Every finding on record at Topeka Presbyterian Manor

Based on observation, record review, and interviews, the facility failed to maintain an effective controlled substance reconciliation system, which included reconciling Resident (R) 1's narcotic medication upon delivery. Findings included:- R1 admitted to the facility on [DATE]. R1's Electronic Medical Record (EMR) documented diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), secondary osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain), gout (inflammation of the joints), and polyneuropathy (a condition in which a person's peripheral nerves are damaged). The Annual Minimum Data Set (MDS) dated 08/04/2025, documented R1 had a Brief Interview for Mental Status (BIMS) score of nine, which indicates moderate cognitive impairment. R1 received scheduled pain medication and had no complaints of pain during the assessment. The Quarterly MDS dated 04/29/2026, documented R1 had a BIMS score of seven, which indicated severe cognitive impairment. R1 received scheduled and as needed (PRN) pain medication and had no complaints of pain during the assessment. The Cognitive Loss/Dementia Care Area Assessment (CAA) dated 08/05/2026, documented R1 had issues with recall ability and cognition. The Activities of Daily Living (ADL) Functional/Rehabilitation Potential CAA dated 08/06/2026, documented R1 required limited to total assistance with ADLs, transfers, and mobility. R1 reported no discomfort upon interview. R1's Care Plan revised 02/13/2025, documented R1 had chronic pain related to arthritis, gout, and neuropathy. R1's 'Care Plan documented the following interventions:02/05/2025- Staff evaluated the effectiveness of pain interventions.02/05/2025- Staff identified, recorded, and treated R1's existing conditions which may have increased pain and/or discomfort.02/05/2025- Staff monitored/documented for side effects of pain medication.02/05/2025- Staff monitored/recorded/reported to the nurse any signs/symptoms of R1's nonverbal pain.02/05/2025- Staff notified the physician if R1's interventions were unsuccessful or if her current complaint was a significant change from her past experience of pain.05/12/2025- Staff monitored/recorded pain characteristics PRN.12/15/2025- Staff attempted non-pharmacological interventions for pain control.12/24/2025- Staff observed and reported any changes in R1's usual routine, sleep patterns, decrease in her functional abilities, decrease in her range of motion (ROM), or any withdrawal or resistance of cares.02/02/2026- Staff administered analgesia medications per orders, which included hydrocodone (narcotic pain medication) for pain management. R1's EMR documented an order with a start date of 11/19/2025, for hydrocodone-acetaminophen 5-325 milligrams (mg) with instructions to give one tablet every six hours as needed for moderate to severe pain related to secondary osteoarthritis. The facility's Investigation dated 06/23/2026, documented on 06/15/2026 between 01:30 PM and 02:00 PM, Licensed Nurse (LN) G reported R1's hydrocodone medication card and narcotic count sheet were not in the cart. Administrative Nurse D and Administrative Nurse E immediately searched all four medication carts, treatment carts, and medication rooms, including the narcotic destruction boxes, but the facility did not find the hydrocodone card. Administrative Nurse D spoke to all of the nurses on the schedule since the medication was last given. LN H gave the last dose on 06/13/2026 at 10:38 PM, and she counted and signed off with LN I who worked 06/14/2026 morning. LN I worked day and evening shifts and later counted the narcotics with another evening nurse, LN J. LN K, who worked night shift, received the keys from LN J, but did not count the narcotics until she counted with the oncoming day shift nurse on 06/15/2026. Later that shift on 06/15/2026, LN G reported the missing medication. The facility replaced R1's hydrocodone medication on 06/16/2026 and the facility was unable to identify a perpetrator. LN J's notarized witness statement on 06/14/2026, documented she counted the treatment cart and medication cart on 06/14/2026 at 09:00 PM with LN I. She stated the count was accurate. LN J's notarized witness statement on 06/16/2026, documented she arrived at the Prairie Point unit on 06/15/2026 at 12:00 AM after she was pulled from assisted living. She stated she counted the narcotics with the evening nurse for the Sunflower unit because LN J was working both Prairie Point and Sunflower units that night. She stated LN J told her that she counted with LN I, who worked evening shift on Prairie Point and had worked since 06:00 AM on 06/14/2026, then LN I left. LN J stated it was a busy night, and she did not get a chance to count the narcotics until the day shift nurse arrived. She stated she counted the number of pages and medications, and everything was correct at that time. LN I's statement, via email on 06/16/2026 at 10:18 AM, documented she worked day shift on 06/14/2026 and had counted at the beginning of the shift with the night nurse. She stated she did not notice whether R1's hydrocodone was present at the time or not. LN I stated she did not give R1 any PRN medications throughout the shifts she worked and when she counted the cart before she left on 06/14/2026 night, the count was correct. LN H's statement, via email on 06/17/2026 at 09:25 PM, documented on 06/13/2026, she gave R1 a PRN medication and returned it to the locked box. She stated she counted with the day shift nurse on 06/14/2026 and all medication cards and counts were accounted for. She stated she always counted oncoming and off-going with her peer nurses per protocol. On 07/16/2026 at 12:54 PM, R1 sat in her wheelchair in her room with her eyes closed. On 07/16/2026 at 01:12 PM, the Prairie Point treatment cart narcotic binder was reviewed. Review revealed an Eight Hour Verification Controlled Substances Count sheet from 07/01/2026 day shift to 07/16/2026 had 17 out of 92 possible signature spaces, blank. The Narcotic Count Sheet Reconciliation Log from 07/11/2026 day shift to 07/16/2026 day shift had seven out of 32 possible signature spaces, blank. On 07/16/2026 at 10:49 AM, Administrative Nurse D stated the facility never figured out what happened to R1's hydrocodone card. On 07/16/2026 at 11:32 PM, Administrative Nurse D stated she did one-on-one education after the incident to count the narcotics every shift and sign off on the sheets. She stated she did not have any sign-in sheets for the education or documentation. On 07/16/2026 at 11:43 PM, Administrative Nurse D stated the facility did not complete abuse, neglect, and exploitation (ANE) education after the incident. On 07/16/2026 at 01:14 PM, LN L stated she counted narcotics every shift or when she exchanged keys with a nurse or Certified Medication Aide (CMA). She stated she signed on and off on the reconciliation narcotic count sheets. LN L stated if she gave a PRN narcotic, she checked the order, assessed the resident's pain, then verified the correct dose in the narcotic box and popped the medication out. She stated she signed out the narcotic medication on the count sheet and in the computer. LN L stated each slot on the shift count sheets should have a signature, and she signed off the narcotic reconciliation sheet on and off her shift when she counted with the other nurse. She stated during count, she counted the controlled items and made sure they were accurate with the reconciliation sheet. LN L stated if she found a narcotic medication discrepancy, she notified Administrative Nurse D. She stated she counted the narcotics with every nurse or CMA if the keys changed hands and she did not let anybody use her keys. On 07/16/2026 at 01:18 PM, CMA T stated she counted narcotics at the beginning and end of the shift and signed off on the narcotic count sheet. On 07/16/2026 at 01:47 PM, Administrative Nurse E stated on 06/15/2026, LN G realized R1's hydrocodone card and narcotic count sheet were missing. He stated the last dose given was on 06/13/2026 at 10:38 PM. He stated the facility started going through who worked, how many doses were given, and where the medication could have gone. Administrative Nurse E stated the original nurse who received the hydrocodone card from pharmacy did not add the card to the reconciliation sheet and updated the count number, so the count number on the reconciliation sheet was correct when it went missing. He stated the facility obtained statements from the nurses who worked, and nobody seemed to remember if R1's card was there when they counted. He stated they looked through the medication rooms and shred box, but could not find the hydrocodone card. Administrative Nurse E stated the facility did a process of elimination and since the only new nurse to work at the facility was LN I, they canceled her through her agency. He stated the facility was unable to find the actual perpetrator. Administrative Nurse E stated the facility did not audit the other residents' narcotics to see if there were any other discrepancies. On 07/16/2026 at 01:47 PM, Administrative Nurse D stated the facility also looked in R1's room for the hydrocodone card and in discarded medications but could not find it. She stated she reviewed the camera footage, but due to the angle of the camera to where the cart sat, the camera did not catch anything. Administrative Nurse D stated she told LN I's agency the facility did not have anything on her related to the hydrocodone, but it was a recommendation from corporate to cancel LN I after the facility reviewed everything. She stated she expected that when pharmacy delivered new narcotic cards, the nurses counted the cards together and added it to the reconciliation paper. She expected nursing to count narcotics with shift change or any time the keys changed hands. Administrative Nurse D stated she expected staff to immediately notify the nurse on call with any discrepancies. The facility's Medication Storage- Controlled Meds policy, last revised 10/08/2021, directed the count sheet reconciliation log was placed in the front of each narcotic sign out book and each medication accountability record was logged in and out of that log. The facility counted the number of medication accountability records at the beginning of the narcotic count to see that the number matched on the reconciliation log. The policy directed at each shift change, two licensed/certified nursing staff conducted a physical inventory of controlled medications and documented on the Eight Hour Verification Controlled Substances Count form.

