Plan dated 01/07/26 documented the resident had a history of falls, was a high risk for falls, had cognitive impairment, poor safety awareness, and wandering behaviors. The care plan directed staff to meet the residents' needs, be sure the call light was within reach, the bed was in the lowest position, and when in a wheelchair, be sure the brakes are locked. The care plan documented staff would have the resident wear shoes or nonskid socks. The staff would attempt to determine the cause of falls, record the root cause, and remove any potential cause.The Nurses Note dated 01/25/26 at 04:00 PM documented R25 had a fall in her room. A Certified Nurse's Aide (CNA) had just been in R25's room and changed her brief, and the resident was in bed and covered up to rest. A few minutes later the aide notified the nurse R25 got out of bed, (which was not typical for the resident). The nurse documented when the resident fell and it appeared she hit her head most likely on her roommate's wheelchair. Observation revealed R25 had a laceration to the left-center of forehead and was bleeding. The Licensed Nurse (LN) and CNA got R25 off the floor and transferred her to bed and immediately obtained her vital signs. The LN cleansed the forehead wound and placed a dressing on the wound. The LN called the physician and asked to send the resident to the hospital for evaluation due to the resident being on Lovenox (blood thinner). Emergency Medical Services arrived, and the resident was sent to the hospital at 04:30 PM. The Nurse's Note dated 01/25/26 at 09:30 PM documented R25 returned from the hospital with three sutures in place to the left forehead laceration, which measured two centimeters (cm), and noted a small hematoma (collection of blood trapped in the tissues of the skin or in an organ, resulting from trauma) present. Orders from the hospital directed staff to remove the sutures in seven days. R25 was restless upon return to the facility, and the nurse administered Dilaudid (narcotic pain relief medication) and Xanax (antianxiety medication), which provided effective results. R25's Computer Tomography (CT) scan of the head, brain, and spine was within normal limits.R25's EMR lacked any investigative notes indicating the facility conducted an investigation to determine the root cause of the fall and related interventions to prevent future falls. Upon request, the facility was unable to provide additional investigation information related to the 01/25/26 fall.On 01/27/26 at 11:30 AM, observation revealed R25 sat in a wheelchair, dressed in street clothes. She had a laceration with sutures on her forehead and wore anti-skid socks. Continued observation revealed the resident was able to propel her wheelchair around slowly at the nurse's station.On 01/28/26 at 04:00 PM, Administrative Nurse E stated the medical records documented the resident had a fall with laceration to her forehead on 01/25/26 and verified the facility did not investigate the incident. The facility's Compliance with Reporting Allegations of Abuse/Neglect/Exploitation policy, dated 01/01/26, documented the facility would report all allegations of abuse/neglect/exploitation or mistreatment including injuries of unknown sources and misappropriation of resident property are reported immediately to the Administrator of the facility and to other appropriate agencies in accordance with current state and federal regulations within prescribed timeframes. The License Nurse would:a. Respond to the needs of the resident and protect the resident from further incident.b. Remove the accused employee from resident care areas. c. Notify the Administrator or designee.d. Notify the attending physician, resident's family/legal representative, and Medical Director.e. Monitor and document resident's condition, including response to medical treatment or nursing interventions.f. Document action taken in the medical record.The Administrator or designee would:a. Notify the appropriate agencies immediately; as soon as possible, but o later than 24 hours after discovery of the incident. In the case of serious bodily injuries, no later than 2 hours after discovery or forming the suspicion.b. Obtain statements from direct care staff.c. Suspend the accused employee pending completion of the investigation.d. Report to the state nurse aide registry or nursing board any knowledge of any actions which would indicate an employee is unfit for service.e. Within 5 working days of the incident, report sufficient information to describe the results of the investigation, and indicate any corrective action taken, if the allegation was verified. - R44's diagnoses included metabolic encephalopathy (a condition in which brain function is disturbed either temporarily or permanently due to different diseases or toxins in the body), anemia (an inadequate number of healthy red blood cells to carry adequate oxygen to body tissues), fracture right femur (thigh bone), pneumonia (a lung infection that causes inflammation and fluid or pus to fill the air sacs of the lungs), and nicotine dependency.R44's admission Minimum Data Set (MDS) dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The MDS documented R44 was dependent on staff with activities of daily living (ADL), used a wheelchair for mobility and required staff supervision in the facility. The MDS documented R44 did not use tobacco.R44's Activities of Daily Living Care Area Assessment (CAA) dated 12/22/25 documented the resident required substantial assistance with toileting, bathing, dressing, bed mobility and transfers. The CAA documented that the resident was non ambulatory and used a wheelchair for all mobility. The CAA documented that the resident was alert and oriented.R44's Care Plan dated 12/28/25 directed staff to assist R44 with a stand pivot transfer. The care plan noted R44 used a wheelchair and did not ambulate. The plan lacked interventions related to smoking. R44's Smoking Safety Risk assessment dated [DATE] documented R44 did not currently smoke or use electronic smoking devices.A 01/06/26 Encounter Notes documented R44 smoked half a pack of cigarettes a day.On 01/28/26 at 08:35 AM, observation revealed R44 sat on the side of his bed. Certified Medication Aide R administered R44's morning medications.On 01/27/26 at 04:05 PM, Administrative Staff A verified R44 was admitted to the facility and said a Safe Smoking Assessment was completed but did not identify that the resident smoked. Administrative Staff A verified the staff should have filled out the smoking assessment accurately, to see if R44 was able to smoke safely or and identify if he needed staff assistance Administrative Staff A verified the facility would complete an updated Safe Smoking Assessment for R44.The Smoking Assessment policy, dated 01/02/26, documented that the facility would promote resident centered care by providing a safe smoking area for the residents that request to smoke and are capable of safe smoking behaviors either independently or with supervision unless the facility is a designated nonsmoking facility. The policy documented e-cigarettes and vaporizers would be treated as a traditional cigarette and residents would be assessed by the interdisciplinary team (IDT) and designated as dependent or independent. The policy documented smoking assessments for the residents who requested to smoke would be completed on admission, quarterly and with any change in condition. Assessment for independent or supervised smoking would be determined by the IDT team to assess for level of cognition for safe smoking, level of dexterity to manage smoking and smoking materials, assessment of ability to understand and comply with the policy, and assessment of ability to smoke safely. Smokers would be permitted to smoke only in designated smoking areas on the South patio and outside smoking may be prohibited by the Executive Director if weather conditions are determined to be a risk to resident safety. Facility staff would secure smoking materials in a locked area when not in use by the residents for both independent and supervised smokers. The facility would document resident and family education in the medical records for acknowledgement of the Resident Smoking policy.

The facility had a census of 70 residents. The sample included 18 residents. Based on observation, interview, and record review, the facility failed to establish and implement a system to accurately reconcile the disposition of controlled medications and failed to account for all controlled substances.Findings included:- On 01/29/26 at 10:00 AM, observation of a controlled substance reconciliation revealed one bottle of morphine (narcotic pain medication with high potential for abuse) 20 milligrams (mg) per milliliter (ml) concentrate was unaccounted for.Review of the Pharmacy Spreadsheet revealed the morphine was listed with a prescription number, medication name and date of delivery. The missing medication belonged to Resident (R) 16.On 01/27/26 at 02:55 PM, Licensed Nurse (LN) K stated that at the end of her shift, she counted the narcotics with the oncoming nurse and compared them with the controlled drug administrative record. LN K stated that if the count was off, staff would recount, and if it was still inaccurate, the nurses reported the discrepancy to the director of nursing (DON) or assistant director of nursing (ADON).On 01/26/26 at 03:05 PM, LN G stated that before he left at the end of his shift, counted nad compared the narcotics to the controlled drug administration record with the ongoing nurse. If the count was off, he checked the math on the controlled drug administration record sheet, against the Medication Administration Record (MAR) to make sure the administration matched the count. LN G stated that if the count was still off, he would report to ADON or DON.On 01/28/26 at 12:45 PM, Administrative Nurse E stated that the staffing coordinators were responsible for monitoring the narcotics, but both no longer work at the facility. Administrative Nurse E stated that the night shift managers were also responsible for monitoring the narcotics. Administrative Nurse E verified that the facility did not currently have a system for monitoring narcotics and to identify potential diversion.On 01/29/26 at 11:00 AM, Administrative Staff A and Administrative Nurse D verified R16's bottle of morphine was missing.The facility's Medication Administration Policy, revised 01/01/25, documented narcotics would be signed out in the narcotics log as well as documented in the electronic medical record when given. The policy directed staff not to share or borrow medications from other residents.

The facility identified a census of 67 residents. The sample included nine residents, with two residents reviewed for involuntary discharge. Based on record review and interviews, the facility failed to include the required information on an emergency discharge notice for Resident (R) 1 and on a 30-day discharge notice for R2. This deficient practice had the risk for miscommunication between the facility and resident/family, a possible missed opportunity for healthcare services, and involuntary discharge for R1 and R2.Findings included:- R1 admitted to the facility on [DATE] and discharged to the hospital on [DATE].R1's Electronic Medical Record (EMR) documented diagnoses of other Schizophrenia (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought), diffuse traumatic brain injury (TBI- an injury to the brain caused by external forces) with a loss of consciousness, affective mood disorder (category of mental health problems, feelings of sadness, helplessness, guilt, and wanting to die were more intense and persistent than what may normally be felt from time to time), and encephalopathy (a broad term for any brain disease that alters brain function or structure).The admission Minimum Data Set (MDS) dated 10/29/24, documented R1 had a Brief Interview for Mental Status (BIMS) score of nine, which indicated moderate cognitive impairment. R1 had verbal behavioral symptoms directed towards others and other behavioral symptoms not directed towards others one to three days in the assessment period. R1's overall goal was to remain in the facility with no active discharge planning.The Quarterly MDS dated 07/06/25, documented a BIMS was not conducted due to R1 being rarely/never understood. R1 had verbal behaviors directed towards others one to three days in the assessment period. R1 had no active discharge planning.The Cognitive Loss/Dementia (a progressive mental disorder characterized by failing memory and confusion) Care Area Assessment (CAA) dated 11/12/24, documented R1 became agitated easily and became verbally threatening.The Psychosocial Well-Being CAA dated 11/13/24, documented R1 had verbal outbursts of yelling and cursing at staff and peers. R1's outbursts usually occurred when his requests did not happen immediately.R1's Care Plan dated 10/23/24, documented R1 planned to remain in the facility for permanent placement. The plan directed that staff addressed concerns in a timely manner and contacted R1's responsible party for any concerns.R1's Care Plan dated 01/06/25 and revised 04/04/25, documented R1 had the ability and history of being physically aggressive with others related to anger, poor impulse control, and TBI. The plan directed staff to assess and anticipate R1's needs; the facility monitored, documented, and reported any signs of R1 posing a danger to himself and others; and R1 lived in a private room due to aggression.R1's EMR revealed the following:An Orders- Administration Note on 07/11/25 at 09:15 AM documented R1 had a non-injury fall in his room by the closet door while attempting to look inside his closet. R1 denied hitting his head and denied any injuries anywhere on his body. The staff notified the Assistant Director of Nursing (ADON), R1's family, and the provider.An Orders- Administration Note on 07/11/25 at 11:54 AM documented the facility received an order to send R1 to the emergency room (ER) to evaluate and treat for R1's complaints of not feeling well. R1 left in a wheelchair via facility transportation. R1's family was aware.A Nurses Note on 07/11/25 at 02:49 PM documented the nurse communicated clinical information to Consultant GG. Administrative Staff A communicated to Consultant GG that R1 was not able to return to the facility due to behavior indicating a potential risk to himself and others. Administrative Staff A informed Consultant GG of the situation as they were unable to adequately meet R1's needs at that time.A Social Services Note on 07/14/25 at 01:02 PM documented R1 was sent to the hospital per his request and his representative consented. Due to R1's aggression, the facility determined they could not meet R1's needs. R1 had numerous altercations with other residents resulting in police reports made to police. Administrative Staff A notified the hospital that the facility would not accept R1 back due to the above reasons.Upon request, the facility provided a Notice of Discharge dated 07/11/25 for R1. The notice documented the facility had notified R1 of the necessity to discharge immediately on 07/11/25. The notice documented the reasons for the discharge as R1's needs could not be met by the facility and the safety of other individuals was endangered. The notice listed R1's representative's address as his discharge address. The notice explained R1's right to an appeal but did not explain how to file an appeal, who would help R1 file an appeal, or the correct agency and contact information to file an appeal with. The notice listed the long-term care ombudsman's (LTCO) address and phone number but did not list the LTCO's email address. Administrative Staff A signed the notice on 07/14/25.On 08/05/25 at 12:13 PM, Administrative Staff A stated R1's representative informed him that R1 had multiple police interventions at the hospital prior to his facility admission. R1 was hitting people left and right and the facility tried to refer him to several places.On 08/06/25 at 12:23 PM, Administrative Staff A stated corporate sent the template for the discharge notices for the facility to fill out. He stated R1 wanted to go to the hospital, and Administrative Staff A told R1's representative the facility could not handle R1 anymore which she understood. He stated the facility issued a 30-day notice, but he was already out of the building. Administrative Staff A stated the information required on the notice should be in the facility's policy and the facility let the LTCO and family know.The facility's Transfer and Discharge (including against medical advice [AMA]), not dated, directed the facility provided the transfer/discharge notice to the resident and their representative in a language and manner they could understand. The policy documented the notice included all of the following information at the time it was provided: the specific reason and basis for transfer or discharge; the effective date of transfer or discharge; the specific location to which the resident was to be transferred or discharged ; an explanation of the right to appeal the transfer or discharge to the State; the name, address (mailing and email) and telephone number of the state entity which received such appeal hearing requests; information on how to obtain an appeal form; information on obtaining assistance in completing and submitting the appeal hearing request; the name, address (mailing and email) and phone number of the representative of the LTCO; and for nursing home residents with intellectual and developmental disabilities or with mental illness, the notice included the name, mailing and email addresses, and phone number of the state agency responsible for the protection and advocacy of these populations.- R2 admitted to the facility on [DATE] and discharged on 07/31/25.R2's Electronic Medical Record (EMR) documented diagnoses of major depressive disorder (major mood disorder), repeated falls, and generalized anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear).The admission Minimum Data Set (MDS) dated 03/04/25, documented R2 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. R2's overall goal was to remain in the facility, and she had no discharge plan.The Quarterly MDS dated 05/30/25, documented R2 had a BIMS score of 15, which indicated intact cognition. R2 had active discharge planning with a discharge date three or fewer months away.The Functional Abilities Care Area Assessment (CAA) dated 03/13/25, documented R2 needed assistance with functional abilities, and she reported weakness from a recent illness.R2's Care Plan, dated 07/17/25, documented R2 wished to be discharged back to the community to her own home. The plan directed the facility established a pre-discharge plan with R2 and evaluated her progress and revised the plan as needed. The plan directed staff evaluated and discussed with R2 her prognosis for independent or assisted living. The plan directed staff evaluated R2's motivation to return to the community and make arrangements with required community resources to support independence post-discharge.R2's EMR revealed the following:A Social Services Note on 07/16/25 at 12:54 PM, documented a Zoom meeting was held with R2 and her insurance care team for her return back into the community. R2's insurance care team was aware that R2 received a 30-day notice due to non-payment and the discharge date was 07/31/25. During the meeting, R2 had to be redirected at times due to accusations being made. R2 stated she was looking into a place in another town. R2's insurance care team asked if her 30-day notice could be extended, and they were informed that corporate would make that decision. R2 stated she did not have to leave if she did not want to. The insurance care team discussed possibly getting funds for a motel until an apartment was available.A Social Services Note on 07/18/25 at 02:02 PM, documented a meeting was held regarding R2's upcoming discharge. It was discussed that R2 could manage medications and was independent with her activities of daily living (ADL). The insurance care team mentioned they had roadblocks with finding placement due to R2's background and they continued to explore housing for her. R2 was resistant to receiving facility assistance and would not divulge any personal finances.A Nurses Note on 07/31/25 at 10:28 AM, documented the nurse received discharge orders to discharge home with current medications and no narcotics (pain medication).A Nurses Note on 07/31/25 at 12:46 PM, documented the staff notified Consultant GG of R2 requesting medication to be sent to the pharmacy after she self-discharged on 07/31/25. Consultant GG stated R2 could receive a seven-day supply before discharge but R2 already discharged . Consultant GG stated he could not call those medications in and R2 would have to contact an outside primary care provider to get narcotics called in.A Social Service Note on 07/31/25 at 12:51 PM, documented R2 chose to discharge to a motel in another town. Her insurance care team was unaware of her intentions. The facility transported her to the motel.Upon request, the facility provided a Notice of Discharge, dated 07/01/25, for R2. The notice documented the facility notified R2 of the necessity to discharge in 30-days on 07/31/25. The notice documented the reasons for the discharge as R2's bill for services had not been paid after reasonable and appropriate notice to pay. The notice listed R2's family's address as her discharge address. The notice explained R2's right to an appeal but did not explain how to file an appeal, who would help R2 file an appeal, or the correct agency and contact information to file an appeal with. The notice listed the long-term care ombudsman's (LTCO) address and phone number but did not list the LTCO's email address.On 08/05/25 at 01:40 PM, Administrative Staff A stated that the facility issued a 30-day notice to R2, and her insurance care team got involved. He stated the facility made efforts to place R2 in the least restrictive environment. Administrative Staff A stated R2 was independent with ADLs and was capable. He stated that when the facility went to set up appropriate discharge planning, R2 wanted to stay in the facility and not pay. He stated R2 continued to not pay her liability, and the corporate advised him to issue a 30-day discharge notice for nonpayment. Administrative Staff A stated R2 left on 07/31/25 on her own accord, and her insurance care team was unaware.On 08/06/25 at 12:23 PM, Administrative Staff A stated that corporate sent the template for the discharge notices for the facility to fill out. He stated R2's discharge notice was initiated by corporate. Administrative Staff A stated that the information required on the notice should be in the facility's policy, and the facility let the LTCO and family know.The facility's Transfer and Discharge (including against medical advice [AMA]), not dated, directed the facility to provide the transfer/discharge notice to the resident and their representative in a language and manner they could understand. The policy documented the notice included all of the following information at the time it was provided: the specific reason and basis for transfer or discharge; the effective date of transfer or discharge; the specific location to which the resident was to be transferred or discharged ; an explanation of the right to appeal the transfer or discharge to the State; the name, address (mailing and email) and telephone number of the state entity which received such appeal hearing requests; information on how to obtain an appeal form; information on obtaining assistance in completing and submitting the appeal hearing request; the name, address (mailing and email) and phone number of the representative of the LTCO; and for nursing home residents with intellectual and developmental disabilities or with mental illness, the notice included the name, mailing and email addresses, and phone number of the state agency responsible for the protection and advocacy of these populations.