Based on observation, record review, and interviews, the facility failed to prevent misappropriation of a narcotic medication for Resident (R) 1. Findings included:- R1 admitted to the facility on [DATE]. R1's Electronic Medical Record (EMR) documented diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), secondary osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain), gout (inflammation of the joints), and polyneuropathy (a condition in which a person's peripheral nerves are damaged). The Annual Minimum Data Set (MDS) dated 08/04/2025, documented R1 had a Brief Interview for Mental Status (BIMS) score of nine, which indicates moderate cognitive impairment. R1 received scheduled pain medication and had no complaints of pain during the assessment. The Quarterly MDS dated 04/29/2026, documented R1 had a BIMS score of seven, which indicated severe cognitive impairment. R1 received scheduled and as needed (PRN) pain medication and had no complaints of pain during the assessment. The Cognitive Loss/Dementia Care Area Assessment (CAA) dated 08/05/2026, documented R1 had issues with recall ability and cognition. The Activities of Daily Living (ADL) Functional/Rehabilitation Potential CAA dated 08/06/2026, documented R1 required limited to total assistance with ADLs, transfers, and mobility. R1 reported no discomfort upon interview. R1's Care Plan revised 02/13/2025, documented R1 had chronic pain related to arthritis, gout, and neuropathy. R1's 'Care Plan documented the following interventions:02/05/2025- Staff evaluated the effectiveness of pain interventions.02/05/2025- Staff identified, recorded, and treated R1's existing conditions which may have increased pain and/or discomfort.02/05/2025- Staff monitored/documented for side effects of pain medication.02/05/2025- Staff monitored/recorded/reported to the nurse any signs/symptoms of R1's nonverbal pain.02/05/2025- Staff notified the physician if R1's interventions were unsuccessful or if her current complaint was a significant change from her past experience of pain.05/12/2025- Staff monitored/recorded pain characteristics PRN.12/15/2025- Staff attempted non-pharmacological interventions for pain control.12/24/2025- Staff observed and reported any changes in R1's usual routine, sleep patterns, decrease in her functional abilities, decrease in her range of motion (ROM), or any withdrawal or resistance of cares.02/02/2026- Staff administered analgesia medications per orders, which included hydrocodone (narcotic pain medication) for pain management. R1's EMR documented an order with a start date of 11/19/2025, for hydrocodone-acetaminophen 5-325 milligrams (mg) with instructions to give one tablet every six hours as needed for moderate to severe pain related to secondary osteoarthritis. The facility's Investigation dated 06/23/2026, documented on 06/15/2026 between 01:30 PM and 02:00 PM, Licensed Nurse (LN) G reported R1's hydrocodone medication card and narcotic count sheet were not in the cart. Administrative Nurse D and Administrative Nurse E immediately searched all four medication carts, treatment carts, and medication rooms, including the narcotic destruction boxes, but the facility did not find the hydrocodone card. Administrative Nurse D spoke to all of the nurses on the schedule since the medication was last given. LN H gave the last dose on 06/13/2026 at 10:38 PM and she counted and signed off with LN I who worked 06/14/2026 morning. LN I worked day and evening shift and later counted the narcotics with another evening nurse, LN J. LN K, who worked night shift, received the keys from LN J, but did not count the narcotics until she counted with the oncoming day shift nurse on 06/15/2026. Later that shift on 06/15/2026, LN G reported the missing medication. The facility replaced R1's hydrocodone medication on 06/16/2026, and the facility was unable to identify a perpetrator. LN J's notarized witness statement on 06/14/2026, documented she counted the treatment cart and medication cart on 06/14/2026 at 09:00 PM with LN I. She stated the count was accurate. LN J's notarized witness statement on 06/16/2026, documented she arrived at the Prairie Point unit on 06/15/2026 at 12:00 AM after she was pulled from assisted living. She stated she counted the narcotics with the evening nurse for the Sunflower unit because LN J was working both Prairie Point and Sunflower units that night. She stated LN J told her that she counted with LN I, who worked evening shift on Prairie Point and had worked since 06:00 AM on 06/14/2026, then LN I left. LN J stated it was a busy night, and she did not get a chance to count the narcotics until the day shift nurse arrived. She stated she counted the number of pages and medications, and everything was correct at that time. LN I's statement, via email on 06/16/2026 at 10:18 AM, documented she worked day shift on 06/14/2026 and had counted at the beginning of the shift with the night nurse. She stated she did not notice whether R1's hydrocodone was present at the time or not. LN I stated she did not give R1 any PRN medications throughout the shifts she worked, and when she counted the cart before she left on 06/14/2026 night, the count was correct. LN H's statement, via email on 06/17/2026 at 09:25 PM, documented on 06/13/2026, she gave R1 a PRN medication and returned it to the locked box. She stated she counted with the day shift nurse on 06/14/2026, and all medication cards and counts were accounted for. She stated she always counted oncoming and off-going with her peer nurses per protocol. On 07/16/2026 at 12:54 PM, R1 sat in her wheelchair in her room with her eyes closed. On 07/16/2026 at 10:49 AM, Administrative Nurse D stated the facility never figured out what happened to R1's hydrocodone card. On 07/16/2026 at 11:32 PM, Administrative Nurse D stated she did one-on-one education after the incident to count the narcotics every shift and sign off on the sheets. She stated she did not have any sign-in sheets for the education or documentation. On 07/16/2026 at 11:43 PM, Administrative Nurse D stated the facility did not complete abuse, neglect, and exploitation (ANE) education after the incident. On 07/16/2026 at 01:14 PM, LN L stated she prevented misappropriation of medications by counting narcotics every shift or when exchanging keys with a nurse or Certified Medication Aide (CMA). She stated she signed on and off on the reconciliation narcotic count sheets. LN L stated if she gave a PRN narcotic, she checked the order, assessed the resident's pain, then verified the correct dose in the narcotic box and popped the medication out. She stated she signed out the narcotic medication on the count sheet and in the computer. LN L stated if she found a narcotic medication discrepancy, she notified Administrative Nurse D. She stated she counted the narcotics with every nurse or CMA if the keys changed hands and she did not let anybody use her keys. On 07/16/2026 at 01:18 PM, CMA T stated she prevented misappropriation of medications by counting narcotics at the beginning and end of the shift and signing off the medication on the narcotic count sheet and in the EMR. On 07/16/2026 at 01:47 PM, Administrative Nurse E stated on 06/15/2026, LN G realized R1's hydrocodone card and narcotic count sheet were missing. He stated the last dose given was on 06/13/2026 at 10:38 PM. He stated the facility started going through who worked, how many doses were given, and where the medication could have gone. Administrative Nurse E stated the original nurse who received the hydrocodone card from pharmacy did not add the card to the reconciliation sheet and updated the count number, so the count number on the reconciliation sheet was correct when it went missing. He stated the facility obtained statements from the nurses who worked, and nobody seemed to remember if R1's card was there when they counted. He stated they looked through the medication rooms and shred box, but could not find the hydrocodone card. Administrative Nurse E stated the facility did a process of elimination and since the only new nurse to work at the facility was LN I, they canceled her through her agency. He stated the facility was unable to find the actual perpetrator. Administrative Nurse E stated the facility did not audit the other residents' narcotics to see if there were any other discrepancies. On 07/16/2026 at 01:47 PM, Administrative Nurse D stated the facility also looked in R1's room for the hydrocodone card and in discarded medications but could not find it. She stated she reviewed the camera footage, but due to the angle of the camera to where the cart sat, the camera did not catch anything. Administrative Nurse D stated she told LN I's agency the facility did not have anything on her related to the hydrocodone, but it was a recommendation from corporate to cancel LN I after the facility reviewed everything. She stated she expected that when pharmacy delivered new narcotic cards, the nurses counted the cards together and added it to the reconciliation paper. She expected nursing to count narcotics with shift change or any time the keys changed hands. Administrative Nurse D stated she expected staff to immediately notify the nurse on call with any discrepancies. The facility's ANE: Abuse Prevention, Intervention, Reporting, and Investigation- Staff Treatment of Residents policy, last revised 06/25/2026, directed residents had the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, exploitation, and involuntary seclusion. The policy defined misappropriation of property as deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's belongings or money without their consent.