The facility identified a census of 67 residents. The sample included nine residents, with three residents reviewed for discharge. Based on record review and interviews, the facility failed to document a recapitulation of stay for Residents (R) 2, R3, and R4. This deficient practice had the risk for miscommunication of services received during the stay in the facility and if post-discharge care needs for the affected residents.Findings included:- R2 admitted to the facility on [DATE] and discharged on 07/31/25.R2's Electronic Medical Record (EMR) documented diagnoses of major depressive disorder (major mood disorder), repeated falls, and generalized anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear).The admission Minimum Data Set (MDS) dated 03/04/25, documented R2 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. R2's overall goal was to remain in the facility, and she had no discharge plan.The Quarterly MDS dated 05/30/25, documented R2 had a BIMS score of 15, which indicated intact cognition. R2 had active discharge planning with a discharge date three or fewer months away.The Functional Abilities Care Area Assessment (CAA) dated 03/13/25, documented R2 needed assistance with functional abilities, and she reported weakness from a recent illness.R2's Care Plan, dated 07/17/25, documented R2 wished to be discharged back to the community to her own home. The plan directed the facility established a pre-discharge plan with R2 and evaluated her progress and revised the plan as needed. The plan directed staff evaluated and discussed with R2 her prognosis for independent or assisted living. The plan directed staff evaluated R2's motivation to return to the community and make arrangements with required community resources to support independence post-discharge.R2's EMR revealed the following:A Social Services Note on 07/16/25 at 12:54 PM, documented a Zoom meeting was held with R2 and her insurance care team for her return back into the community. R2's insurance care team was aware that R2 received a 30-day notice due to non-payment and the discharge date was 07/31/25. During the meeting, R2 had to be redirected at times due to accusations being made. R2 stated she was looking into a place in another town. R2's insurance care team asked if her 30-day notice could be extended, and was informed that corporate would make that decision. R2 stated she did not have to leave if she did not want to. The insurance care team discussed possibly getting funds for a motel until an apartment was available.A Social Services Note on 07/18/25 at 02:02 PM, documented a meeting was held regarding R2's upcoming discharge. It was discussed that R2 was capable of managing medications and was independent with her activities of daily living (ADL). The insurance care team mentioned they had roadblocks with finding placement due to R2's background and they continued to explore housing for her. R2 was resistant to receiving facility assistance and would not divulge any personal finances.A Nurses Note on 07/31/25 at 10:28 AM, documented the nurse received discharge orders to discharge home with current medications and no narcotics (pain medication).A Nurses Note on 07/31/25 at 12:46 PM, documented the staff notified Consultant GG of R2 requesting medication to be sent to the pharmacy after she self-discharged on 07/31/25. Consultant GG stated R2 could receive a seven-day supply before discharge but R2 already discharged . Consultant GG stated he could not call those medications in and R2 would have to contact an outside primary care provider to get narcotics called in.A Social Service Note on 07/31/25 at 12:51 PM, documented R2 chose to discharge to a motel in another town. Her insurance care team was unaware of her intentions. The facility transported her to the motel.R2's EMR lacked documentation of a discharge summary including a recapitulation of stay.On 08/06/25 at 10:59 AM, Social Services X stated when a resident planned to discharge, she talked to the resident and/or their representative about setting up home health and obtaining pharmacy orders.On 08/06/25 at 11:50 AM, Licensed Nurse (LN) G stated when a resident discharged , she completed a head-to-toe assessment, completed a medication reconciliation with the resident and/or their representative, asked the resident for their designated pharmacy, and made sure the resident had a 30-day supply of medications sent to the facility or if authorized by the provider, sent the medications with the resident or their representative. She stated she documented in the discharge instructions assessment which included vital signs, any skin issues, treatments provided while they were a resident and why they were in the facility, medications and when to take them. LN G was unable to find the recapitulation of stay in the discharge instructions assessment when asked. She confirmed the assessment used for discharge instructions was titled [NAME]-Discharge Instructions- Interdiscipline. LN G stated she had not been instructed on if the facility had a separate discharge summary separate than the discharge instructions.On 08/06/25 at 12:06 PM, Administrative Nurse D stated when a resident discharged , nursing received the order for discharge and if the facility could send home the resident's medications. She stated the nurse documented a discharge summary in the assessment opened by Social Services and the nurse reviewed it with the resident and/or their representative. She stated the nurse went over the resident's medications with the resident and/or their representative and had them sign off on the discharge summary and medications. Administrative Nurse D confirmed the assessment used to document the discharge summary was titled [NAME]-Discharge Instructions- Interdiscipline and she was unable to find a recapitulation of stay in the discharge instructions. She stated a recapitulation of stay should be documented in the discharge summary note but she did not know if the nurses had been doing that. She stated most of the discharge summary was included in the discharge instructions that the resident received a copy of. Administrative Nurse D stated the discharge instructions included how much assistance was needed, any wounds or treatments that needed done, follow-up appointments, list of medications, and the facility contact information in case of questions. She stated the nurse went over the discharge instructions with the resident or their representative unless they left abruptly or against medical advice (AMA) and did not want to go over the instructions. She stated the nurse should still document their attempt at giving the discharge instructions.The facility's Discharge Summary, dated January 2025, directed the facility ensured a discharge summary was provided upon a resident's discharge which addressed the resident's discharge goals and needs, including caregiver support and referrals to local contact agencies. The policy defined a recapitulation of stay as a concise summary of the resident's stay and course of treatment in the facility. The policy directed a discharge summary included a recapitulation of the resident's stay that included but was not limited to diagnoses; course of illness/treatment or therapy; pertinent labs, radiology, and consultation results.- R3 admitted to the facility on [DATE] and discharged [DATE].R3's Electronic Medical Record (EMR) documented diagnoses of sepsis (a life-threatening systemic reaction that develops due to infections that cause inflammation throughout the entire body), generalized muscle weakness, and unsteadiness on feet.The admission Minimum Data Set (MDS) dated 06/16/25, documented R3 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. R3 had an overall goal to discharge to the community and had active discharge planning with a discharge date three or fewer months away.The Functional Abilities Care Area Assessment (CAA) dated 06/18/25, documented R3's plan was to return home with his family after his rehab was completed.R3's Care Plan revised 06/16/25, documented R3 wished to return home when he met his goals. The plan directed that staff established a pre-discharge plan with R3, evaluated his progress, and revised his plan. The plan directed that staff made arrangements with required community resources to support R3's independence post-discharge.R3's EMR revealed the following:An [NAME]- Discharge Instructions- Interdiscipline assessment, effective 06/26/25 at 09:32 AM, documented R3 discharged home on [DATE] at 09:45 AM under the care of an organized home health service. The assessment included R3's equipment needs, therapy referrals, medications with instructions, diet, assistance with activities of daily living (ADL), education given, and skin conditions. The assessment lacked documentation of a recapitulation of R3's stay in the facility.A Discharge Summary note on 06/26/25 at 10:28 AM documented R3 discharged from the facility that date to home with home health. The facility provided discharge instructions including medication review and education to R3 and his family at bedside. R3 and his family had no questions or concerns. The facility called R3's medications to the pharmacy. The note lacked documentation of a recapitulation of R3's stay in the facility.On 08/06/25 at 10:59 AM, Social Services X stated when a resident planned to discharge, she talked to the resident and/or their representative about setting up home health and obtaining pharmacy orders.On 08/06/25 at 11:50 AM, Licensed Nurse (LN) G stated when a resident discharged , she completed a head-to-toe assessment, completed a medication reconciliation with the resident and/or their representative, asked the resident for their designated pharmacy, and made sure the resident had a 30-day supply of medications sent to the facility or if authorized by the provider, she sent the medications with the resident or their representative. She stated she documented in the discharge instructions assessment which included vital signs, any skin issues, treatments provided while they were a resident and why they were in the facility, medications and when to take them. LN G was unable to find the recapitulation of stay in the discharge instructions assessment when asked. She confirmed the assessment used for discharge instructions was titled [NAME]-Discharge Instructions- Interdiscipline. LN G stated she had not been instructed on if the facility had a separate discharge summary separate than the discharge instructions.On 08/06/25 at 12:06 PM, Administrative Nurse D stated when a resident discharged , nursing received the order for discharge and if the facility could send home the resident's medications. She stated the nurse documented a discharge summary in the assessment opened by Social Services and the nurse reviewed it with the resident and/or their representative. She stated the nurse went over the resident's medications with the resident and/or their representative and had them sign off on the discharge summary and medications. Administrative Nurse D confirmed the assessment used to document the discharge summary was titled [NAME]-Discharge Instructions- Interdiscipline and she was unable to find a recapitulation of stay in the discharge instructions. She stated a recapitulation of stay should be documented in the discharge summary note, but she did not know if the nurses had been doing that. She stated most of the discharge summary was included in the discharge instructions that the resident received a copy of. Administrative Nurse D stated the discharge instructions included how much assistance was needed, any wounds or treatments that needed done, follow-up appointments, list of medications, and the facility contact information in case of questions. She stated the nurse went over the discharge instructions with the resident or their representative unless they left abruptly or against medical advice (AMA) and did not want to go over the instructions. She stated the nurse should still document their attempt at giving the discharge instructions.The facility's Discharge Summary, dated January 2025, directed the facility ensured a discharge summary was provided upon a resident's discharge which addressed the resident's discharge goals and needs, including caregiver support and referrals to local contact agencies. The policy defined a recapitulation of stay as a concise summary of the resident's stay and course of treatment in the facility. The policy directed a discharge summary included a recapitulation of the resident's stay that included but was not limited to diagnoses; course of illness/treatment or therapy; pertinent labs, radiology, and consultation results.- R4 admitted to the facility on [DATE] and discharged [DATE].R4's Electronic Medical Record (EMR) documented diagnoses of major depressive disorder (major mood disorder), generalized muscle weakness, history of falling, and contusion (bruise) of right hip.The admission Minimum Data Set (MDS) dated 05/06/25, documented R4 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated moderate cognitive impairment. R4's overall goal was to stay in the facility, and she had no active discharge planning.The Cognitive Loss/Dementia (a progressive mental disorder characterized by failing memory and confusion) Care Area Assessment (CAA) dated 05/07/25, documented R4 had respiratory problems and mood disorders that could impact cognition.R4's Care Plan dated 05/01/25, documented R4 expressed a desire to remain in the facility for permanent placement. The plan directed the facility addressed R4's concerns in a timely manner and contacted R4's responsible party for any concerns.R4's EMR revealed the following:A Social Services Note on 07/11/25 at 12:09 PM, documented R4 planned to discharge out of the facility on 07/21/25 to housing in another town. R4 chose a home health service to follow for nursing needs.An incomplete [NAME]- Discharge Instructions- Interdiscipline assessment, effective 07/14/25 at 12:38 PM, documented R4 required no equipment and had a referral for a home health nurse with the name of the home health company documented. The assessment lacked documentation of R4's discharge status, medication reconciliation, assistance level with activities of daily living (ADL), skin conditions, and a recapitulation of stay.A Social Services Note on 07/18/25 at 12:37 PM, documented R4 planned to discharge to an apartment in another town on 07/21/25. R4's family planned to pick her up and transport her.A Social Services Note on 07/21/25 at 10:46 AM, documented R4 planned to discharge that day, and she had a home health service in place for medication management.A Social Services Note on 07/21/25 at 10:49 AM, documented the facility faxed R4's medication list to her preferred pharmacy.R4's EMR lacked documentation of a discharge summary with a recapitulation of stay.On 08/06/25 at 10:59 AM, Social Services X stated when a resident planned to discharge, she talked to the resident and/or their representative about setting up home health and obtaining pharmacy orders.On 08/06/25 at 11:50 AM, Licensed Nurse (LN) G stated when a resident discharged , she completed a head-to-toe assessment, completed a medication reconciliation with the resident and/or their representative, asked the resident for their designated pharmacy, and made sure the resident had a 30-day supply of medications sent to the facility or if authorized by the provider, she sent the medications with the resident or their representative. She stated she documented in the discharge instructions assessment which included vital signs, any skin issues, treatments provided while they were a resident and why they were in the facility, medications and when to take them. LN G was unable to find the recapitulation of stay in the discharge instructions assessment when asked. She confirmed the assessment used for discharge instructions was titled [NAME]-Discharge Instructions- Interdiscipline. LN G stated she had not been instructed on if the facility had a separate discharge summary separate than the discharge instructions.On 08/06/25 at 12:06 PM, Administrative Nurse D stated when a resident discharged , nursing received the order for discharge and if the facility could send home the resident's medications. She stated the nurse documented a discharge summary in the assessment opened by Social Services and the nurse reviewed it with the resident and/or their representative. She stated the nurse went over the resident's medications with the resident and/or their representative and had them sign off on the discharge summary and medications. Administrative Nurse D confirmed the assessment used to document the discharge summary was titled [NAME]-Discharge Instructions- Interdiscipline and she was unable to find a recapitulation of stay in the discharge instructions. She stated a recapitulation of stay should be documented in the discharge summary note but she did not know if the nurses had been doing that. She stated most of the discharge summary was included in the discharge instructions that the resident received a copy of. Administrative Nurse D stated the discharge instructions included how much assistance was needed, any wounds or treatments that needed done, follow-up appointments, list of medications, and the facility contact information in case of questions. She stated the nurse went over the discharge instructions with the resident or their representative unless they left abruptly or against medical advice (AMA) and did not want to go over the instructions. She stated the nurse should still document their attempt at giving the discharge instructions.The facility's Discharge Summary, dated January 2025, directed the facility ensured a discharge summary was provided upon a resident's discharge which addressed the resident's discharge goals and needs, including caregiver support and referrals to local contact agencies. The policy defined a recapitulation of stay as a concise summary of the resident's stay and course of treatment in the facility. The policy directed a discharge summary included a recapitulation of the resident's stay that included but was not limited to diagnoses; course of illness/treatment or therapy; pertinent labs, radiology, and consultation results.