Based on record review and interviews, the facility failed to prevent a significant medication error when on 06/27/26 at approximately 08:30 AM, Certified Medication Aide (CMA) R administered unknown medications to Resident (R) 2 without verifying she had the correct resident. Findings included:- R2 admitted to the facility on [DATE]. R2's Electronic Medical Record (EMR) documented diagnoses of chronic heart failure (a condition with low heart output and the body becomes congested with fluid) and Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness). The Significant Change Minimum Data Set (MDS) dated 05/12/2026, documented R2 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The Activities of Daily Living (ADL) Functional/Rehabilitation Potential Care Area Assessment (CAA) dated 05/14/2026, documented R2 had a recent stay for respiratory failure, and she required limited to substantial assistance with ADLs, transfers, and mobility. R2's Care Plan dated 10/17/2025, documented R2 had a potential for impaired cognitive function or impaired thought processes related to Parkison's disease and heart failure. The Care Plan documented the following interventions:10/17/2025- R2 was usually alert and oriented, and she made her own decisions.10/17/2025- R2 had a durable power of attorney (DPOA) in place in case she needed assistance in making decisions.10/17/2025, revised 12/23/2025- Staff monitored/documented/reported as needed (PRN) any changes in cognitive function. The facility's Investigation dated 07/03/2026, documented on 06/27/2026 at approximately 08:30 AM in the dining room, CMA R administered a medication cup of unknown medications to R2 while she was in the dining room. Around the same time, CMA S gave R2 her morning medications and R2 then reported to CMA S that she was double dosed on medications that morning. CMA S immediately reported the medication administration error. R3 and R4 stated to Licensed Nurse (LN) PP that they had not received their morning medications. LN PP assessed R2, R3, and R4 and notified the physician, who gave orders to monitor the residents' vital signs every four hours with monitoring for signs and symptoms of changes. R3 and R4 had no observed changes noted. After the facility investigated the situation, they were unable to identify whose medications R2 received. At around 12:00 PM, R2 complained of nausea and the physician gave an order for a PRN Zofran (anti-nausea medication), which R2 received with reported improvement. At approximately 05:30 PM, staff observed R2 sitting at a dining room table with her head in her hands. LN PP assessed R2, who looked pale and shaky. R2 reported feeling unwell, lightheaded, and having an upset stomach. LN PP immediately contacted the physician, who gave orders to send R2 to the hospital. The facility contacted CMA R's agency who stated they would determine CMA R's competency and provide education to her. CMA S's notarized witness statement on 06/27/2026, documented on 06/27/2026, she went into R2's room to take her blood pressure and pulse, then R2 took her pills. She stated about 10 minutes later, R2 came out of her room and said she thinks she had the same pills she had given her this morning at breakfast. CMA S stated she told R2 that she had just gotten on shift, and her pills had not been signed out yet. CMA S stated R2 said a short, brown-headed girl had given her the pills in the dining room. CMA S stated she called CMA R and asked her about it and CMA R stated she must have given R2 another resident's pills accidentally. CMA S stated they took R2's vital signs and monitored her. CMA R's notarized witness statement on 06/29/2026, documented on 06/27/2026, CMA R passed medications in the dining room then she left at 08:30 AM. She stated she received a call at about 10:00 AM about a medication error. CMA R stated she went back to the facility, and she realized when she asked R2 her name, she verified the name. She stated she did ask for verification on resident names, but she was told after the incident that it was not the right resident. On 07/16/2026 at 01:19 PM, R2 was out of the facility at that time. On 07/16/2026 at 01:18 PM, CMA T stated she prevented medication errors by double checking for the right person, right medication, right time, and right dose. She stated she introduced herself and asked the resident their name. CMA T stated if she noticed she gave the wrong medications, she notified the nurse. On 07/16/2026 at 01:21 PM, LN L stated she prevented medication errors by following the five rights of medication administration, which were right person, right route, right drug, right dose, and right time. She stated she verified a resident's identity by their room number, by their picture in the EMR, by their date of birth if they were coherent enough to give it, by asking another staff member, and/or by asking them their name. On 07/16/2026 at 02:05 PM, Administrative Nurse E stated on 06/27/2026, CMA R passed medications first thing in the morning in the dining room. When CMA S came in later and started passing medications, she gave R2 her medications and R2 took the medications then stated she was double dosed. He stated there was no way that CMA R gave R2 her medications because she worked on a different medication cart than where R2's medications were. He stated the facility tried to figure out what medications she received and there were two residents, R3 and R4, who stated they had not received their medications that morning, but they were not good historians. Administrative Nurse E stated LN PP received orders to monitor the residents' vital signs for the day to see if anything changed. He stated around lunch, R2 started feeling nauseous and weak then around 05:30 PM, the facility sent her out to the hospital. Administrative Nurse E stated the facility notified CMA R's agency about the incident and canceled her. He stated he started educating CMAs and nurses on the five rights of administration. He stated the facility determined CMA R stated had asked R2 her name, but she did not look at the picture on the EMR to properly identify R2. On 07/16/2026 at 02:05 PM, Administrative Nurse D stated the facility completed five rights of administration education with their staff even though CMA R was not one of their staff members. She stated she expected staff to not pass medications in the dining room due to confusion with everyone in there and to give their medications before they got to the dining room. Administrative Nurse D stated she expected staff to verify the five rights of medication administration. The facility's Medication Errors policy, last revised 09/30/2021, defined a medication error by the type of error and could be categorized as omission, wrong dose, wrong drug, unauthorized drug, wrong dosage form, wrong time, and wrong route of administration. The facility's Medication Administration policy, last revised 06/02/2023, directed the procedure for medication administration included identifying the resident. The facility put the following corrections into place: 1. The facility sent R2 to the hospital for evaluation and treatment on 06/27/2026. 2. The facility notified CMA R's agency of the medication error and canceled her shifts at the facility. 3. The facility educated CMAs and LNs on the five rights of medication administration on 06/29/2026. Due to the facility's completion of all corrective actions prior to the onsite visit, the deficient practice was deemed past noncompliance at a scope and severity of a D (isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy).