The facility identified a census of 67 residents. The sample included nine residents, with three residents reviewed for bathing. Based on observations, record review, and interviews, the facility failed to provide consistent bathing for Residents (R) 5 and R6. This deficient practice had the risk of poor hygiene and decreased self-esteem and dignity for the affected residents.Findings included:- R5's Electronic Medical Record (EMR) documented diagnoses of generalized muscle weakness and unsteadiness on feet.The admission Minimum Data Set (MDS) dated 03/14/25 documented R5 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated intact cognition. R5 required substantial/maximal assistance with bathing.The Quarterly MDS dated 06/04/25, documented R5 had a BIMS score of 13, which indicated intact cognition. R5 required partial/moderate assistance with bathing.The Functional Abilities Care Area Assessment (CAA) dated 03/21/25 documented R5 reported weakness to upper and lower extremities as well as decreased range of motion (ROM- the full movement potential of a joint, usually its range of flexion and extension).R5's Care Plan dated 03/14/25 documented R5 preferred female caregivers only for showers, toileting, and all cares provided due to modesty and comfort level. The plan directed staff promoted R5's preference of choice regarding her individualized care.R5's Care Plan dated 05/22/25, documented R5 had an activities of daily living (ADL) self-care performance deficit requiring minimal to extensive assistance with ADLs. The plan directed R5 required extensive assistance with bathing.The Documentation Survey Report for 05/01/25 to 08/05/25 revealed the following documentation for R5's ADL- Bathing on Tuesday and Friday task: not applicable (NA) for 19 out of 28 scheduled bathing days, resident unavailable on one out of 28 scheduled bathing days, and blank documentation for eight out of 28 scheduled bathing days.The Documentation Survey Report for 05/01/25 to 07/29/25 revealed R5 received shampoo with her shower/bath on 05/23/25, 06/03/25, and 06/17/25.On 08/05/25 at 03:57 PM, R5 sat on the side of her bed. Her hair appeared slightly greasy, and she had debris noted on her gown. R5 stated she last received a shower last week and she was not getting her showers regularly. She stated she would like more showers and would be happy with one shower a week. R5 stated not getting regular showers made her feel dirty.On 08/06/26 at 11:40 AM, Certified Nurse Aide (CNA) M stated CNAs were responsible for bathing and they had assigned bathing. She stated the CNAs struggled to get bathing done recently. CNA M stated she documented bathing on paper and in the EMR. She stated if NA was documented, it might have meant that the CNA did not get to the bathing that day or they did not know how to document the bathing. She stated if a resident refused bathing, she asked them twice and if they continued to refuse then another CNA went in to ask them before they reported it to the nurse. CNA M stated R5 preferred to bathe in the sink, and it depended on how she felt that day if she accepted bathing.On 08/06/25 at 11:50 AM, Licensed Nurse (LN) G stated CNAs were responsible for their assigned bathing and when completed, the CNA gave the nurse the shower sheet and documented in the EMR. She stated if a resident refused bathing, the CNA told the nurse and filled out the shower sheet as a refusal then the nurse attempted to get the resident to bathe. LN G stated the CNAs documented refusals in the EMR and if the documentation was blank then she thought that meant the bathing did not get done. She stated R5 voiced her concerns but R5 did not report any bathing concerns to her.On 08/06/25 at 12:06 PM, Administrative Nurse D stated CNAs completed bathing and documented in the EMR and on a shower sheet. She stated if a resident refused bathing, the CNA reapproached one more time than the nurse offered bathing. Administrative Nurse D stated NA meant not applicable and she expected no blank documentation. She stated she expected CNAs to chart showers and refusals in the EMR. Administrative Nurse D stated she expected CNAs to complete their assigned bathing. She stated she had only had one resident complain about not getting baths and that was R5.The facility's Resident Showers policy, not dated, directed the facility assisted residents with bathing to maintain proper hygiene, stimulate circulation, and help prevent skin issues as per current standards of practice. The policy directed residents were provided showers as per request or as per facility schedule protocols and based upon resident safety.- R6's Electronic Medical Record (EMR) documented diagnoses of generalized muscle weakness, unsteadiness on feet, and need for assistance with personal care.The admission Minimum Data Set (MDS) dated 04/14/25, documented R6 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated intact cognition. R6 required substantial/maximal assistance with bathing.The Quarterly MDS dated 07/08/25, documented R6 had a BIMS score of 14, which indicated intact cognition. R6 required substantial/maximal assistance with bathing.The Functional Abilities Care Area Assessment (CAA) dated 04/21/25, documented R6 was at risk for falls, complications of immobility, and depression (major mood disorder) due to functional decline.R6's Care Plan revised 08/04/25, documented R6 had an activities of daily living (ADL) self-care/mobility performance deficit. The plan directed R6 required extensive to total assistance with transfers using the stand-pivot method. The plan did not address bathing assistance.The Documentation Survey Report for 05/01/25 to 08/05/25 revealed the following documentation for R6's ADL- Bathing task: shower received for nine out of 28 scheduled days, not applicable (NA) for six out of 28 scheduled bathing days, resident unavailable for four out of 28 scheduled bathing days, and blank documentation for nine out of 28 scheduled bathing days.The Documentation Survey Report for 05/01/25 to 08/05/25 revealed R6 received shampoo with her shower/bath on 05/18/25, 07/06/25, 07/17/25 and 08/04/25.On 08/05/25 at 03:45 PM, R6 sat in his wheelchair in his room and looked through his bedside table. His hair appeared greasy. R6 stated he did not get enough showers, and he wanted more.On 08/06/26 at 11:40 AM, Certified Nurse Aide (CNA) M stated CNAs were responsible for bathing and they had assigned bathing. She stated the CNAs struggled to get bathing done recently. CNA M stated she documented bathing on paper and in the EMR. She stated if NA was documented, it might have meant that the CNA did not get to the bathing that day or they did not know how to document the bathing. She stated if a resident refused bathing, she asked them twice and if they continued to refuse then another CNA went in to ask them before they reported it to the nurse.On 08/06/25 at 11:50 AM, Licensed Nurse (LN) G stated CNAs were responsible for their assigned bathing and when completed, the CNA gave the nurse the shower sheet and documented in the EMR. She stated if a resident refused bathing, the CNA told the nurse and filled out the shower sheet as a refusal then the nurse attempted to get the resident to bathe. LN G stated the CNAs documented refusals in the EMR and if the documentation was blank then she thought that meant the bathing did not get done.On 08/06/25 at 12:06 PM, Administrative Nurse D stated CNAs completed bathing and documented in the EMR and on a shower sheet. She stated if a resident refused bathing, the CNA reapproached one more time than the nurse offered bathing. Administrative Nurse D stated NA meant not applicable and she expected no blank documentation. She stated she expected CNAs to chart showers and refusals in the EMR. Administrative Nurse D stated she expected CNAs to complete their assigned bathing. She stated she had only had one resident complain about not getting baths and that was R5.The facility's Resident Showers policy, not dated, directed the facility assisted residents with bathing to maintain proper hygiene, stimulate circulation, and help prevent skin issues as per current standards of practice. The policy directed residents were provided showers as per request or as per facility schedule protocols and based upon resident safety.

The facility identified a census of 71 residents. Based on record review, interview, and observation, the facility failed to ensure staff implemented care and treatment consistent with standards of care when staff failed to follow a physician order to assess Resident (R) 1's blood glucose levels four times daily. The facility failed to ensure staff transcribed and performed physician ordered blood glucose checks for R1. On [DATE] R1 readmitted to the facility as an emergency admission. Licensed Nurse (LN) I called the emergency room (ER) physician for order clarification and received orders for a Accu-checks (use of a handheld machine to test blood sugar levels) four times daily for seven days. LN H entered the Accu-check order into the Electronic Medical Record (EMR) incorrectly. As a result, staff did not perform the Accu-checks. On [DATE] staff found R1 lethargic and unable to follow commands. Staff checked a blood glucose level, and it was 21 milliliters to deciliters (mL/dL) (blood sugar below 70 mg/dL is considered low). Staff administered glucose and called 911. When Emergency Medical Services (EMS) arrived, R1's blood glucose measured Lo. R1 was transported by ambulance to the local hospital. During the transport, R1, who also had atrial fibrillation (rapid, irregular heartbeat), experienced cardiac arrest in the ambulance and required cardiopulmonary resuscitation (CPR). She expired upon arriving to the hospital. The facility failure to follow the physician's orders to assess R1's blood glucose levels resulted in an acute episode of severe hypoglycemia (less than normal amount of sugar in the blood) which placed R1 in immediate jeopardy. Findings included: - R1's EMR documented under the Diagnoses tab included the following diagnoses: congestive heart failure (CHF - a condition with low heart output and the body becomes congested with fluid), diabetes mellitus two (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), hypertension (high blood pressure), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), and chronic obstructive pulmonary disease (COPD- progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). The Entry Minimum Data Set (MDS) dated [DATE] documented R1 admitted to the facility on [DATE]. The Discharge MDS dated [DATE] documented R1 discharged from the facility on [DATE]. The Entry MDS dated [DATE] documented R1 readmitted to the facility on [DATE]. The Discharge MDS dated [DATE] documented R1 discharged from the facility on [DATE]. Review of R1's Admission Packet with the re-admitting orders dated [DATE] documented the following orders: Amoxicillin-clavulanate (antibiotic) ,d+[DATE] milligrams (mg) per tablet take one tablet by mouth two times a day for seven days. Aspirin (nonsteroidal anti-inflammatory drug used to reduce pain, fever, and/or inflammation) 81 mg take one tablet by mouth daily for 30 days. Atorvastatin (medication to lower cholesterol) 20 mg tablet take one tablet by mouth nightly for 30 days. Duloxetine (medication used to treat major mood disorders or chronic pain) 60 mg take one capsule 60 mg total by mouth daily for 30 days. Lasix (medication which increases urination and relieves excess fluid from the body) 40 mg tablet take one tablet by mouth two times a day for 30 days. The Nurses Note dated [DATE] at 02:02 PM documented LN I spoke with the ER physician and received emergency admission orders and clarified R1's medications. The physician ordered warfarin (blood thinner) five mg to be given daily and Accu-checks four times a day for seven days. Review of the Orders tab in the EMR in the order category of Diagnostic revealed an an order entered on [DATE] at 02:27 PM for Accu-checks twice daily as a standard diagnostic (other) order which did not populate to the Medication Administration Record (MAR) or the Treatment Administration Record (TAR). Review of R1's Vitals tab in the EMR revealed one blood sugar, checked on [DATE] at 02:05 AM, which was recorded as 21 mg/dL. The EMR lacked further documentation of any blood sugar being checked or documented. The Nurses Note dated [DATE] at 02:10 AM documented staff identified R1 was lethargic and unable to follow commands. R1's blood glucose was 21 ml/dL. Staff administered R1 glucose gel by mouth. Staff provided R1 with a protein drink, which was ineffective at raising R1's blood glucose level. LN H's notarized Witness Statement dated [DATE] documented R1 admitted and discharged out of the facility with her family after a couple of days. LN H documented the facility was contacted a few days later for readmission from the emergency room . The facility accepted, and R1's discharge orders were sent via email. Another set of orders arrived with R1. LN H recalled the orders did not match when auditing the admission. LN I placed a call for clarifications. The ER physician returned the call and clarified the warfarin order and also said R1's blood sugars could be checked in house for a week to try to establish a baseline. LN H documented on the night shift of [DATE] - [DATE], R1 was found very lethargic. LN K took R1's Accu-check and R1's blood sugar was very low. LN K attempted to raise R1's blood sugar with glucose and a protein drink but R1's blood glucose was not rising enough. LN K called the physician who ordered to transfer R1 to the ER. EMS arrived, took R1's blood sugar and got a 'LO' reading. R1 was transferred to the hospital. LN H received an update from the ER that R1 went into atrial fibrillation on the way to the hospital and coded (cardiac arrest). R1 was pronounced dead in the ER at the hospital. On [DATE] at 11:25 AM Administrative Staff A stated administrative staff reviewed R1's chart and noted the orders for R1's Accu-check were improperly entered into the chart. R1's Accu-check orders were entered into the diagnosis section on the EMR which would not trigger for the nurses to look at it. On [DATE] at 12:20 PM LN G stated that the facility had no checklist to turn in related to admissions. LN G further stated she hoped there was a second nurse that reviewed the medications orders that were entered into the chart, but she could not state it happened for sure. On [DATE] at 01:31 PM LN H stated R1 admitted to the facility for rehabilitation but R1's family decided to take R1 home. R1 then required to be readmitted through an emergency admission. LN H revealed that R1 had several discharge orders at the facility and none of the orders matched. LN H revealed that LN J initially placed the admission orders for R1 into the computer and LN H and LN I audited the admission orders. LN H revealed that LN H and LN I compared the orders, and nothing matched. LN H stated that the ER physician was contacted for clarification on R1's orders. LN I took the orders and placed it in a nursing note, and LN H entered the clarified orders into the EMR incorrectly. LN H stated that LN H and LN I came up with doing an in-house blood sugar to get a base line for R1. LN H stated that previously, R1's diabetes was managed with R1's diet. On [DATE] at 03:25 PM LN J recalled that she only put in a section of R1's orders and that LN H and LN I assisted with the other orders. LN J revealed that she thought LN H and LN I completed the pharmacy orders. On [DATE] at 09:15 AM LN G revealed the current admission process was a work in progress. LN G further revealed that in the past, orders were entered and once completed, placed in the medical records inbox. LN G stated the admission packet sat there until medical records scanned it into the EMR. LN G revealed the packet could be there for a while. On [DATE] at 09:35 AM Certified Nurse Aide (CNA) M stated she found R1, who seemed off The morning of [DATE]. CNA M stated that R1 was very pale. CNA M stated she located LN K and informed LN K that R1 needed to be checked. CNA M revealed that she could not recall any nurses checking R1's blood sugar prior to that incident. CNA M further revealed that she believed R1 was not a diabetic. On [DATE] at 10:03 AM LN K stated that CNA M asked her if R1 was a diabetic, because R1 did not look right, and LN K might want to check R1's blood sugar. LN K stated she knew R1 was a diabetic and recalled that she checked R1's blood sugar previously and entered it into the Vitals tab but could not explain why R1 had only on blood sugar entered in the Vitals tab. LN K further stated that when R1 readmitted to the facility that there were no orders for monitoring R1's blood sugar. LN K revealed she was told R1 would have a trial monitoring R1's blood sugar, but when LN K looked in the MAR/TAR the order did not show up, so LN K thought the trial had ended. The facility's Reconciliation of Medications on Admission revised [DATE] documented the purpose of this procedure was to ensure medication safety by accurately accounting for the resident's medications, routes, and dosages upon admission or readmission to the facility. Medication reconciliation is the process of comparing pre-discharge medications to post-discharge medications by creating an accurate list of both prescription and over the counter medications for the purpose of preventing unintended changes or omissions at transition points in care. The policy directed staff to review the list carefully to determine if there were any discrepancies or conflicts. The facility failure to follow the physician's orders to assess R1's blood glucose levels resulted in an acute episode of severe hypoglycemia, which placed R1 in immediate jeopardy. The following corrections were completed on [DATE]: All residents with a diabetes diagnosis had their orders reviewed for Accu-check orders and ensured all orders were accurate and up to date. All nurses received training related to inputting orders into the EMR correctly. The facility discussed the issue in their Quality Assurance and Performance Improvement meeting. All corrective measures were completed prior to the onsite survey therefore the citation was issued as past noncompliance and existed at the scope and severity of J.

The facility had a census of 55 residents. The sample included 17 residents, with eight residents reviewed for unnecessary medication. Based on interview and record review, the facility failed to adequately monitor the efficacy of [MEDICATION NAME] (blood thinning drug) for Resident (R) 40 who the hospital admitted with a critically high International Normalized Ratio (INR) (a laboratory measurement used to determine the effects of oral anticoagulants, blood thinners) which lead to the resident's hospitalization for a critically low hemoglobin (substance that allows for the transport of oxygen throughout the body), placing the resident in immediate jeopardy (IJ). Findings included: - R40's Admission Minimum Data Set (MDS), dated [DATE], documented the resident had intact cognition with a Brief Interview for Mental Status (BIMS) score of 13. The MDS documented the resident required supervision for eating and extensive assistance of two staff for all other Activities of Daily Living (ADLs), The MDS documented the resident received scheduled and as needed (PRN) pain medication, had recent surgery, and received anticoagulant medication seven days of the look back period. The Anticoagulant Care Plan, dated 01/11/21, directed staff to administer anticoagulant medication as ordered, monitor for side effects and effectiveness, obtain labs as ordered, and report abnormal results to the physician. The care plan further documented the Black Box Warning (BBW) for [MEDICATION NAME] stated the drug can cause major or fatal bleeding, and directed staff to perform regular monitoring of INR on all treated patients. A care plan revision dated 01/26/21, directed staff to monitor, document, and report any adverse reactions of anticoagulant therapy. The Physician Order, dated 01/12/21, directed staff to administer [MEDICATION NAME], 4 milligrams (mg) daily. The medication was held 01/15/21 to 01/18/21 and discontinued. The Physician Order, dated 01/19/21, directed staff to administer [MEDICATION NAME], 3 mg daily, and discontinued 01/21/21. The January 2021 Medication Administration Record [REDACTED] The Physician Order, dated 01/26/21, directed staff to administer [MEDICATION NAME], 2 mg daily. The INR lab results, dated 01/28/21, documented an INR of 1.2, which measured below therapeutic range (blood concentration usually expected to achieve the desired result), (2.0-3.0) for this resident. The Physician Order, dated 01/28/21, directed staff to administer [MEDICATION NAME], 4 mg daily, and redraw an INR on Monday, 02/01/21. The INR lab results, dated 02/01/21, documented an INR of 2.5. The Medical Record lacked further INR test results. The Progress Note, dated 03/07/21 at 07:10 AM, documented R40 had emesis (vomit) with a dime size blood clot, and blood pressure of 130/105 (higher than normal). The nurse notified the physician and received an order to send the resident to the emergency room (ER). The Progress Note, dated 03/07/21 at 09:55 AM, documented the hospital admitted R40 for a critically low hemoglobin. On 03/11/21 at 08:50 AM, Administrative Nurse D verified the facility had not obtained INR tests for R40 twice per week, as the physician ordered. Administrative Nurse D stated she was unaware the lab discontinued the INR lab tests after 02/01/21 and verified staff had not noted the lack of INR lab tests from 01/28/21 to 03/07/21. On 03/15/21 at 10:40 AM, Consultant (C) GG, the resident's physician, stated he expected staff to obtain the INR level every Monday and Thursday for his patients that received [MEDICATION NAME], especially when the patient required a higher dose. C GG stated he received an INR test result 03/02/21, but no further INR tests. C GG verified the facility had not informed him of the lack of INR testing. The facility's undated Administration Procedures for All Medication policy documented staff were to check for vital signs or other tests to be done prior to medication administration and monitor for side effects or adverse drug reactions. Upon request, the facility did not provide a policy for Labwork. The facility failed to follow up to ensure physician ordered labwork was completed for R40 to monitor the levels of blood thinner in her blood, placing the resident in immediate jeopardy when no lab monitoring was completed for 35 days, and the resident required hospitalization . On 03/11/21 at 03:46 PM, Administrative Staff A and Administrative Nurse D were provided the IJ template and notified the facility's failure to monitor the effectiveness of R40's [MEDICATION NAME], as ordered by the physician, which placed R40 in immediate jeopardy. The facility presented an acceptable plan for removal of the immediate jeopardy on 03/11/21 at 06:15 PM, which included the following: All residents receiving [MEDICATION NAME] would be audited to ensure PT/INR labs were completed as ordered and reported to the physician. All licensed nursing staff would be educated before their next scheduled shift regarding [MEDICATION NAME] administration, PT/INR requirement and [MEDICATION NAME] management and tracking form. Training initiated 03/11/21. The DON or designee would monitor [MEDICATION NAME] management form weekly to ensure compliance. A [MEDICATION NAME] Management form was implemented 03/09/21 for residents receiving [MEDICATION NAME]. A surveyor validated the removal of the immediate jeopardy on 03/15/21 at 10:30 AM. The deficient practice remained at a G scope and severity, following the removal of the immediate jeopardy.

The facility identified a census of 66 residents. The sample included 28 residents with 1 resident reviewed for pressure ulcers. Based on record review, observation and interview the facility failed to implement interventions to avoid the development of and promote healing of pressure ulcers which resulted in a pressure ulcer for resident #40. Findings included: - Resident #40's electronic medical record (EMR) listed [DIAGNOSES REDACTED]. The annual minimum data set ((MDS) dated [DATE] recorded a Brief Interview for Mental Status (BIMS) score of 7 which indicated severe cognitive impairment. The MDS documented the resident required extensive assistance of one person for bed mobility, transfers, toilet use and personal hygiene. He/she required assistance of one person for bathing. The MDS documented the resident had no pressure ulcers but was at risk for pressure injury. He/she had a pressure reducing mattress and wheelchair cushion. The quarterly MDS dated [DATE] recorded a BIMS score of 6, which indicated severe cognitive impairment. The resident required extensive assistance of one person for most activities of daily living (ADL) which included bed mobility, dressing, transfers, toilet use and personal hygiene. He/she required assistance from one person for bathing. The resident did not walk during the look back period. The MDS recorded the resident was at risk for pressure ulcers and pressure reducing devices were in use. The pressure ulcer care area assessment (CAA) dated 7/7/18 recorded the resident triggered the care area due to the need for assistance with bed mobility. The resident was unable to reposition him/herself independently when in bed. It further documented the resident was free from pressure ulcers but would continue with a plan of care for the risk of pressure injury. The Braden assessment (formal assessment tool used to measure risk for pressure ulcers) completed on 9/2/18 record a score of 19 which indicated the resident was at risk for pressure ulcers. The care plan revised on 7/26/18 recorded the resident had potential/actual skin integrity impairment. It directed staff to keep the resident's skin clean and dry. It directed staff to apply barrier ointment as needed for skin irritation. The care plan lacked further interventions related to reducing pressure, preventing and/or healing pressure injuries. The physician's orders [REDACTED]. The (MONTH) (YEAR) nurse treatment administration record (TAR) recorded the physician order [REDACTED].M. - 6 P.M.) and once for night shift (6 P.M. - 6 A.M.). The TAR lacked documentation the cream was applied for 10 days on day shift (12/1, 12/6, 12/10, 12/11, 12/19, 12/20, 12/24, 12/28, 12/29, and 12/30) and once on night shift (12/31). The medical record lacked evidence the weekly skin assessment was performed on 12/29/18 as scheduled. The (MONTH) 2019 TAR continued the physician order [REDACTED]. The 1/5/19 weekly skin assessment identified blanchable redness on the resident's coccyx (small triangular bone at the base of the spine). The medical record lacked evidence staff performed a weekly skin assessment on 1/12/19 and 1/27/19 as scheduled. The (MONTH) 2019 TAR continued the physician order [REDACTED]. The 2/16/19 weekly skin assessment documented blanchable redness to the resident's coccyx. The medical record lacked evidence staff performed a weekly skin assessment on 2/2, 2/9 and 2/23 as scheduled. The (MONTH) 2019 TAR continued the physician order [REDACTED]. The weekly skin assessment on 3/3/19 documented the resident had no new skin concerns and continued to receive barrier cream to coccyx. The medical record lacked documentation that staff performed the weekly skin assessment on 3/9/19 as scheduled. The nurses note dated 3/10/19 recorded the resident had a wound to the coccyx which measured 1.2 centimeters (cm) x 0.4 cm and depth was unknown due to 100% yellow slough in the wound bed. The note recorded a 0.5 cm diameter stage 1 (closed) pressure area on each side of the wound. The resident was encouraged to spend some time off his/her buttocks and to lie down throughout the day to relieve pressure . The medical record lacked evidence of further assessment, measurement and stage (description and severity of pressure ulcer) of wound. The physician's progress note dated 3/11/19 documented the resident developed a sacral (shield-shaped bony structure that is located at the base of the lumbar vertebrae and is connected to the pelvis) decubitus ulcer (pressure ulcer) and effort was being made to reduce the amount of time the resident was putting pressure on the area. The (MONTH) 2019 TAR documented a dressing order dated 3/10/19. The order directed staff to cleanse the coccyx wound and apply calcium alginate (highly absorbent, biodegradable alginate dressing derived from seaweed) to wound bed and cover with a bordered foam dressing every other day and as needed. The treatment was administered daily on 3/10 through 3/20 and then every other day until it was discontinued on 3/25. The (MONTH) 2019 TAR documented a treatment order dated 3/25/19 which directed staff to apply Skin Prep (a skin barrier preparation) twice daily, once on day shift and once on night shift. The TAR lacked documentation the treatment was applied twice on day shift on 3/27 and 3/28. The medical record lacked documentation that staff performed the weekly skin assessment on 3/23/19 or 3/30/19 as scheduled. On 04/03/19 at 11:20 AM the resident propelled him/herself in a wheelchair to the hall and sat at the window. On 04/04/19 at 7:42 AM the resident sat on a cushion in his/her wheelchair. The resident was observed continuously from 7:42 AM through 9:51 AM, seated in his/her wheelchair, in the same position. No staff provided assistance or encouragement to the resident to reposition or shift weight. On 04/08/19 at 9:51 AM the resident was wheeled in his/her wheelchair into a room on the 300 hall to be seen by the dentist. On 04/08/19 at 9:59 AM the resident propelled him/herself in the wheelchair out of the room after seeing the dentist and down the hall. On 04/08/19 at 10:51 AM the resident sat in his/her wheelchair in the activity room. The resident smelled of urine and stool. On 04/08/19 11:11 AM at the request of surveyor, direct care staff O asked the resident if he/she would like to use the bathroom. The resident said yes. On 04/08/19 at 11:13 AM direct care staff O assisted the resident into his/her bathroom. Staff O assisted the resident to stand at the grab bar. When the resident stood, observation revealed the back of the resident's pants and the wheelchair cushion were saturated with urine and stool. Staff O removed the resident's pants which revealed an adult incontinence brief soaked with urine and stool. Stool dripped from either side of the brief and spread upwards over the resident's entire sacral area to the lower back. Staff O removed the brief and cleansed the area. Once the stool was removed, the skin on the coccyx was red, as well as both buttocks. The area blanched when staff O pressed on it. The coccyx had an open area approximately 1 cm long by 0.2 cm wide. The wound bed was yellow. Multiple pinpoint open areas were observed to the right of the coccyx wound. The area was surrounded by dark purple, intact skin. On 04/08/19 at 11:21 AM direct care staff O applied barrier cream to the resident's buttocks, but not to the inner buttock area which included the coccyx. On 04/08/19 at 11:13 AM direct care staff O stated that he/she thought the resident would alert staff if he/she was uncomfortable or needed to use the bathroom. Staff O stated he/she was not aware the resident had any skin issues. He/she stated no report had been given on the resident's care. Staff O stated he/she sometimes used the barrier cream if it looked like the resident's skin was red or irritated. On 04/08/19 at 11:13 AM direct care staff N stated the resident used to alert staff of her needs. Staff N stated he/she was not aware of any skin issues or concerns for the resident, but usually applied the barrier cream if the resident had an incontinent episode. On 04/08/19 at 11:27 AM licensed staff G stated the nurses did skin assessments weekly for all residents. He/she stated if a skin concern was identified nursing would notify the physician and implement a treatment. Staff G stated the nurses were responsible for administering the treatments on the TAR. He/she stated the staff should have received a verbal report of which residents were at risk for skin breakdown or needed additional assistance. He/she stated resident #40's wound was mostly healed. On 04/08/19 at 3:03 PM administrative nursing staff E stated nursing staff used the Braden assessment to determine risk for pressure injuries and the Braden would be completed at least quarterly. Staff E stated if the resident had a pressure wound or was at risk, interventions would be implemented to reduce the risk for wound development. Staff E stated he/she expected the nurses to administer creams and treatments listed on the TAR. He/ she expected resident #40 to be repositioned and toileted at least every two hours, more if needed. On 04/08/19 at 3:37 PM administrative nurse staff D stated he/she expected all interventions related to wound care and prevention of pressure ulcers to be on the care plan and followed by all staff. Staff D stated the nursing staff know what cares to provide to the resident by reviewing the plan of care and tasks in the point of care system. Staff D stated he/she expected a weekly skin to be performed and documented on both the TAR and in the EMR. Staff D stated that the specifics related to resident #40's wound and the treatments were the responsibility of the assistant director of nursing (ADON) who was the wound nurse. On 4/8/19 at 5:03 PM the physician was unavailable for interview. The facility policy Pressure Injury and Skin Assessment directed each resident would have a weekly skin assessment by a licensed nurse. The policy dated 1/15/18 titled Pressure Ulcer Prevention instructed staff to keep the resident's skin clean and dry. It directed staff assist residents to reposition at least every two hours. The facility failed to administer treatment, implement and provide interventions to prevent the development of pressure ulcers and failed to provide care and services to promote healing of pressure ulcers. The facility failed to provide ongoing monitoring of the pressure ulcer. This deficient practice resulted in an unhealed pressure ulcer to resident # 40, who was cognitively impaired and had limited mobility .