Based on observation, interview, and record review, the facility failed to provide follow-up care and services for Resident (R) 1's fractured wrist when staff failed to make an appointment and take her to a surgeon as ordered by the physician. This resulted in a non-removable device existing for longer than intended without physician oversight, which caused a Stage 3(full-thickness pressure injury extending through the skin into the tissue below) pressure ulcer on R1's thumb. Findings Included:- R1's Electronic Medical Record (EMR) revealed the following diagnoses: Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), chronic kidney disease, and a Stage 3 pressure ulcer (full-thickness pressure injury extending through the skin into the tissue below). R1's 01/22/26 Quarterly Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. The MDS recorded R1 was at risk for pressure ulcers and had no pressure areas or wounds at that time. R1's Incident Note dated 02/21/26 at 12:30 PM documented the nurse received a phone call from the hospital reporting R1 was ready to return to the facility. R1 had a fractured right wrist, which was wrapped and had a sling. R1 was to follow up with orthopedics the next week. R1 also had a fractured tailbone. R1's Health Status Note dated 02/21/26 at 07:52 PM, documented R1 returned from the hospital with a referral to Orthopedic Surgery for R1's wrist fracture, at a local Orthopedics & Sports Medicine Clinic. The note listed the address and phone number of the clinic. The note documented staff were to keep the splint dry and intact until the follow-up with orthopedics, R1 should wear the sling for comfort, and return to the emergency room (ER) immediately if she developed numbness or tingling in her fingers, worsening pain, or any other concerns. R1's After Visit Summary (AVS) from the hospital dated 02/21/26 documented R1 went to the emergency room after a fall with a fracture to her right wrist. A sugar-tong splint (a temporary splint that immobilizes the wrist and elbow while allowing free use of fingers) was applied. The AVS included instructions to keep the bandage around the splint clean and dry and a referral to Orthopedics Surgery was made to the Orthopedics and Sports Medicine clinic and named the clinic. The AVS instructed the facility to call for a follow-up visit as soon as possible for R1's wrist fracture. R1's progress notes lacked evidence that the staff attempted to call and schedule a follow-up appointment until 03/05/26, nine business days later. R1's Progress Note dated 03/05/26 at 07:12 AM, documented the writer of the note tried to make an appointment with the orthopedic doctor, but R1 was not in network. The writer of the note called another orthopedic surgeon, and a referral was faxed over along with the ER note. The note documented that the surgeon's office would call the writer [of the note] back to schedule an appointment. R1's EMR lacked evidence staff attempted to contact the orthopedic surgeon regarding a follow-up appointment until 03/25/26, 31 days after the application of the sugar-tong splint. R1's Progress Note dated 03/25/26 at 12:06 PM, documented an appointment was made to see an orthopedic nurse practitioner for 03/27/26 at 09:15 AM. R1's Progress Note from the office visit with the Physician's Assistant (PA) for the Orthopedic Surgeon documented R1 had a fracture of her right wrist. It documented R1 had a fall on 02/21/26 and was seen in the emergency room. The facility failed to follow up on the order to follow up with orthopedic surgeon. The note documented R1 had pain in her fingers and hand. R1 had been in a sugar tong splint since her emergency room visit. The note contained a right-hand exam, which documented a pressure sore on the base of the thumb from the sugar splint. R1's provider note 'SKIN AND WOUND NOTE, dated 03/31/26 at 02:39 PM, documented R1 had a fall on 02/21/26 and broke her right wrist. In the emergency room, she was placed in a sugar-tong splint and somehow did not get her follow-up appointment until 03/27/26, when a cast was placed on her. R1 reported she had significant swelling in her wrist and complained of discomfort in her wrist. The note further documented that the resident had a Stage 3 pressure ulcer to her right thumb that measured 0.5 centimeters (cm) by 1.5 cm, and 0.2 cm deep. The wound was 50 percent covered with slough (dead tissue, usually cream or yellow in color). A treatment order was given to wash the wound, apply Hydrogel (a water-based gel that donates moisture and aids autolytic debridement), and a bordered dressing. On 04/01/26 at 01:45 PM, R1 sat in her room on her couch. R1's hand was not elevated and was swollen with a blue tint to it. R1's pressure area on her right thumb was visible, and the ordered dressing was not in place. On 04/01/26 at 01:48 PM, Licensed Nurse (LN) G stated R1 was alert and oriented most of the time with a little confusion. R1 had a new cast. She was mostly independent in her room. LN G was a contract worker, so she was not aware of the specific situation with R1 but stated when someone returned with an order to have an appointment, she filled out a transportation slip and put it on the calendar. On 04/01/26 at 02:41 PM, Administrative Nurse E stated the ER paperwork documented that the ER sent a referral to the orthopedic doctor on 02/21/26, and the facility staff did not notice the orders in the AVS directed the facility to call the surgeon to make the appointment. Administrative Nurse E verified the facility should have made a follow-up appointment with the orthopedic doctor the following week and confirmed the facility did not follow up with that orthopedic surgeon since they were waiting for the orthopedic surgeon to call to schedule the appointment. Administrative Nurse E said when she reached out to the orthopedic surgeon on 03/04/26 (11 days after the splint was applied and orders given), the clinic said that R1 was not in network, so she called another orthopedic doctor and sent them the referral paperwork. She said staff awaited a call back from the surgeon's office with an appointment and verified that staff did not follow up regarding the appointment until 03/16/26. Administrative Nurse E called the surgeon's office back and learned they had not received the referral sent on 03/04/26. Administrative Nurse E sent the referral again but did not call back until 03/25/26 (nine days later) when she was told the clinic did not require a referral, so an appointment for R1 was scheduled for 03/27/26. On 04/01/26 at 03:30 PM, Administrative Nurse D stated she was not at the facility at the time of the incident and was unsure of the policy for follow-up appointments. The facility's policy Professional Medical Consulting Services and Guidelines documents the policy is to provide medical services necessary for supporting the care and treatment of the resident.

The facility reported a census of 68 residents. The sample included four residents, with four reviewed for accidents and supervision. Based on observations, interviews, and record review, the facility failed to provide adequate supervision for Resident (R) 1 resulting in an elopement from the facility. This deficient practice placed R1 at risk for preventable accidents and injuries. Findings included: - The Medical Diagnosis section within R1's Electronic Medical Record (EMR) included diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), generalized anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and chronic obstructive pulmonary disorder (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). R1's Quarterly Minimum Data Set (MDS) completed 06/05/25 noted a Brief Interview for Mental Status (BIMS) of nine, indicating moderate cognitive impairment. The MDS noted he had physically aggressive behaviors, rejections of care, and wandering observed for one to three days. The MDS noted he had bilateral lower extremity impairments but could walk independently with his walker. The MDS noted no falls. R1's Functional Ability Care Area Assessment (CAA) completed 03/11/25 indicated he required limited to extensive assistance with his activities of daily living (ADLs). The CAA noted he could ambulate independently with his walker. The CAA noted he could speak clearly and make his needs known. The CAA noted he had no falls since the last review. R1's Behaviors CAA completed 03/11/25 noted he had physical and verbal behaviors noted in the past. The CAA noted he had wandering behaviors due to his Alzheimer's and wore a Wanderguard (proximity bracelet that alerted staff when he was close too to the exit doors). R1's Care Plan initiated on 02/24/25 indicated he was at risk for elopement related to his Alzheimer's disease. The plan noted he used a walker and was able to ambulate independently. The plan indicated he had a Wandergurad and instructed staff to check its placement each shift and functionality daily. The plan noted he would pace by the facility entrance waiting for his wife to come visit. The plan instructed staff to provide redirection, food, drinks, or activities when pacing. R1's EMR under Physician's Orders revealed an order (dated 02/24/25) indicating he wore a Wanderguard bracelet on his right wrist The order instructed staff to check its placement each shift and functionality daily. R1's EMR under Progress Notes revealed a Behavior Note completed on 06/01/25. The note revealed that R1 followed someone out the door before the door's lock could engage. The note revealed the facility's Wanderguard alarm system activated alerting staff to the elopement. The note revealed staff found R1 resting against the brick wall outside the main entry to the facility. The note indicated R1 was assessed with no injuries and R1 was redirected back into the facility. A Facility Incident Report #5756 completed on 06/02/25 revealed that R1 eloped from the facility on 06/01/25 at 08:29 AM. The report indicated his Wanderguard bracelet alerted staff to the front entrance to find R1 leaning up against a brick wall waiting for his wife to arrive to take him to church. The report indicated staff escorted him back inside the facility and assessed him. The report's root-cause analysis revealed that R1 exited the facility behind a visitor leaving the facility. The report revealed all resident designated power of attorneys (DPOAs) were notified not to allow residents out of the facility without checking with staff. The report also noted signage was placed next to the door entry indicating visitors were to check with staff before allowing residents to exit the building. The report indicated all staff were provided education related to wandering and elopement. On 06/17/25 at 09:02 AM an inspection of the Main Entrance revealed signage posted next to the entry doors. The sign indicated All visitors must check with staff before allowing residents to exit the facility. On 06/17/25 at 11:15 AM, R1 rested in his bed. R1 stated he preferred to wait for his wife to arrive at the facility and often met her at the entrance. R1 stated he could not recall the elopement incident but felt he was safe to go outside when he wanted to. R1's Wanderguard bracelet was around his right wrist. On 06/17/25 at 12:05 PM, Licensed Nurse G stated R1's Wandergaurd was checked each shift and tested before bedtime. She stated he liked to wait in the front lobby area for his wife to arrive at the facility to go on outings. She stated that R1 was often confused and required supervision while being outside. On 06/17/25 at 12:20 PM, Administrative Nurse D stated that R1 would often wait for his wife and go to church with her. She stated that R1 followed a visitor out of the facility. She stated the Wanderguard system was triggered, and staff were able to get him back inside without behaviors or issues. She stated the facility had educated staff and visitors about the risks of wandering and elopement. The facility's Wandering and Elopement policy (undated) indicated the facility would monitor all residents at risk for elopement would be closely monitored. The policy noted staff would follow each resident's individualized care interventions as well as facility-wide processes. The facility implemented and completed the following corrective actions related to this incident prior to onsite survey: 1. R1 was immediately assessed on 06/01/25. 2. The facility emailed all DPOAs education related to checking with staff before allowing residents to exit the facility and placed signage on 06/02/25. 3. The facility identified all at-risk residents with potential elopement risks on 06/02/25. 4. The facility completed an audit of all residents with Wanderguard bracelets on 06/02/25. 5. Staff training and education were provided related to wandering and elopement risks on 06/02/25. 6. A medication review was completed for R1 on 06/02/25. Due to the corrective actions completed on 06/02/25, prior to the onsite visit on 06/17/25, the deficient practice was deemed past non-compliance at a D (potential for harm) scope and severity.