The facility identified a census of 66 residents. The sample included 28 residents of which two were reviewed for nutrition. Based on record review, observation and interview the facility failed to identify, implement, monitor, and modify interventions to prevent weight loss for resident #15 which resulted in a 9.47 percent weight loss over 3 months. Findings include: - Resident #15's electronic medical record (EMR) listed [DIAGNOSES REDACTED]. The annual minimum data set ((MDS) dated [DATE] recorded no behaviors and a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. The resident was independent after set up assistance for activities of daily living (ADL) which included bed mobility and eating and required supervision of one person for personal hygiene. The MDS documented a weight of 159 pounds (lbs) and no weight loss. The quarterly MDS dated [DATE] recorded a BIMS score of 9 which indicated moderate cognitive impairment and wandering behavior. The MDS recorded the resident was independent with no staff assist, set up or supervision for all ADL except personal hygiene. The MDS documented a weight of 147 lbs and no weight loss. The nutrition care area assessment (CAA) dated 9/27/18 documented the resident was at risk for nutrition. His/her appetite was good, and his/her weight was stable. He/she required set up assistance with meals and had a regular diet. The care plan revised on 11/5/18 recorded the resident was at risk for altered nutrition. The 11/29/17 interventions directed staff to obtain a weight monthly and as needed (PRN). The interventions dated 8/7/18 directed staff to document meal intakes each shift and notify the physician of significant weight changes. The intervention dated 12/26/18 directed staff to give the resident Readycare 1.7 (a liquid premade nutritional drink) 60 milliliters (ml) three times daily due to steady weight loss. The (MONTH) 2019 physician's orders [REDACTED]. The (MONTH) Medication Administration Record [REDACTED]. No intakes were recorded for supplement. The (MONTH) meal intake record lacked intake percentage for 45 of the 93 meals. The EMR documented a weight of 147.8 lbs obtained 1/1/2019. The nutrition note documented on 1/16/19 by the registered dietician (RD) recorded the resident had less than 76 percent meal intakes at most meals and good intake of ordered supplement. The RD recommended further monitoring of weight and intake. The (MONTH) 2019 physician's orders [REDACTED]. The (MONTH) 2019 MAR indicated [REDACTED]. No intakes were recorded for supplement. The (MONTH) meal intake record lacked documentation of meal percentage consumed for 50 out of 84 meals. The EMR recorded a weight of 146.8 lbs. on 2/11/19. The nutrition note documented on 2/18/19 by RD recorded the resident consumed less than 50 percent at documented meals. The RD documented overall weight loss continued and recommended the Readycare 1.7 be increased to 90 ml three times daily. The RD recommended continued monitoring of intake and weight. The (MONTH) 2019 physician's orders [REDACTED]. The (MONTH) 2019 Medication Administration Record [REDACTED]. No intakes were recorded for supplement. The (MONTH) 2019 meal intake record lacked documentation of meal percentage consumed for 74 of the 93 meals. The EMR lacked evidence the staff weighed the resident in March. The facility was unable to find a weight sheet or documentation of the resident's (MONTH) 2019 weight. The nutrition note documented by the RD on 3/20/19 recorded the resident's intake as variable. The note documented the weight as 146.8 with a date of 2/19/19. The RD identified the resident continued on 60 ml of Readycare 1/.7 three times daily and recommended to continue intake and weight monitoring. The (MONTH) 2019 physician's orders [REDACTED]. The (MONTH) 2019 Medication Administration Record [REDACTED]. No intakes were recorded for supplement. The subsequent doses from the afternoon on 4/6 through 4/8 were recorded as refused by the resident. The (MONTH) 2019 meal intake record lacked documentation of meal percentage consumed for 11 of 21 meals. The EMR recorded a weight of 133.8 lbs on 4/8/19 . The nurse note dated 4/8/19 at 11:57 AM documented a call had been placed to the resident's physician to report weight loss of 10 percent. The note documented the resident was currently receiving Readycare 1.7 60 ml three times daily. On 04/04/19 at 7:49 AM the resident left the dining room. An empty juice cup was at the resident's place at the table. The resident had not been served food yet. On 04/04/19 at 8:17 AM the resident laid in bed with eyes closed. Observation of the resident's room revealed no drinks or snacks available in the room. On 04/08/19 at 8:15 AM staff served the resident 2 sausage links, 2 eggs, a slice of toast and hot cereal. The resident consumed 100 percent of the meal. On 04/08/19 at 9:45 AM the resident laid in bed with his/her eyes closed. Observation of the room revealed no drinks or snacks available in the room. On 04/08/19 at 11:27 AM licensed staff G stated the weights were obtained by the certified nursing assistants (CNA). He/she stated the list was provided to nursing by the assistant director of nursing (ADON). Staff G stated that once weights were obtained staff returned the list to the ADON for review and to be entered the EMR. He/she stated that the certified medication aides (CMA) administered nutritional supplements and expected the CMA to report to nursing if the resident refused the supplement. Staff G stated he/she was unaware of any weight loss for resident #15. He/she stated the resident fed him/herself and took him/herself to meals. On 04/08/19 at 2:26 PM direct care staff M stated the resident had been taking the ordered supplement until recently. He/she stated the resident started to refuse to drink the supplement over the last few days and would pour it into the sink. Staff M verbalized that the staff encouraged the resident to consume the supplement. He/she stated the restorative aides obtained the weights for the resident and turned the weight in to the ADON or director of nursing (DON). Staff M stated resident #15 would frequently leave the dining room before meals were served or walked back and forth from the dining room to the resident's room. Staff M verbalized he/she was not aware of any weight concerns for resident #15. On 04/08/19 at 3:03 PM administrative nursing staff E stated normally the staff tried to obtain monthly weights before the fifth of each month. He/she stated the CNA obtained the weights and then returned to the ADON for review and to enter into the EMR. Staff E stated anytime there was a significant loss for a resident, the facility would review and monitor the interventions and weights and intakes. Staff E stated he/she thought resident #15's weight was stable. Staff E verbalized he/she was uncertain what the RD reviewed each month. Staff E stated he/she did not communicate directly with the RD with regards to weight concerns. Staff E stated the RD recommendations went to the dietary manager and to the DON. Staff E verbalized uncertainty why the recommended interventions to prevent weight loss were not implemented for resident #15. On 04/08/19 at 3:37 PM administrative nursing staff D stated that the weights were obtained by the CNA and reviewed by the ADON. Staff D stated he/she expected to be notified before there was an actual weight loss. He/she stated the facility should be identifying residents at risk and monitoring meal, supplement and snack intakes. Staff D stated the RD evaluated every resident every month and the dietary manager and the ADON received a report of the recommendations. Staff D stated the ADON would follow up on those recommendations. On 4/8/19 at 1:57 PM the RD was unavailable for interview. On 4/8/19 at 2:13 PM the physician was unavailable for interview. The undated facility policy Nutrition Monitoring directed staff to monitor and record meal intakes and measure and record monthly weights. It directed staff to assess factors affecting appropriate nutritional intake and take corrective action. The facility failed to adequately monitor, implement and assess effectiveness of weight loss interventions for resident #15. This deficient practice resulted in a severe (9.47 percent) weight loss over 3 months for resident #15 who was at risk for impaired nutrition.

The facility identified a census of 63 residents. The sample included 3 residents. Based on observation, record review, and interview, the facility failed to protect residents from potential abuse when Direct care staff M, Licensed Nursing Staff H and Licensed Nursing Staff I had knowledge of an allegation of abuse to resident #1 by licensed nursing staff H. Staff H continued to provide resident care on the north unit for the remainder of his/her shift (approximately 6 hours). This deficient practice placed the residents on the north unit in the facility in immediate jeopardy. Findings included: - The quarterly Minimum Data Set ((MDS) dated [DATE] for resident #1 documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The resident required limited assistance of one staff member with most activities of daily living, such as ambulation, dressing and personal hygiene, and used a wheelchair for mobility. The nurse's note dated 5/23/17 at 12:55 AM documented licensed nursing staff H applied ointment to the resident's knees. The resident touched staff H's arm, and staff H pulled his/her arm back. Staff H finished providing care for the resident and left the room. The resident engaged the call light, and direct care staff M answered it. The resident accused staff H of trying to hit him/her. Review of the facility investigation, undated, documented staff informed administrative staff A on 5/23/17 at 8:40 AM of an incident between the resident and licensed nurse H (approximately 8 hours and 40 minutes after the incident). On 5/25/17 at 7:30 AM, the resident laid in bed with his/her eyes closed. On 5/25/17 at 6:35 AM, direct care staff M denied observing the incident between the resident and licensed nursing staff H on 5/23/17. Staff M stated he/she walked into the resident's room a short while later to provide care for the resident's roommate. Staff M stated the resident reported to him/her that he/she thought licensed nursing staff H was going to hit him/her. Staff M stated he/she reported this allegation to staff H. On 5/25/17 at 8:02 AM, the resident stated he/she asked licensed nursing staff H for some medication. The resident reported while staff H applied the medication, they talked about the temperature in the resident's room, and the resident thought the room was cold. The resident stated he/she placed his/her hand on staff H's arm, to show him/her how cold his/her hand was. The resident stated staff H yanked his/her arms back, and he/she thought staff H was going to hit him/her. The resident further stated he/she was afraid of licensed nursing staff H. On 5/25/17 at 11:35 AM, social services staff KK stated on 5/23/17 at 8:30 AM, the resident reported the incident with licensed nursing staff H. Staff KK stated he/she immediately notified the director of nursing at that time. On 5/25/17 at 12:06 PM, licensed nursing staff H stated on 5/23/17 around midnight, the resident asked for some medication. Staff H reported while he/she applied the medication, the resident placed his/her hand on staff H's arm. Staff H stated he/she pulled his/her arms back, because the resident had startled him/her. Staff H relayed he/she finished applying the medication, and left the room. Staff H stated a short while later, direct care staff M reported to staff H the resident stated he/she thought staff H was going to hit her. Staff H further stated he/she reported all allegations of abuse to his/her immediate supervisor, but did not see this as an allegation of abuse, because the resident had behaviors of lying about other staff. On 5/25/17 at 12:10 PM, licensed nursing staff I stated staff H reported on 5/23/17, the resident stated he/she thought staff H was going to hit him/her, and asked staff I to be a witness when staff H talked to the resident about the allegation. Staff I stated he/she reported all allegations of abuse to his/her immediate supervisor, but did not see this as an allegation of abuse, because the resident had behaviors of lying about other staff. On 5/25/17 at 3:30 P.M. administrative nursing staff D stated he/she was not aware of the situation until approximately 8:40 AM on 5/23/17 (approximately 8 hours and 40 minutes after staff H, staff I and staff M were aware of the alleged abuse). Staff D further stated he/she expected staff to follow the facility's policy and immediately report all allegations of abuse to himself/herself or to administrative staff A. On 5/3/17 at 3:35 P.M. administrative staff A stated staff D reported the incident between the resident and staff H around 8:40 AM on 5/23/17. Staff A reported he/she suspended staff H immediately upon receiving the report. Staff A further stated he/she expected staff to immediately report all allegations of abuse to him/her. The facility's policy Prevention of Resident Abuse, Neglect, Mistreatment or Exploitation, revised October 2016, documented employees who have knowledge of any abuse situation immediately notified the supervisor, who then notified the administrator and/or the director of nursing. The facility failed to protect residents in the facility from potential abuse when a resident reported an allegation of abuse against a staff member, and the staff member continued to provide care to the residents for the remainder of his/her shift (approximately 6 hours). This deficient practice placed the residents in the north unit in the facility in immediate jeopardy. This deficient practice was determined to be past non-compliance when the facility suspended licensed nursing staff J and provided abuse in-service training to staff on 5/25/17.

The facility identified a census of 71 residents. The sample included 5 residents. Based on record review and interview, the facility failed to ensure staff administered the right medication to the right resident for one of 5 residents sampled. Resident #1 required hospitalization on [DATE] to monitor for potential adverse reactions after he/she received another resident's pain relief medications on 2/25/17 which included medication noted on his/her allergy list. Findings included: - The February 2017 physician's orders [REDACTED].#1 recorded the resident had no know medication allergies [REDACTED].>The admission 5 day Minimum Data Set ((MDS) dated [DATE] documented staff assessed the resident's memory as good; he/she had awareness of his/her surroundings, and was able to make his/her needs known. The resident required extensive assistance of one to two staff with most activities of daily living (ADLs). The care plan dated 2/22/17 directed staff to give his/her medications as ordered and monitor for side effects and effectiveness. The care plan lacked documentation the resident had any medication allergies [REDACTED].>Review of the physician's signed history and physical dated 2/24/17 documented the resident was allergic (allergy - hypersensitivity of the immune system to something in the environment that usually causes little or no problem in most people) to [MEDICATION NAME] and [MEDICATION NAME] (both are narcotic pain relievers used to treat moderate to severe pain). The nurse's progress note dated 2/25/17 at 10:02 P.M. documented the resident received the wrong medication at this time. Licensed nurse H spoke with the resident and encouraged him/her to vomit at 10:03 P.M. The resident vomited some of the medication he/she swallowed. Nurse H contacted the physician's advanced registered nurse practitioner (ARNP) and received an order to send the resident to the emergency room for evaluation and treatment. Staff notified the resident's family. The resident was alert and oriented, vital signs such as his/her blood pressure, temperature, heart rate, and breathing were within normal limits, and at 10:10 P.M., the resident left the facility with emergency medical staff. Review of the facility's investigation dated 2/27/17 documented the resident inadvertently received [MEDICATION NAME] sulfate 90 milligrams (mg), [MEDICATION NAME] 0.5 mg, (an anti-anxiety medication) and [MEDICATION NAME] 10 mg (a pain reliever) at 10:01 P.M. on 2/25/17. This report recorded the resident's allergic reaction to [MEDICATION NAME] included hallucinations (a false perception such as seeing something that is not real) and [MEDICATION NAME] caused [DIAGNOSES REDACTED] (muscular weakness). On 4/10/17 at 2:12 P.M. licensed nurse H stated he/she had prepared medications for resident #2, when staff alerted him/her about a phone call. He/she stated he/she gave the medications to direct care staff O and indicated they were for resident #2. Staff H further stated when he/she turned back around, resident #2 had left the area, and direct care staff O entered resident #1's room. Nurse H quickly followed direct care staff O and asked if he/she gave the medications to resident #1, and he/she replied he/she had. Nurse H further stated he/she promptly assessed the resident, and sent him/her to the hospital. Interview on 4/10/17 at 2:41 P.M. direct care staff O stated on 2/25/17, resident #1 had requested a pain pill, along with resident #2. Staff O stated nurse H gave a cup of medication to him/her. Staff O confirmed the medications were for resident #1, and proceeded to administer them to him/her. Staff O further stated after resident #1 had taken 2 of the 4 pills, Nurse H came into the room and stated the medication was for resident #2. Staff O stated Nurse H assessed the resident and sent him/her to the hospital for an evaluation. On 4/10/17 at 4:30 P.M. administrative licensed nurse D stated he/she expected staff to follow the facility's policy and acceptable standards of practice when it came to administering medications. On 4/12/17 at 1:30 P.M. physician consultant M was not available for comment. The facility's Medication Administration Policy, revised 8/1/2015, recorded medications shall be administered according to the physician's written and verbal orders, upon verification of the right medication, dose, route, time and positive verification of the resident's identity, when no contraindications were identified and the medication was labeled according to acceptable standards. Medications may not be prepared in advance, and only the individual who prepared the resident's medications may administer them. The facility failed to administer medications to the right resident when staff administered medications to resident #1 designated for resident #2. This deficient practice resulted in hospitalization for resident #1.

The facility reported a census of 37 residents. Based on observation, interview, and record review the facility failed to provide an environment free of sexual abuse from resident #1 when he/she inappropriately touched an opposite gender resident (#3) on 06/26/2016. Resident #1 also inappropriately touched opposite gender resident #5 on 06/29/2016. This deficient practice placed the 26 opposite gender residents in immediate jeopardy. Findings Included: - The physician's orders [REDACTED].#1 included the following [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set ((MDS) dated [DATE] noted the resident had a Brief Interview for Mental Status (BIMS) score of 11 which indicated moderately impaired cognition. He/she experienced wandering behaviors, and self-propelled in a wheelchair. The Care Area Assessment (CAA) for behaviors dated 07/02/2015 documented the resident had a behavior problem related to exhibiting episodes of verbal and physical aggression towards staff and other residents. He/she had the behavior of entering other residents rooms uninvited. The resident propelled him/herself in wheel a chair throughout the facility. The Care Plan dated 03/14/2016 revealed the resident had a history of [REDACTED]. He/she had a behavior of entering other residents rooms uninvited and grabbing residents of the opposite gender in an inappropriate manner. The care plan directed staff in these situations to explain to the resident why the behavior was inappropriate and unacceptable; and redirected the resident to another location. The care plan lacked interventions and measures to provide safety for opposite gender residents after the incidents on 06/26/2016 and 06/29/2016. The social service note dated 02/28/2016 at 10:44 A.M. recorded that on 02/07/16 the resident wheeled down the hallway saw an opposite gender resident heading to his/her room. The resident wheeled around behind him/her and grabbed his/her bottom. Resident #1 was immediately sent out and admitted to an acute mental health hospital and when the resident returned, the doctor had the resident on [MEDICATION NAME] (antipsychotic medication). The facility doctor started reduction on 03/25/2016 that decreased from 3 times a day to 2 times a day and on 04/26/2016 it was reduced to 1 time daily, on 5/25/2016 was discontinued. On 06/26/2016 at 3:07 P.M. a nursing note documented direct care staff reported to the nurse that he/she observed resident #1 touching opposite gender resident #3 in an inappropriate body location. Staff separated the residents and placed resident #1 on 15 minute monitoring. On 06/28/2016 at 2:59 P.M. a social service note documented resident #1 exhibited sexual behaviors of inappropriate touching towards opposite gender residents. Facility staff placed a phone call to a hospital's behavior unit, sent information for admission, and waited on admission availability. Staff would continue 15 minute checks until availability at the behavior unit occurs. A social service note dated 06/29/2016 documented that staff continued to observe the resident #1 on 15 minute checks. This note recorded that resident #5 sat inside the door way of his/her room and resident #1 approached him/her and touched resident #5 inappropriately. Review of the clinical record lacked documentation of interventions implemented other than the 15 minute monitoring to protect the opposite gender residents from resident #1's unwanted sexual behaviors. The 15 minute monitoring failed to prevent resident #1's unwanted sexual behaviors toward opposite gender resident #5. At this time the facility placed resident #1 on 1 on 1 with staff. The clinical record documented resident #1 discharged to an inpatient behavior hospital 06/29/16 after unwanted sexual behaviors toward resident #5. An interview with licensed staff H on 07/27/2016 at 4:34 P.M. revealed on 06/26/2016 he/she witnessed resident #1's sexually inappropriate behavior of fondling resident #5's breast. Staff reported he/she intervened and separated resident #1 and resident #5. Staff assessed opposite gender resident #5 for any bruising, or scratches, placed the resident #1 on 15 minute checks and then notified the administrator. On 07/27/2016 at 8:59 A.M. an interview with administrative staff A revealed resident #1 was not in the building. The facility obtained a physician order [REDACTED].M. when the hospital had availability. The resident was on 15 minute monitoring from 06/26/16 to 06/29/16 when he/she was placed on 1 on 1 after an incident with opposite gender resident. Interview with administrative nursing staff D at 5:14 P.M. on 07/27/2016 revealed nurse H reported to administrative staff A the event and staff placed resident #1 on 15 minute checks. Staff D directed the charge nurse to make sure that opposite gender resident #5 was okay and let social services know what happened. Staff called the doctor and resident #1 was put back on [MEDICATION NAME] (an antipsychotic medication) and staff attempted to get the resident transferred out to an acute hospital inpatient behavior unit. During an interview on 07/28/2016 at 11:18 A.M. direct care staff O stated that he/she worked on 06/26/2016 and observed resident #1 and opposite gender resident #3 sitting by the north nurses station in their chairs. Staff O observed resident #1 touching opposite gender resident #3 sexually, licensed staff H separated the residents and moved resident #1 to another location. Documentation on 06/27/2016 at 2:21 P.M. in social service notes opposite gender resident #5's clinical record stated that he/she was afraid and would stay in his/her room until resident #1 was out of the building. An interview on 0727/2016 at 2:25 P.M. with social service staff U stated resident #3 had a potential for a psychosocial well-being problem related to resident #1 touching him/her in a sexual inappropriate way. The facility policy titled Protection 1.6.1 Protection of residents during abuse investigations. Directed the facility would protect residents from harm during investigations of abuse allegations. Standard and Practice Guidelines directed during abuse investigation, resident will be protected from harm by the following measures: If the alleged abuse involved another resident, the accused resident's legal representative and attending physician were informed of the alleged abuse incident and that the accused resident will not be permitted to make visits to other residents rooms unattended. If necessary the accused resident's family members may be required to provide assistance in meeting this requirement. Inquiries concerning protection of residents during abuse investigations were referred to the Director of Risk Management/Abuse Prevention Coordinator and/or Administrator. The facility failed to provide an environment free of sexual inappropriate behaviors, after two incidents of sexually inappropriate touching of opposite gender residents on 06/26/2017 and 06/29/2016. This deficient practice placed the 26 opposite gender residents of the facility in immediate jeopardy. The facility abated the immediate jeopardy on 08/01/2016 at 5:00 PM by initiating the following: Staff Training/Education Follow-up Monitoring Behavior Evaluation Form The facility revised their policy on abuse: Practice Guideline Patient/Resident to Patient/Resident Occurrence The purpose of this guideline was to prevent repeated incidents, ensure appropriate reporting, and provide guidance to centers concerning the appropriate nursing center practice regarding reporting Patient/Resident-to Patient/Resident alleged abuse. Reporting Incidents and Abuse When either a reportable incident or actual abuse occurs, the center must: 1. Report the incident or abuse 2. Conduct and document a thorough investigation of each incident 3. Complete and appropriate assessment of the Patients/Residents involved 4. Implement a plan of action designed to prevent recurrence. 5. Patient/Resident supervision was a core component of the systems approach to safety. The type and frequency of Patient/Resident supervision was determined by the individual Patient's/Resident's assessed needs. 6. The type and frequency of Patient/Resident supervision may vary among Patients/Residents and over time for the same Patient/Resident. Supervision was determined by the individual and may need to be increased when there is a change in the Patient's/Resident's condition. 7. Patient/Resident to Patient/resident occurrence of inappropriate sexual contact would result in Patient/Resident placed on 1 on 1 monitoring. The deficient practice remained at a scope and severity of an E.

The facility reported a census of 37 residents. The sample included 2 residents reviewed for abuse. Based on observation, interview, and record review the facility failed to protect residents from sexual abuse from 1 resident #1 when this resident inappropriately touched opposite gender resident (#3) on 06/26/2016 and inappropriately touched opposite gender resident #5 on 06/29/2016. This deficient practice placed 26 opposite gender residents in immediate jeopardy. Findings Included: - The physician's orders [REDACTED].#1 included the following [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set ((MDS) dated [DATE] noted the resident had a Brief Interview for Mental Status (BIMS) score of 11 which indicated moderate impaired cognition. He/she experienced wandering behaviors, and self-propelled in a wheelchair. The Care Area Assessment (CAA) for behaviors dated 07/02/2015 documented the resident had behavior problem related to exhibiting episodes of verbal and physical aggression towards staff and other residents. He/she had behavior of entering other resident's rooms uninvited. The resident propelled him/herself in wheel a chair throughout the facility. The Care Plan dated 03/14/2016 revealed the resident had a history of [REDACTED]. He/she had a behavior of entering other resident's rooms uninvited and grabbing residents of the opposite gender in an inappropriate manner. The care plan directed staff in these situations to explain to the resident why the behavior was inappropriate, unacceptable and redirected the resident to another location. The care plan lacked interventions and measures to provide safety for opposite gender residents after the incidents on 06/26/2016 and 06/29/2016. The social service note dated 02/28/2016 at 10:44 A.M. that on 02/07/16 the resident wheeled down the hallway saw a unsampled opposite gender resident heading to his/her room, and he/she wheeled around behind him/her and grabbed his/her bottom. Resident #1 was immediately sent out and admitted to an acute mental health hospital and when the resident returned the doctor had the resident on [MEDICATION NAME] (antipsychotic medication). The facility doctor started reduction on 03/25/2016 that decreased from 3 times a day to 2 times a day and on 04/26/2016 it was reduced to 1 time daily, on 5/25/2016 was discontinued. On 06/26/2016 at 3:07 P.M. a nursing note documented direct care staff reported to the nurse that he/she observed resident #1 touching opposite gender resident #3 in an inappropriate body location. Staff separated the residents and placed resident #1 on 15 minute monitoring. On 06/28/2016 at 2:59 P.M. a social service note documented resident #1 had exhibited sexual behaviors of inappropriate touching towards opposite gender residents. Facility staff placed a phone call to a hospital's behavior unit, sent information for admission, and waited on admission availability. Staff would continue 15 minute checks until availability at the behavior unit occurs. A social service note dated 06/29/2016 documented that staff continued to observe the resident #1 on 15 minute checks. This note recorded that resident #5 sat inside the door way of his/her room and resident #1 approached him/her and touched resident #5 inappropriately. Review of the clinical record lacked documentation of interventions implemented other than the 15 minute monitoring to protect the (opposite gender) residents from resident #1's unwanted sexual behaviors. The 15 minutes monitoring failed to prevent resident #1's unwanted sexual behaviors toward opposite gender resident #5. At this time the facility placed the resident #1 was placed on 1 on 1 with staff. The clinical record documented resident #1 discharged to an inpatient behavior hospital 06/29/16 after the attempt of unwanted sexual behaviors toward opposite gender resident #5. An interview with licensed staff H on 07/27/2016 at 4:34 P.M. revealed on 06/26/2016 he/she witnessed resident #1 sexually inappropriate behavior with resident #5. Staff reported he/she intervened and separated resident #1 and resident #5. Staff assessed opposite gender resident #5 for any bruising, or scratches and placed resident #1 on 15 minute checks and then notified the administrator. On 07/27/2016 at 8:59 A.M. an interview with administrative staff A revealed resident #1 was not in the building. The facility obtained a physician order [REDACTED].M. when the hospital had availability. Resident #1 was placed on 15 minute monitoring on 06/26/2016 and after the incident on 06/29/2016 he/she was placed 1 on 1 with staff. Interview with administrative nursing staff D at 5:14 P.M. on 07/27/2016 revealed the nurse reported the event and staff resident #1 on 15 minute checks. Staff D directed the charge nurse to make sure that opposite gender resident #5 was okay and let social services know what had happened. Staff called the doctor and resident #1 was put back on [MEDICATION NAME] (an antipsychotic medication) and staff attempted to get the resident transferred out to an acute hospital inpatient behavior unit. During an interview on 07/28/2016 at 11:18 A.M. direct care staff O stated that he/she had worked on 06/26/2016 and observed resident #1 and opposite gender resident #3 sitting by the north nurses station in their chairs. Staff O observed resident #1 touching opposite gender resident #3 fondling his/her breast and licensed staff H separated the residents and moved resident #1 to another location. Documentation on 06/27/2016 at 2:21 P.M. in opposite gender resident #5's clinical record stated that he/she was afraid and would stay in his/her room until resident #1 was out of the building. An interview on 06/27/2016 at 2:25 P.M. with social service staff U stated resident #3 had a potential for a psychosocial well-being problem related to resident #1 touching him/her in a sexual inappropriate way. On 07/27/2016 at 5:00 PM an interview with administrative staff A stated that staff was checking on resident #1 location every 15 minutes, starting on 06/26/2016 and we had an order to transfer out to inpatient behavioral unit and was waiting on availability, then on 06/29/2016(NAME)tried to pull resident #5 gown up, staff saw him/her and intervened at that time we he/she was placed on 1 on 1 with staff and he was transported out about an hour later The facility policy titled Protection 1.6.1 Protection of residents during abuse investigations. Directed the facility would protect residents from harm during investigations of abuse allegations. Standard and Practice Guidelines directed during abuse investigation, resident will be protected from harm by the following measures: If the alleged abuse involved another resident, the accused resident's legal representative and attending physician were informed of the alleged abuse incident and that the accused resident will not be permitted to make visits to other residents rooms unattended. If necessary the accused resident's family members may be required to provide assistance in meeting this requirement. Inquiries concerning protection of residents during abuse investigations were referred to the Director of Risk Management/Abuse Prevention Coordinator and/or Administrator. The facility failed to provide an environment free of sexual inappropriate behaviors, after two incidents of sexually inappropriate touching of opposite gender residents on 06/26/2017 and 06/29/2016. This deficient practice, placed the opposite gender residents of the facility in immediate jeopardy. The facility abated the immediate jeopardy on 08/01/2016 at 5:00 PM by initiating the following: Staff Training/Education Follow-up Monitoring Behavior Evaluation Form Revised their policy on abuse: Practice Guideline Patient/Resident to Patient/Resident Occurrence The purpose of this guideline was to prevent repeated incidents, ensure appropriate reporting, and provide guidance to centers concerning the appropriate nursing center practice regarding reporting Patient/Resident-to Patient/Resident alleged abuse. Reporting Incidents and Abuse When either a reportable incident or actual abuse occurs, the center must: 1. Report the incident or abuse 2. Conduct and document a thorough investigation of each incident 3. Complete and appropriate assessment of the Patients/Residents involved 4. Implement a plan of action designed to prevent recurrence. 5. Patient/Resident supervision was a core component of the systems approach to safety. The type and frequency of Patient/Resident supervision was determined by the individual Patient's/Resident's assessed needs. 6. The type and frequency of Patient/Resident supervision may vary among Patients/Residents and over time for the same Patient/Resident. Supervision was determined by the individual and may need to be increased when there is a change in the Patient's/Resident's condition. 7. Patient/Resident to Patient/resident occurrence of inappropriate sexual contact would result in Patient/Resident placed on 1 on 1 monitoring. The deficient practice remained at a scope and severity of an E.