The facility identified a census of 63 residents. The sample included 18 residents. Based on observation, record review, and interviews, the facility failed to provide consistent weekend activities on Saturdays to promote socialization. This deficient practice placed the affected residents at risk for decreased psychosocial well-being, boredom, and isolation. Findings included: - A review of the facility's Activity Calendar for October, November, and December 2024 was completed. The Activity Calendar for October recorded the following Saturday activities: for 10/05/24 were Chronicles and Current Events, afternoon bingo, deep breathing, exercise, and balance; and on 10/12/24 the activity was afternoon bingo, exercise, balance, and deep breathing. The Activities Calendar recorded no activities for 10/19/24, and 10/26/24. The Activity Calendar for November 2024 recorded no activity on 11/02/24, and 11/09/24. The Activity Calendar listed 11/16/24 was a musical performance. The Activity Calendar on 11/23/24 listed deserts for Thanksgiving open house, and no activities on 11/30/24. The Activities Calendar for December 2024 revealed each Saturday had no activities listed. On 12/10/24 at 08:59 AM, Resident Council members reported on weekends, starting in October, there were not many activities. The council reported they could go to church services on Sundays. The Resident Council stated there were no consistent activities on Saturday and residents stayed in their rooms and watched TV. The Resident Council stated the weekends get very long and boring. On 12/11/24 at 11:06 AM, Activities Staff Z verified the facility did not have consistent weekend activities. She stated the facility was working on getting volunteers from the churches and staff for activities on the weekends. On 12/11/24 at 12:54 PM, Certified Nursing Aide (CNA) Q stated she was unsure if there were weekend activities. She stated she had never done any weekend activities for the residents. On 12/11/24 at 03:24 PM, Administrative D stated the facility had volunteers on Sundays, and the nursing staff could do weekend activities. She stated the facility had activities that nursing staff could hand out to the residents on the weekends. The facility's Life Enrichment Programs policy reviewed on 10/13/21 documented that group life enrichment programs would be provided which are designed to meet, in accordance with the comprehensive assessment, the interest and the physical, mental, and psychosocial well-being of each resident. Residents would be encouraged to participate in group life enrichment of interest and encouraged to develop new interests. The facility failed to provide consistent weekend activities for the residents to promote socialization. This deficient practice placed the affected residents at risk for decreased psychosocial well-being, boredom, and isolation.

The facility had a census of 63 residents. The sample included 18 residents with eight reviewed for accidents. Based on observation, record review and interview the facility failed to secure electrical panels and cleaning chemicals in a safe, locked area, and out of reach of the ten cognitively impaired, independently mobile residents. The facility additionally failed to provide adequate supervision for Resident (R) 33 and follow R43's care-planned fall interventions related to her wheelchair placement. This placed the affected residents at risk for preventable accidents and injuries. Findings Included: - On 12/09/24 at 07:05 AM, a walk-through of the Cedar View halls was completed with the following observations: An inspection of an unsecured housekeeping closet in the 580's hallway revealed numerous heavy-duty 3M brand cleaning products on the wall. The room also contained multipurpose sprays and floor cleaners. The cleaning products contained the warning label, Keep out of reach of children, hazardous to humans can cause eye irritation, harmful if swallowed. An inspection of an unsecured soiled linen closet in the 580's hallway revealed a bottle of crystal spray spot cleaner on a shelf. The bottle contained the warning label, Keep out of reach of children, hazardous to humans can cause eye irritation, harmful if swallowed. The room also contained three unlocked electrical panels with the warning high voltage - the danger of electric shock. On 12/09/24 at 07:05 AM, an inspection of an unsecured storage closet in the 560's hallway revealed three unlocked electrical panels with the warning high voltage - the danger of electric shock. On 12/09/24 at 07:31 AM, Maintenance Staff U stated all the storage rooms and closets should be locked. He then checked the closet doors and secured them. On 12/11/24 at 11:45 AM, an inspection of the Spa room on the 560's hallway revealed the door was unsecured. An inspection of the room revealed an unlocked cabinet with unsecured purple sanitary bleach wipes. On 12/11/24 at 11:50 AM, Licensed Nurse (LN) G stated the Spa room should be always locked and residents should not be in the room without a staff member present. She stated the utility rooms and janitor closets should always be locked. On 12/11/24 at 02:47 PM, Administrative Nurse D stated the utility rooms and closets were to remain locked. She stated residents should not have access to areas containing potential hazards. She stated staff were expected to check the rooms and ensure they remained secured. The facility did not provide a policy related to accidents and hazards as requested on 12/11/24. The facility failed to secure electrical panels and cleaning chemicals in a safe, locked area, and out of reach of the ten cognitively impaired, independently mobile residents. This placed the affected residents at risk for preventable accidents and injuries. - The Diagnosis section within R33's Electronic Medical Records (EMR) noted diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), history of fractures (broken bones) related to falls, hearing loss, age-related physical debility, fatigue, urinary retention, and age-related macular degeneration (progressive deterioration of the retina). R33's Quarterly Minimum Data Set (MDS) completed 03/21/24 documented a Brief Interview of Mental Status (BIMS) score of nine indicating moderate cognitive impairment. The MDS documented she required partial to moderate staff assistance with toileting, bathing, dressing, personal hygiene, and transfers. The MDS indicated she was fully dependent on staff assistance for walking or ambulation. The MDS documented she had a history of falls since her last assessment. R33's Quarterly MDS dated [DATE] documented a BIMS score of three indicating severe cognitive impairment. The MDS indicated she was fully dependent on staff assistance for transfers, bed mobility, bathing, toileting, personal hygiene, and dressing. The MDS documented she had one fall since her last assessment. The MDS documented bed rails were not in use. R33's Functional Abilities Care Area Assessment (CAA) completed 04/29/24 indicated she was at risk for falls related to her medical diagnoses and cognitive impairment. The CAA documented she had visual and hearing impairments. The CAA documented she required extensive to total assistance from staff for her activities of daily living (ADLs) and transfers. R33's Fall CAA completed 04/29/24 indicated she had one fall since and was at risk due to her impaired vision, hearing, cognition, and mobility. R33's Care Plan initiated on 12/19/23 indicated she was at risk for falls and required extensive to total assistance from staff for grooming, toileting, bathing, transfers, and repositioning. The care plan instructed staff to follow her implemented toileting plan, assist with ADLs, ensure her bed was in the lowest position, and encourage her to use her call light for assistance. The care plan documented she had a positional rail (grab bar) mounted on the right side of her bed. A note dated 04/14/24 at 07:49 PM, in R33's EMR under Notes, documented staff heard R33 yelling for help in the unit's shower room. The note indicated staff assessed R33 for injuries and assisted her into her recliner. The note revealed no injuries. The facility's Root Cause Analysis Investigation completed on 04/15/24 indicated R33 was seen in her recliner before her fall. The report indicated that R33 walked into the shower room and fell while attempting to toilet herself. On 12/10/24 at 12:45 PM, R33 sat in her Broda chair (specialized wheelchair with the ability to tilt and recline) in front of the fireplace area. The recliner area was located directly access from the shower room. An inspection of the shower room revealed a sign on the back stating Leave door locked at all times. On 12/11/24 at 11:45 AM, an inspection of the Spa room on the 560's hallway revealed the door was unsecured. An inspection of the room revealed an unlocked cabinet with unsecured purple sanitary bleach wipes. On 12/11/24 at 11:50 AM, Licensed Nurse (LN) G stated R33 required supervision even before her fall. She stated that R33 was impulsive and often attempted to transfer herself or walk without staff present. She stated the shower room should be locked at all times and residents should never be allowed to go in alone due to the chance of falls or accidents. On 12/11/24 at 02:01 PM, Administrative Nurse D stated R33 was impulsive and walked herself to the shower room. She stated the shower room should have been locked and residents were not allowed to enter them alone. She stated she put R33 on a toileting program to prevent her from seeking out a bathroom. She stated staff were educated to leave the doors locked. The facility's Falls policy dated 10/08/24 documented that residents would be identified for risk of falls and interventions implemented to reduce the risk of falls. Fall risk screening tool would be completed on admission, quarterly for healthcare, and annually for assisted living and when there was a significant change of condition and as applicable, after a fall. Residents' high-risk status would be documented on the comprehensive plan of care or service plan. The facility failed to ensure consistent supervision for R33 resulting in a fall in an unsecured shower room. This deficient practice placed R33 at risk for preventable accidents and injuries. 49634 - R43's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), kidney failure (a condition where one or both kidneys no longer work on their own), chronic obstructive pulmonary disease (COPD - a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), hypertension (high blood pressure), major depressive disorder (major mood disorder that causes persistent feelings of sadness), Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness), and chronic respiratory failure with hypoxia (when there was not enough oxygen in the blood). The Significant Change in Status Minimum Data Set (MDS) for R43 dated 10/09/24 recorded a Brief Interview for Mental Status (BIMS) score of 12, which indicated moderately impaired cognition. The MDS documented R43 was dependent on staff for personal hygiene, toileting, and dressing. The MDS documented R43 was at risk for falls and had one non-injury fall. R43's Fall Care Area assessment dated [DATE] documented R43 scored at high risk for falls. R43 had a non-injury unwitnessed fall on 10/09/24. R43 was started on hospice services. The CAA documented R43 required extensive assistance of one staff with transfers, had daily incontinence, and required total assistance with toileting needs. R43's CAA documented R43 used a wheelchair for mobility and required total assistance from one staff. R43's Care Plan dated 07/11/22 documented staff were to encourage R43 to wear long sleeves or arm protectors due to the high risk of bruising. R43's plan of care documented staff were to encourage R43 to allow staff to put footwear on in the mornings. R43's plan of care documented staff would ensure R43's wheelchair was next to her. R43's plan of care dated 11/04/24 documented staff were to put R43 in her chair or in her bed after each meal. R43's EMR under ID Notes dated 10/09/24 documented nursing staff were called to R43's room by a Certified Nurse Aide (CNA). Upon arrival, the nurse noted R43 was sitting in front of her wheelchair on top of the wheelchair foot pedals. R43 denied hitting her head and stated there was someone in her recliner but was unable to elaborate. R43 stated she did not have to go to the bathroom. The nurse and CNA assisted R43 to her recliner. R43 was able to bear weight and assist with the transfer. Staff notified R43's physician and hospice provider and the CNA staff assisted R43 with her evening cares. On 12/10/24 at 02:14 PM, R43 sat in her easy chair. R43's pedals to her wheelchair sat by her chair. R43's wheelchair was folded up inside her bathroom and out of her reach. On 12/11/24 at 11:15 AM, Licensed Nurse (LN) J stated all staff had access to the resident's care plan. LN J stated all staff working the hall were responsible for ensuring the safety of all residents. LN J stated the CNAs had a paragraph on their daily charting that tells the CNA pertinent information about each resident. On 12/11/24 at 12:54 PM, CNA Q stated she was able to see each resident's care plan. She stated that on most days, she does not have time to read each resident's care plan. She stated the charge nurse on her hall would let her know if there was anything specific she needed to know about each resident she was caring for. On 12/11/24 at 03:24 PM, Administrative Nurse D stated all nursing staff had access to the residents' care plans. Administrative Nurse D stated she expected staff to read the resident's care plan and take care of the resident as the care plan stated. The facility's Falls policy dated 10/08/24 documented that residents would be identified for risk of falls and interventions implemented to reduce the risk of falls. Fall risk screening tool would be completed on admission, quarterly for healthcare, and annually for assisted living and when there was a significant change of condition and as applicable, after a fall. Residents' high-risk status would be documented on the comprehensive plan of care or service plan. The facility failed to ensure R43's wheelchair was placed next to her per her plan of care to prevent further falls. This deficient practice placed R43 at risk for falls and fall-related injuries.

The facility identified a census of 63 residents. The sample included 18 residents and five Certified Nurse Aides (CNA) were reviewed for yearly performance evaluations and the associated in-service training. Based on record review and interview, the facility failed to ensure one of the five CNA staff reviewed had yearly performance evaluations completed. This placed the residents at risk for inadequate care. Findings included: - A review of the facility's staffing list revealed the following CNAs were employed with the facility for more than 12 months: CNA N, hired 09/05/23, had no yearly performance evaluation upon request. On 12/11/24 at 09:28 AM, Administrative Staff A stated CNA N had just been there a year and her yearly performance had not been completed at this time. Administrative Staff A stated the facility was a little behind in completing their staff's yearly performance. The facility failed to provide a policy related to yearly staff performance reviews. The facility failed to ensure one of the five CNA staff reviewed had the required yearly performance evaluations completed. This placed the residents at risk for inadequate care.

The facility identified a census of 63 residents with one kitchen and three dining rooms. Based on observation, record review, and interviews, the facility failed to follow sanitary dietary standards related to maintaining a sanitary service environment for food storage and meal service. These deficient practices placed the affected residents at risk related to food-borne illnesses and food safety concerns. Findings Included: - On 12/09/24 at 07:21 AM, an inspection of the dining room for Cedar View revealed dirty plates stored on the table next to the kitchenette's serving window from the previous evening's meal service. The table contained a stack of domed plate covers stored in an upward position. Inspection of the condiment shelf in the dining room to the right of the service window revealed a large, uncovered container of instant food thickener with no lid on the top shelf. Thickener residue covered the top of the countertop. On 12/09/24 at 08:40 AM, an inspection of the Cedar View dining room revealed that the thickener container had been moved to the table next to the service window. The container remained uncovered, with no lid present. On 12/09/24 at 08:50 AM, Certified Nurse Aide (CNA) M received a plate from the kitchenette and placed a dome cover on top of the plate. The dome cover sat directly on top of the food pushing it downward. The plate was then delivered to Resident (R) 29 in her room. On 12/09/24 at 08:55 AM, CNA M assisted R56's positioning and returned to the service window. CNA M received R56's breakfast plate and placed a dome lid on it. CNA M placed the food in front of R56 with the dome still on it and walked away from the table. CNA M then walked across the dining room to R56's table. CNA M repositioned and wheeled R23 over to R56's table while R23 slept. CNA M then sat at the table and assisted a male resident with his meal without completing hand hygiene before assisting R23. On 12/10/24 at 07:03 AM, an inspection of the Cedar View dining area revealed dirty plates and drink glasses on the table next to the service window. The food thickener container remained uncovered with no lid. On 12/10/24 at 07:10 AM, Dietary Staff BB cleaned up the dining room service area. He put a dome cover on top of the food thickener container and stated staff should keep this covered at all times when not in use. He stated staff should be attempting to keep the area clean and organized. On 12/10/24 at 10:01 AM, the thickener container was moved to the second shelf on the condiment table. No lid or cover was placed on it. On 12/11/24 at 12:55 PM, CNA Q stated staff were expected to complete hand hygiene before, during, and after assisting residents in meal service. She stated staff should be hand sanitizing in between delivering meal trays and assisting residents at the table. On 12/11/24 at 01:02 PM, Licensed Nurse (LN) G stated staff should be using the hand sanitizer dispenser before touching meal trays and after moving the residents to the tables. She stated staff were expected to ensure the dining areas remained clean and sanitary. She stated staff should be storing the plates inside the kitchenette when the dietary staff were not available to keep the area clean. On 12/11/24 at 02:46 PM, Administrative Nurse D stated staff were expected to complete hand hygiene in between assisting residents and providing meals. The facility's Equipment: Storage, Cleaning and Sanitizing policy (undated) indicated food service areas would remain clean and sanitary. The policy indicated the facility would ensure all food and supplies would be stored appropriately to ensure quality and maximize the safety of the food. The facility failed to follow sanitary dietary standards related to maintaining a sanitary service environment for food storage and meal service. These deficient practices placed the affected residents at risk related to food-borne illnesses and food safety concerns.