The facility census totaled 68 residents with 3 sampled. Based on observation, record review, and interviews, the facility failed to provide the necessary treatment and services to promote healing, prevent infection and prevent new sores from developing for 1 of 1 sampled resident (#3) for pressure ulcers. Findings included: - Resident #3 ' s admission Minimum Data Set assessment ((MDS) dated [DATE] documented the Brief Interview for Mental Status (BIMS) scored 5 which indicated the resident with severe cognitive impairment. The MDS documented the resident required extensive assistance of 2 staff members with bed mobility, transfers, dressing, toilet use, and personal hygiene. The MDS further documented the resident was frequently incontinent of bladder and always incontinent of bowel. The MDS documented no pressure ulcers. The pressure ulcer Care Area Assessment (CAA) dated 3/27/15 documented the resident utilized a pressure reducing mattress which was protocol for this facility. The initial care plan for activities of daily living dated 3/16/15 documented the resident required extensive assistance with bed mobility, transfers, locomotion, dressing, toilet use, personal hygiene, and bathing. The approaches included to turn and reposition by shifting weight to enhance circulation, and to provide only the amount of assistance/supervision that was needed. An undated skin risk evaluation and plan of care documented the risk factors for the development of pressure ulcers but lacked interventions for preventing pressure ulcers. The 3/16/15 Braden Scale (tool used to assess risk for skin breakdown) scored 15 which indicated the resident was at risk for skin breakdown. The nursing evaluation dated 3/16/15 documented the resident with intact skin. The wound treatment evaluation record documented on 4/17/15 a new Stage 2 pressure ulcer on the coccyx measured 4.0 centimeters (cm) by 4.0 cm with wound bed red, surrounding tissue was pink, and had a minimal amount of serous (clear) drainage. The last updated wound treatment record documented on 5/6/15 of the Stage 2 pressure ulcer on the coccyx measured 3.0 cm by 3.0 cm with red/purple wound bed, surrounding tissue was purple, and had minimal amount of serous drainage. On 5/12/15 at 10:45 A.M. direct care staff P went into the resident ' s room to finish assistance with breakfast meal. The resident ate 2 fried eggs, half piece of toast, and drank a glass of water. The resident ' s head of bed was elevated to approximately 45 degrees; he/she was scooted down in the bed, and his/her heels lay on the low loss air mattress with no protective devices to prevent pressure. On 5/12/15 at 10:50 A.M. direct care staff O and direct care staff P went into the resident ' s room to provide incontinent care. Direct care staff P turned the resident to his/her left side and observed a dressing on his/her coccyx dated 5/11/15. During incontinent care, observation revealed necrotic tissue (pertaining to the death of tissue in response to disease or injury) on the right side of the resident ' s foot just below the little toe and the left heel dark purple in color. The dressing on the resident ' s coccyx had bowel movement on the lower portion of the dressing. Direct care staff O stated they were not to remove dressings like they use to. Direct care staff P stated he/she would tell the nurse about the dressing. The resident was on his/her back with the head of the bed elevated to a 45 degree angle and heels on the mattress. The resident remained in the same position at 11:15 A.M., 11:30 A.M., 11:45 A.M., 12:00 noon, 12:15 P.M., 12:30 P.M., and 12:45 P.M. On 5/12/15 at 12:45 P.M. asked licensed nursing staff H to check the resident. Staff repositioned the resident at this time by pulling him/her up in the bed and heels remained on the mattress. On 5/12/15 at 12:55 P.M. direct care staff P stated he/she did not tell the nurse about the resident ' s dressing because he/she had been very busy. On 5/12/15 at 1:00 P.M. direct care staff O provided the resident with the lunch tray of ground turkey, buttered noodles, broccoli, and peaches with cream. The resident spit out a bite of turkey, a bite of noodles, and a bite of broccoli. The resident ate all of the peaches and cream and drank glass of water. On 5/12/15 at 1:27 P.M. licensed nursing staff H and licensed nursing staff I went to the resident ' s room to provide wound care treatment, both washed their hands and applied gloves. The resident was on his/her back with his/her feet on the mattress. Staff repositioned the resident to his/her left side and licensed nursing staff H removed the dressing on the coccyx, removed his/her gloves, washed hands with alcohol gel, applied new gloves, and cleaned the wound with normal saline. Licensed nursing staff H stated he/she measure the whole area as one pressure ulcer and not each open area as one pressure ulcer. The coccyx had 3 small open areas on the left buttocks approximately 0.5 centimeters (cm) by 0.5 cm and 2 open areas in the sacral crease approximately 0.5 cm by 0.5 cm. Licensed nursing staff H covered all open areas on the coccyx with a gel that contained silver, and covered the wounds with border gauze. Both licensed staff then removed their gloves. Licensed nursing staff H stated they did not know about the necrotic area on the right foot. Upon request licensed nursing staff H checked the resident ' s left heel and he/she stated it was discolored, might be deep tissue injury and was not aware of that skin issue either. Licensed nursing staff H told direct care staff P to get some pillows and elevate the resident ' s feet off of the bed. On 5/12/15 at 2:30 P.M. the family was at bedside and gave the resident a banana which he/she held and ate by him/herself and drank a protein drink. Review of dietary progress notes dated 5/4/15 documented the resident with a Stage 2 wound on his/her coccyx. The laboratory value for the [MEDICATION NAME] level (protein level in the blood) was low at 2.4 grams per deciliter with a normal range is 3.4 - 5.4 grams per deciliter. The dietary recommendations included to increase the protein supplement to three times a day, Vitamin C daily for 3 weeks, and a multiple vitamin with minerals daily to increase nutritional status. The recommendations were not implemented at this time. A new wound treatment evaluation record dated 5/12/15 documented an unstageable pressure ulcer to the right lateral foot measured 2.1 cm by 1.2 cm of black eschar and left heel with suspected deep tissue injury measured 5 cm by 5.3 cm with a red/purple wound bed. On 5/12/15 at 4:50 P.M. licensed nursing staff H told direct care staff Q to get some pillows and elevate the resident ' s feet off the mattress. Direct care staff Q returned with 3 pillows and elevated the resident ' s feet off the mattress. Interview on 5/12/15 at 10:35 A.M. direct care staff R stated the resident was total care, needed to be repositioned, assisted with meals, and was incontinent. Direct care staff R stated any skin problems would be reported to the nurse. Interview on 5/12/15 at 1:27 P.M. with licensed nursing staff H stated they were not aware of any skin problems other than the pressure ulcer on his/her coccyx. Interview on 5/12/15 at 3:50 P.M. with administrative nursing staff D stated the direct care staff should report any skin issues to the nurses. The nurses would then assess the issue, call the physician, get orders, and provide the treatment to the skin issue. The nurses should provide preventative measures to the residents at risk such as repositioning and floating heels in bed. Interview on 5/12/15 at 6:30 P.M. with physician AA stated the nursing staff should repositioned a resident every 2 hours to relieve pressure, checked and changed every 2 hours to prevent the resident from having compromised skin conditions, and monitor the resident ' s skin with all cares. The 2006 facility policy Pressure ulcer, prevention of instructed the staff to establish a turning and positioning schedule in the bed and the chair to meet the resident ' s needs. Assist the resident at mealtime to assure adequate nutrition and monitor nutritional status. Offer fluids frequently for adequate hydration and monitor hydration status. Use pressure reducing or relieving devices as necessary. If a pressure ulcer was present, the licensed nurse was responsible to record condition of the skin, including stage, size, depth, color, drainage and odor as well as the treatment provided. Notification of the physician was required when a new pressure ulcer was identified as well as when treatment was not effective. The facility failed to develop and implement interventions to prevent the development of pressure ulcers for this cognitively impaired dependent resident.