The facility identified a census of 63 residents. The facility identified eight residents on Enhanced Barrier Precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms that employ targeted gown and glove use during high contact care). Based on record review, observations, and interviews, the facility failed to develop and implement a system to alert staff and visitors of EBP needs and additionally failed to complete hand hygiene during wound care and to ensure the sanitary storage of oxygen therapy equipment. These deficient practices placed the residents at risk for infectious diseases. Included Findings: - On 12/09/24 the facility identified Resident (R) 2, R5, R9, R13, R48 R50, R51, and R260 as being on EBP. An inspection of the above residents' rooms revealed personal protective equipment (PPE) stored within them though there was no signage related to EBP or the required PPE An inspection of the rooms revealed no visible indicator or signage for EBP. On 12/09/24 at 09:22 AM, R4's nebulizer mask lay directly on her coffee table alongside her recliner. On 12/09/24 at 10:00 AM, R51's nasal cannula and oxygen tubing hung over the end of the bed. R51's nebulizer mask lay directly on the bedside table. On 12/09/24 at 08:35 AM, R23's nasal cannula and oxygen tubing rested directly on her bed. On 12/10/24 at 12:24 AM, R4's nebulizer mask hung over her coffee table next to her recliner. On 12/11/24 at 08:45 AM, an inspection of R27's room revealed her continuous positive airway pressure (CPAP- ventilation device that blows a gentle stream of air into the nose to keep the airway open during sleep) mask lay directly on top of her dresser without a barrier or clean storage bag. On 12/11/24 at 09:07 AM, R13 lay on her bed. Licensed Nurse (LN) H washed her hands and donned a pair of gloves. She removed R13's percutaneous endoscope gastrostomy tube (PEG-a tube inserted through the wall of the abdomen directly into the stomach) site dressing. LN H disposed of the soiled dressing in the trash. Wearing the same soiled gloves, LN H applied R13's clean PEG site dressing. LN H doffed her gloves and performed hand hygiene. On 12/11/24 at 08:20 AM, LN G stated nursing staff passed down information on which residents were on EBP and would let staff know what precautions were necessary. She stated PPE is stored inside closets of each room on the shelves. She was not aware of signage or indicators placed to let staff and visitors know of the required precautions. She stated oxygen equipment and tubing should be stored in a plastic bag when not in use. On 12/11/24 at 10:05 AM, Certified Nurse Aide (CNA) MM stated she was agency and not aware of the indicator placed in the rooms for EBP. She stated the nurses notify direct care staff in person of which residents were on EBP and the EMR displays it. She stated she was not aware of signage or indicators physically placed in the room to show EBP. On 12/11/24 at 11:30 AM, LN G stated she was just notified the blue dots on the resident's doors indicate EBP rooms. On 12/11/24 at 01:58 PM, LN H stated that hand hygiene should be performed between glove changes and going from a dirty field to a clean field. On 12/11/24 at 02:24 PM, Administrative Nurse D stated all staff have been educated on EBP and the requirements of PPE. She stated the rooms were identified with blue dots on the door plates. She stated the facility recently educated all staff on infection control practices. The facility's Hand Hygiene policy dated 09/07/22 documented all staff members would comply with current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines, as effective hand hygiene reduces the incidence of healthcare-associated infections. Hand hygiene in long-term care would be prior to touching a resident, prior to aseptic procedures, after body fluid exposure, and after touching a resident's belongings. The facility's Oxygen Therapy policy dated 10/08/21 documented that oxygen was treated as a medication ordered by the physician. The order includes the amount per minute to be delivered, the device used for delivery, and during what times to deliver oxygen therapy. When the device is not in use, store it in a plastic or other bag to keep the tubing and the device off the floor. The Infection Control policy dated 06/14/24 documented the infection control program included identifying, investigating, controlling, reporting, and preventing infections and communicable diseases in the community including appropriate immunizations, and standard and transmission-based precautions to prevent the spread of infections. Standard precautions include hand hygiene, glove usage, gown, mask, eye protection, or face shield depending on anticipated exposure. The facility failed to ensure the staff were aware of the EBP indicators in place for the residents. The facility additionally failed to complete hand hygiene during wound care and to ensure the sanitary storage of oxygen therapy equipment. These deficient practices placed the residents at risk for infectious diseases.

The facility identified a census of 63 residents. Based on record review and interviews, the facility failed to ensure agency staff received the required resident rights training. This placed the residents at risk for impaired care and decreased quality of life. Findings included: - On 12/11/24 at 09:30 AM, the training record on file at the facility for agency Certified Nurses Aid (CNA) O, CNA P, and Licensed Nurse (LN) I revealed the following: CNA O's facility-provided credentialing file lacked documented training completed for resident rights training. LN I facility credentialing file lacked documented training completed for resident rights training. The file documented she was provided abuse, neglect, and exploitation (ANE) training. On 12/11/24 at 12:48 PM, CNA Q confirmed she was agency staff. She stated she had completed some in-services through the staffing agency through which she was contracted. On 12/11/24 at 01:48 PM, Licensed Nurse (LN) H confirmed she was agency staff. She stated she contracted through several different staffing agencies, and she had completed nursing competency for the agency company. LN H stated she had attended in-services at the facility occasionally during her time working at the facility. On 12/11/24 at 03:25 PM, Administrative Nurse D stated she expected the agency that the facility used for staffing to ensure agency staff had completed the required in-services. Administrative Nurse D revealed she did not have a system in place to ensure the agency staff the facility used to care for the residents had the required in-services. The facility's Education policy dated 08/2022 documented that the goal of the facility was to ensure all staff received appropriate training in order to ensure the safety and well-being of all residents. An electronic learning management system (ELMS) was used as the primary education provider. Additional education was provided via online webinars, conference calls, in-service meetings, and conferences. The facility failed to ensure the required resident rights training was completed by staff who provided care in the facility. This placed the residents at risk for impaired care and decreased quality of life.

The facility identified a census of 63 residents. Based on record review and interviews, the facility failed to ensure agency staff received the required infection control training. This placed the residents at risk for impaired care and decreased quality of life. Findings included: - On 12/11/24 at 09:30 AM the training record on file at the facility for agency Certified Nurses Aid (CNA) O, CNA P and Licensed Nurse (LN) I revealed the following: CNA O's facility-provided credentialing file lacked documented training completed for infection control training. CNA P's facility-provided credentialing file lacked documented training completed for infection control training. The file noted she was provided abuse, neglect, and exploitation (ANE), and resident rights training. LN I facility credentialing file lacked documented training completed for infection control training. The file noted she was provided abuse, neglect, and exploitation (ANE) training. On 12/11/24 at 12:48 PM, CNA Q confirmed she was agency staff. She stated she had completed some in-services through the staffing agency she was contracted through. On 12/11/24 at 01:48 PM, Licensed Nurse (LN) H confirmed she was agency staff. She stated she contracted through several different staffing agencies, and she had completed nursing competency for the agency company. LN H stated she had attended in-services at the facility occasionally during her time working at the facility. On 12/11/24 at 03:25 PM, Administrative Nurse D stated she expected the agency that the facility used for staffing to ensure agency staff had completed the required in-services. Administrative Nurse D stated she did not have a system in place to ensure the agency staff the facility used to care for the residents had the required in-services. The facility's Education policy dated 08/2022 documented the goal of the facility was to ensure all staff received appropriate training in order to ensure the safety and well-being of all residents. An electronic learning management system (ELMS) was used as the primary provider of education. Additional education was provided via online webinars, conference calls, in-service meetings, and conferences. The facility failed to ensure the completion of the required infection control training for staff who provided care in the facility. This placed the residents at risk for impaired care and decreased quality of life.

The facility had a census of 63 residents. The sample included 18 residents with two reviewed for accommodation of needs related to assistive devices. Based on observation, record review, and interview the facility failed to utilize and ensure the appropriate use of foot pedals during wheelchair transports for Resident (R) 1, R41, and R47. This placed the residents at risk for preventable accidents and injuries. Findings Included: - On 12/09/24 at 07:30 AM, R1 (resident with upper and lower extremity impairments) was wheeled out of his room to the medication cart by the nurse's station. R1's foot pedals were not in place as staff pushed him down the hall. At 07:35 AM, staff applied his foot pedals and wheeled him to breakfast. On 12/10/24 at 08:32 AM, R41 (severely cognitively and physically impaired resident) sat upright in his Broda chair as an unidentified staff pushed his chair down the hallway toward the edge of the dining room close to his room. R41's feet slid along on the floor as staff pushed his chair. On 12/10/24 at 08:56 AM, R41 sat upright in his Broda chair by the dining room near his room. R41's feet were not appropriately positioned in his Broda chair and his feet slid on the ground as staff wheeled him down the hallway. On 12/11/24 at 08:00 AM, Licnesed Nurse (LN) G pushed R47 down the Cedar View hallway. R47's wheelchair had no foot pedals in place, and her feet slid on the ground as she was pushed. On 12/11/24 at 11:45 AM, LN G stated all the residents had foot pedals and staff should ensure they were in place before transporting the residents. On 12/11/24 at 12:55 PM, Certified Nurse Aide (CNA) Q stated staff was expected to verify the foot pedals were in place and the residents were in the proper positioning before wheeling them anywhere. On 12/11/24 at 02:01 PM, Administrative Nurse D stated staff were expected to ensure the foot pedals were utilized while transporting residents. The facility did not provide a policy related to accommodation of needs or assistive devices for wheelchairs. The facility failed to utilize and ensure the appropriate use of foot pedals during wheelchair transports for R1, R41, and R47. This placed the resident at risk for preventable accidents and injuries.