The facility census totaled 60 residents with 4 residents sampled for falls. Based on observation, interview and record review, the facility failed to provide supervision and effective interventions to prevent falls for 3 of the 4 sampled residents (#1, #2, and #3) reviewed for falls that resulted in injuries. Findings included: - The closed record for resident #1 contained a physician's orders [REDACTED]. The significant change Minimum Data Set 3.0 assessment ((MDS) dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) score of 0 which indicated the resident with short and long term memory loss and no behaviors. He/she required extensive assistance of 1 staff with bed mobility and dressing, extensive assistance of 2 staff with transfers and toilet use, total dependence on 1 staff with locomotion and personal hygiene, and limited assistance of 1 staff with walking. The resident's balance was not steady and only able to stabilize with staff assistance. His/her range of motion was not impaired and he/she required devices of a walker and a wheelchair for mobility. The resident had 2 or more falls since prior assessment with injuries. The Care Area Assessment (CAA) dated 12/4/12 for falls documented the resident with poor balance, cognitive impairment, a recent fall and he/she received antianxiety medication. The quarterly MDS dated [DATE] documented the resident had falls and 1 fall with no injury since the last assessment. The revised Fall Risk Evaluation and Plan of Care dated 2/20/13 documented the resident with the following risk factors: hypertension (elevated blood pressure), degenerative joint disease (DJD, degeneration of the joints), Alzheimer's or other dementia, psychotropic medications, and external/environmental risk which included time of day, time since last meal, and responding to bowel and/or bladder urgency. The interventions included to observe for medication side effects, reorient to the environment and person/place/time, monitor during the shift change, assistive equipment within reach, evaluate toileting needs, encourage frequent periods of rest, grab-bars in the bathroom and/or transfer pole, appropriate footwear- nonskid, seating strategy to offer a recliner near the nurses' station, give verbal clues, and offer snacks as necessary. Review of the medical records documented the resident had 25 falls from 3/12/12 to 12/19/12 (in 9 months) and staff documented all falls as non-injury. A Therapy Referral and Screening form dated 5/20/13 documented the resident was on hospice. The resident fell out of a new bed because the bed did not have bolsters in place. The bolsters were now in place and therapy was not recommended. The Nurse/Physician Communication Record and the the Fall Risk Evaluation and Plan of Care documented the following falls and interventions from 2/2/13 through 7/20/13: 1) On 2/2/13 at 2:50 P.M. the resident sat in a locked wheelchair at the nurse's desk. Staff heard a "thump" looked up and saw the resident lying on the floor. Staff offered to toilet the resident but he/she refused. Staff applied an ice pack to the resident's forehead, and set up a table with blocks for the resident. 2) On 4/6/13 at 12:00 noon the nurse was informed that a housekeeping staff saw the resident lean forward in his/her wheelchair in the hallway, to touch his/her shoe. The housekeeper yelled for help and the resident was eased down to his/her knees on the floor. Staff assisted the resident back into his/her wheelchair. The resident did not hit his/her head, range of motion (ROM) was within normal limits (WNL) and no complaints of pain from the resident. The intervention included hospice would provide a high back chair to aid in body positioning and a drop seat wheelchair with adjustments. 3) On 5/19/13 at 12:50 A.M. a certified nurses aide (CNA) informed the nurse the resident was on the floor. Upon entering the resident's room staff noted the resident kneeling on a blanket at the head of his/her bed and holding onto the bed. The staff documented the resident was alert with some confused conversation. No apparent injuries noted, skin intact, and no bruising or reddened areas noted. Intervention for hospice to provide a bolster mattress. 4) On 6/2/13 at 3:45 P.M. staff heard the resident yelling out "help me". Staff went to the resident's room and the resident laid on his/her right side near his/her bed. The resident stated "I rolled out of my bed". The call light was within reach. No apparent injuries observed at this time. Assisted the resident up to his/her wheelchair and placed the resident at the nurses' station. Staff placed a pancake call light device (flat call light that any type of pressure would activate it) within reach of the resident for this cognitive impaired dependent resident. 5) On 6/3/13 at 4:30 P.M. the nursing staff was standing at the nursing cart and heard the resident yelling out help. Staff went to his/her room and the resident was sitting on his/her buttocks on the floor in front of his/her wheelchair. The resident stated he/she was trying to get in his/her bed. Staff assisted the resident back to his/her chair and placed the resident near the nurses' station. The resident obtained an abrasion to the left side of his/her back. Staff added the intervention to increase monitoring after the noon meal to the evening meals due to the resident's impulsivity. The care plan lacked specific interventions regarding frequency of monitoring. The hospice note dated 6/13/13, with no time documented, revealed hospice provided 1/4 side rails and a hi/low bed for the resident on 6/6/13 due to the resident trying to get out of the bed independently and fell . 6) On 6/23/13 and untimed, staff documented the resident had a non-injury fall, close to nurses' station. Staff added anti-roll back device to the wheelchair and would evaluate the resident's sleep patterns for 72 hours to benefit the sleep cycle. The hospice note dated 6/27/13, with no time documented, revealed staff applied anti roll back and antitipper to the high back wheelchair on 6/19/13 and the resident had one fall in the past week. 7) On 7/20/13 at 3:30 P.M. staff found the resident on the floor against the wall. The resident complained of pain to the left hip and the left thigh. Pain medication was given after the assessment and the staff assisted the resident into his/her wheelchair. Staff documented the resident's mental status as increasingly agitated with pain in the location of the hip and the leg. The physician was notified and an order for [REDACTED]. The nurses notes dated 7/21/13 at 12:25 A.M. documented the x-ray was completed shortly after 10:00 P.M. and the results were faxed to the facility at 11:21 P.M. The x-ray revealed the resident had a fracture of his/her left leg femur. An order was obtained to send the resident to the hospital and the resident was transferred via ambulance at 12:20 A.M. (9 hours after the fall). The X-ray report dated 7/20/13 revealed a left femur fracture after a fall. On 8/16/13 at 1:18 P.M. administrative licensed nurse B revealed that when a resident had a fall, the plan of care would be updated and the staff would be informed of any new interventions. On 8/16/13 at 1:25 P.M. licensed nursing staff A revealed after a resident had a fall, the nurse would update the fall assessment, and call the doctor and the family. On 8/20/13 at 12:45 P.M. administrative nursing staff A revealed the expectations of the nursing staff was to follow the facility's policy to update the Fall Risk Evaluation and Care Plan. He/she stated the facility used the pancake call light as a positioning device so if the resident moved it would activate the call light. The intervention for increased monitoring after the noon meal to the evening meal meant the staff should look in the resident's room each time they walked by the room. The evaluation for 72 hours was an intervention for staff to identify the resident toileting needs and attempts to get out of bed at night and then incorporate that information into the plan of care. The QA nurse should update the care plan after the 72 hours observation period. The clinical record lacked evidence the facility completed this intervention. The facility Fall Management policy revised 11/15/07 documented the licensed staff would initiate or revise the fall Risk Evaluation and Care Plan to address new interventions in place to reduce recurrence of the fall or minimize potential for injury. and resolve any interventions that were in place and determined ineffective for the resident. The facility failed to provide effective interventions for the prevention of falls for this cognitively impaired dependent resident that had 32 falls in 16 months resulting in a fractured hip. - The closed record for resident #2 included a physician's orders [REDACTED]. The admission Minimum Data Set 3.0 ((MDS) dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) score of 9 which indicated moderately impaired cognitive status. The resident required extensive assistance of 1 person with bed mobility, transfers, locomotion, dressing, toilet use and personal hygiene. The resident's balance was not steady and he/she was only able to stabilize with staff assistance. The resident had a fall history prior to admission in the last month. The fall Care Area Assessment (CAA) dated 3/5/13 documented the resident became very weak at home, fell , and was hospitalized . He/she remained weak with poor balance which puts him/her at risk for further falling. Will proceed with plan of care for risk of falling to prevent serious injuries if he/she should fall again. The resident received therapies to regain better balance and endurance. The required 30 day Medicare MDS dated [DATE] documented the resident's BIMS score of a 5 which indicated severely impaired cognitive status. The MDS further documented the resident with 1 fall with injury since admission. The revised Fall Risk Evaluation and Plan of Care dated 2/20/13 documented the resident with the following risk factors: decline in functional status, chronic or acute condition resulting in physical instability, decline in cognitive skills, psychotropic medications, walker, time of day, time since last meal, responding to bowel and/or urgency, and wheelchair. The interventions included to reorient the resident to the environment, person/place/time, supervise with ambulation with walk to dine (WTD), bed and rails positioned correctly, and appropriate nonskid footwear. Review of the medical record documented on 2/2/13 the resident scored 15 on a Fall Risk Evaluation (if total score is greater than 10, patient is at high risk). The Nurse/Physician Communication Recorded and Fall Risk Evaluation and Plan of Care documented the following falls and interventions: 1) On 2/21/13 at 8:12 A.M. staff found the resident sitting on the floor in his/her room in front of a locked wheelchair. The staff placed the resident in a chair by the nurses' desk so staff could monitor him/her. staff instructed the (cognitively impaired) resident to not get up unless he/she called for assistance. The staff added safety signage and antiroll back devices on the wheelchair. 2) On 2/24/13 at 1:45 P.M. staff found the resident sitting on the floor near his/her bed. The resident stated he/she was trying to get into his/her bed and went down backwards to the floor. No injuries observed at this time. Staff added the intervention for walk to dine with each meal and offer the resident assistance to lay down after meals. 3) On 2/26/13 an untimed nurse's note documented the staff found the resident in a semi-sitting position on the floor between the bed and the recliner. The resident stated he/she was getting up. The resident denied pain or hitting his/her head. Staff added the interventions for a seating strategy to encourage the resident to allow the staff to assist with all transfers and a night light. 4) On 3/16/13 at 9:55 A.M. the staff found the resident sitting on the floor in front of his/her recliner with his/her wheelchair to the side. His/her call light was lying on the side of the recliner seat. The staff added a pancake call light device (flat call light that any type of pressure would activate it) within the resident's reach. 5) On 3/17/13 at 8:00 P.M. staff was sitting at the nurses' desk and the resident sat in front of the desk. The resident started to get up and his/her legs folded and he/she fell to the floor, landing on his/her buttocks. Staff added the interventions: evaluate the resident's toileting needs, during periods of impulsivity staff would assist the resident to the nurses' station for closer monitoring with an activity, safety education provide to the staff and the (cognitively impaired) resident, and for the next 72 hours staff would increase visual monitoring to every hour. 6) On 3/23/13 at 11:30 P.M. staff found the resident sitting on the floor near the cabinets in his/her room. The resident received a skin tear to his/her left elbow and an abrasion on the left side of his/her back. Staff added the intervention for a fall mat at the resident's bedside and staff to not leave the wheelchair at the resident's bedside. 7) On 3/26/13 at 7:15 A.M. the staff found the resident by the nurses' station on the floor. The resident stated he/she was walking to the restroom. The resident had a laceration to his/her left eyebrow and left lower brow, and a skin tear to his/her left hand and knee. The resident was not acting right. Staff sent the resident to the hospital. Staff added the interventions, offer assistance with his/her morning activities of daily living first and then assist the resident into the south dining room and the resident was a high priority resident. 8) On 4/4/13 at 2:00 A.M. staff found the resident laying on his/her right side on the floor next to his/her bed. The resident opened a skin tear to his/her left forearm. Staff added the intervention to refer to hospice and requested increase support. The hospital admission record dated 3/26/13 documented the family stated the resident was trying to get up from his/her wheelchair when he/she likely entangled himself/herself around the Foley catheter (device placed into the resident's bladder to drain the urine) tubing and lost his/her balance resulting in a fall and during the event the Foley came out. The resident started having bleeding per the meatus (opening into the bladder). Also the resident suffered a laceration under his/her left eye brow. The nurse's notes revealed the resident had additional non-injury falls on 2/22/13 and 2/23/13 for which the Fall Risk Evaluation and Plan of Care was not completed. On 8/16/13 at 1:18 P.M. administrative licensed nurse B revealed that when a resident had a fall, the plan of care would be updated and the staff would be informed of any new interventions. On 8/16/13 at 1:25 P.M. licensed nursing staff A revealed after a resident had a fall, the nurse would update the fall assessment, and call the doctor and the family. On 8/20/13 at 12:45 P.M. administrative nursing staff A revealed the expectations of the nursing staff would be to follow the facility's policy to update the Fall Risk Evaluation and Care Plan. He/she stated the facility used the pancake call light as a positioning device so if the resident moved it would activate the call light. He/she stated the intervention to reorient the resident was not an effective goal. The evaluation for 72 hours was an intervention for staff to identify the resident toileting needs and attempts to get out of bed at night and then incorporate that information into the plan of care. The QA nurse should update the care plan after the 72 hours observation period. The clinical record lacked evidence the facility completed this intervention. The facility Fall Management policy revised 11/15/07 documented the licensed staff would initiate or revise the fall Risk Evaluation and Care Plan to address new interventions in place to reduce recurrence of the fall or minimize potential for injury. and resolve any interventions that were in place and determined ineffective for the resident. The facility failed to provide effective interventions to prevent falls for this cognitively impaired dependent resident with a history of falls that had 10 falls in 2 months resulting in a laceration and admission to the hospital. - Resident #3's physician's orders [REDACTED]. The annual Minimum Data Set 3.0 ((MDS) dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) score of 0 which indicated the resident with short and long term memory loss. The resident required extensive assistance of 2 staff with bed mobility, transfers, walking, and toilet use and extensive assistance of 1 staff with locomotion, eating and personal hygiene. The resident's balance was not steady and was only able to stabilize with staff assistance. The resident had 2 or more falls since the prior assessment with no injuries. The fall Care Area Assessment (CAA) dated 6/15/13 documented the resident with poor balance, had recent falls and received psychotropic medications. The resident required assistance when he/she walked with his/her walker. The revised Fall Risk Evaluation and Plan of Care dated 8/24/12 documented the resident with following risk factors: hypertension, decline in functional status, fracture, depression, Alzheimer's or other dementia, and a wheelchair. The interventions included vital signs prior to medications as ordered, observe medication side effects, reorient to environment-person-place-time, assistive devices within reach, evaluate toileting needs, and encourage frequent periods of rest. Review of the medical record revealed a Fall Risk Evaluation dated 3/6/13 with total score of 19 (if total score was greater than 10, the resident was at a high risk for falls). A Fall Risk Evaluation and Plan of Care dated 3/10/13 added the following interventions: a flat call light within reach and the resident moved to a room closer to the nursing station. The Nurse/Physician Communication Record and Fall Risk Evaluation and Plan of Care documented the following falls and interventions: 1) On 4/12/13 an untimed note documented the resident was seen by a visitor on the floor. The resident sat between his/her wheelchair and another chair in another resident's room. The resident stated he/she tried to sit in a chair. The staff added the intervention to assist the resident to the common areas after all activities. 2) On 5/5/13 an untimed note revealed another resident reported a resident just fell and was on the floor. Staff found the resident on the floor in front of his/her wheelchair. The staff added the intervention to encourage (this cognitively impaired) resident to socialize in the common area when not at meals or in an activity. 3) On 6/10/13 at 4:15 P.M. the staff found the resident on the floor at the foot of the first bed in his/her room. The resident was unable to verbalize what happened. He/she did state that he/she needed to urinate. The additional interventions included: staff to monitor during the shift changes, begin hourly monitoring for the next 72 hours, and evaluate the resident's toileting needs and activity of daily living needs. 4) On 8/13/13 at 7:30 A.M. staff found the resident on the floor in the dining room. The resident was flat on his/her back and staff noted a pool of blood around the lower back of his/her head. Staff noted a hematoma (location of blood in the tissues) to the back of the head 2 centimeters (cm) x 3 cm. and a vertical linear open area to the back of the head. At 7:55 A.M. the resident was transferred to the hospital. At 11:50 A.M. the resident returned to facility via facility van with the orders to remove the staples in 7 days. Staff initiated the interventions to adjust the antiroll back device on the wheelchair and decrease the potential risk of falls due to the resident's impulsivity. A therapy referral and screening form dated 6/11/13 documented the resident fell about once a month over the last 4 months: 3/12, 4/12, 5/5, and 6/10. The most recent fall the resident was possibly trying to go to the bathroom. The resident was unable to follow most directions. The resident had decreased attention to task and severe short term memory impairment. The resident was not likely to benefit from skilled therapy at this time. On 8/20/13 at 8:15 A.M. the resident sat in his/her wheelchair in the dining room eating his/her breakfast with 2 staff in the dining room assisting other residents. On 8/20/13 at 10:10 A.M. the resident laid in bed asleep with the wheelchair positioned next to his/her bed and the call light on the bed next to him/her. On 8/20/13 at 11:20 A.M. the resident was awake laid in his/her bed. On 8/20/13 at 12:45 P.M. the resident sat in his/her wheelchair in the dining room. The staff prepared his/her meal and encouraged him/her to eat and then went to sit with another resident. On 8/20/13 at 2:00 P.M. the resident laid in his/her bed with the call light beside him/her and the wheelchair positioned next to the bed. On 8/16/13 at 1:18 P.M. administrative licensed nurse B revealed that when a resident had a fall, the plan of care would be updated and the staff would be informed of any new interventions. On 8/16/13 at 1:25 P.M. licensed nursing staff A revealed after a resident had a fall, the nurse would update the fall assessment, and call the doctor and the family. On 8/20/13 at 12:45 P.M. administrative nursing staff A revealed the expectations of the nursing staff would be to follow the facility's policy to update the Fall Risk Evaluation and Care Plan. The evaluation for 72 hours was an intervention for staff to identify the resident toileting needs and attempts to get out of bed at night and then incorporate that information into the plan of care. The QA nurse should update the care plan after the 72 hours observation period. Administrative nursing staff A stated they would have to readdress all his/her fall interventions. The clinical record lacked evidence the facility completed this intervention. The facility Fall Management policy revised 11/15/07 documented the licensed staff would initiate or revise the fall Risk Evaluation and Care Plan to address new interventions in place to reduce recurrence of the fall or minimize potential for injury. and resolve any interventions that were in place and determined ineffective for the resident. The facility failed to provide effective interventions to prevent falls for this cognitively impaired dependent resident with a history of falls resulting in a laceration to the head requiring staples.