The facility identified a census of 63 residents. The sample included 18 residents with four residents reviewed for activities of daily living (ADL) care. Based on observation, record review, and interviews, the facility failed to ensure staff assisted Resident (R) 4 with grooming. This deficient practice placed R4 at risk for impaired dignity and a further decline in ADL. Finding Included: - R4's Diagnosis section within the Electronic Medical Record (EMR) noted diagnoses of ischemia (decreased supply of oxygenated blood to a body part), heart disease (the heart does not pump as well as it should), myocardial infarction (heart attack), hypertension (high blood pressure), cognitive decline, kidney disease stage four (severe damage to the kidneys and a significant decline in function), and obesity (excessive body fat). R4's Quarterly Minimum Data Set (MDS) dated [DATE] noted a Brief Interview of Mental Status (BIMS) score of four which indicated severe cognitive impairment. The MDS indicated R4 needed partial to moderate assistance with bathing, and setup and clean up with personal hygiene. The MDS documented R4 needed set up and clean up for toileting. R4's Cognitive Loss/Dementia Care Area Assessment (CAA) completed 05/07/24 indicated R4 had some issues with recall ability and orientation. R4 would sometimes refuse her shower. The CAA documented R4 had expressive dysphagia (swallowing difficulty) due to Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure). R4's Communication CAA completed 05/07/24 indicated R4 hears without any difficulty and was able to make her needs known. R4's CAA indicated she had difficulty finding words and finishing her thoughts, and she had poor memory and decision-making. R4's Care Plan dated 06/24/21 documented R4 needed staff assistance with set up to limited assistance with ADLs and staff would document R4 would receive appropriate assistance with ADLs such as grooming, repositioning, toileting, eating, transferring, and bathing. R4's plan of care documented she had no preference of when her shower time would be, or what day. R4's medical record consistently documented refusals for showering. On 12/09/24 at 12:01 PM, R4 sat in her wheelchair at the dining room table, R4's hair was matted at the back of her head, and the top of her hair was sticking straight up. On 12/09/24 at 01:24 PM, R4 stated she would take a shower. R4 stated that she was unable to comb her own hair. On 12/11/24 at 11:15 AM, Licensed Nurse (LN) J stated that R4 gets her hair styled at the salon twice a week and the next day her hair does not look like she has gone to the salon. She stated it was the responsibility of the staff member to get R4 ready to go to lunch and ensure she was clean, and her hair was combed before they took her from her room. On 12/11/24 at 12:34 PM, Certified Nurse's Aide (CNA) Q stated all nursing staff were responsible for ensuring the residents were clean, their hair was combed, and they had on clean clothes before each resident left their room. On 12/11/24 at 03:24 PM, Administrative Nurse D stated it was the expectation of the facility that each staff member be responsible for ensuring the residents look presentable before the resident leaves their room. The facility failed to provide a policy for activities of daily living. The facility failed to ensure staff assisted R4 with grooming. This deficient practice placed resident R4 at risk for impaired dignity and a further decline in ADL.

The facility identified a census of 63 residents. The sample included 18 residents with two residents reviewed for treatment and services to prevent and heal pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, because of pressure, or pressure in combination with shear and/or friction). Based on observation, record review, and interviews, the facility failed to ensure Resident (R)32's low air-loss mattress was set at the appropriate weight for pressure reduction. This placed R32 at increased risk for pressure ulcer development and delayed healing. Findings Included: - R32's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of hemiplegia (paralysis of one side of the body) on the left dominant side, muscle wasting, muscle weakness, difficulty in walking, dysphagia (swallowing difficulty), obesity (excessive body fat), aphasia (condition with disordered or absent language function), anemia (an inadequate number of healthy red blood cells to carry adequate oxygen to body tissues), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), major depressive disorder (major mood disorder that causes persistent feelings of sadness), and Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure). The Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 13 which indicated intact cognition. The MDS documented that R32 had an impairment on one side of her body. The MDS documented R32 was dependent on staff for upper and lower body dressing, and toileting. The MDS documented R32 needed substantial to maximum assistance with showers and oral hygiene and was dependent on staff to roll right to left. The MDS documented R32 was at risk for pressure ulcers and had a pressure-reducing device on her bed and in her chair. R32's Pressure Ulcer/ Injury Care Area assessment dated [DATE] documented R32 was at risk for skin issues and pressure injuries. R32 spends most of her time in her bed. R32 had a low air-loss mattress in place and a turning schedule. R32's CAA documented she was incontinent of bowel and bladder. R32's Care Plan dated 08/16/19 documented R32 was at risk for pressure ulcers and skin impairments, due to decreased mobility and incontinence. R32's plan of care documented she had a low air-loss mattress and staff should set the firmness of her mattress between 190-210 pounds. Staff were to assist R32 with repositioning when she was in bed and in her wheelchair. R32's plan of care dated 07/24/23 documented she should wear a resting splint to her left hand, and staff were to inspect her hand for redness daily. R32's Braden Scale for Prediction Pressure Sore Risk dated 11/05/2024 documented a score of 10 indicating a high risk for pressure ulcers. R32's EMR under Treatment Administration Record (TAR) documented the following physicians' orders: Barrier cream to buttocks after each incontinent episode/brief change, apply three times daily dated 06/19/24. R32's medical record lacked evidence of monitoring of R32's low air-loss mattress. R32's EMR under Vital Stats documented a weight of 201.8 dated 12/07/24. On 12/09/24 at 09:05 AM, R32 lay on her bed on her right side. R32's low air-loss mattress pump (Protect-Aire 2000) was set at 320 (pounds) and had a setting to adjust in 30-pound increments. On 12/11/24 at 1:28 AM, Licensed Nurse (LN) K stated she monitored the low air loss pump to ensure the mattress was plugged in and was set at the correct weight. LN K was unable to find where the bed was being monitored in R32's EMR. LN K stated the nurse in charge when the low air-loss mattress was put in place should have put monitoring of the mattress on the TAR. LN K stated the pump should be set by the current weight of the resident. On 12/11/24 at 12:48 PM, Certified Nursing Aid (CNA) Q stated if she went into a room and the pump was beeping, she would ensure the bed was plugged in and let her charge nurse know. She stated she does not turn the settings on the residents' low air-loss pump. On 12/11/24 at 03:24 PM, Administrative Nurse D stated nursing checks each mattress every day. Administrative Nurse D stated nurses sign off on the Treatment Administration Record (TAR) each shift, stating the mattress was plugged in and the pump was set at the correct weight. The facility's Skin Integrity policy dated 09/05/24 documented that all residents were considered to have some risk for the development of pressure ulcers/injuries. Nursing staff would evaluate skin integrity and tissue tolerance, implement preventative measures as indicated, and treat skin breakdown. The primary care provider admission orders authorize approval to begin using established skin and treatment guidelines. Licensed nurses performed dressing changes. Licensed nurses may delegate minor skin tear treatment and preventative treatments in closed areas who have received appropriate skin care training. The facility failed to ensure R32's low air-loss mattress was set at the correct weight setting to prevent pressure ulcers. This placed R32 at increased risk for pressure ulcer development.

The facility identified a census of 63 residents. The sample included 18 residents with eight residents reviewed for accidents. Based on observation, record review, and interviews, the facility failed to ensure that Resident (R) 33 had a safety assessment for the use of side rails that acknowledged the risks when used with a low air-loss mattress. This deficient practice placed R33 at risk for uninformed decisions and impaired safety related to the risks associated with the use of side rails. Findings Included: - The Diagnosis section within R33's Electronic Medical Records (EMR) documented diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), history of fractures (broken bones) related to falls, hearing loss, age-related physical debility, fatigue, urinary retention, and age-related macular degeneration (progressive deterioration of the retina). R33's Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of three indicating severe cognitive impairment. The MDS indicated she was fully dependent on staff assistance for transfers, bed mobility, bathing, toileting, personal hygiene, and dressing. The MDS documented she had one fall since her last assessment. The MDS documented bed rails were not in use. R33's Functional Abilities Care Area Assessment (CAA) completed 04/29/24 indicated she was at risk for falls related to her medical diagnoses and cognitive impairment. The CAA documented she had visual and hearing impairments. The CAA documented she required extensive to total assistance from staff for her activities of daily living (ADLs) and transfers. R33's Fall CAA completed 04/29/24 indicated she had one fall since and was at risk due to her impaired vision, hearing, cognition, and mobility. R33's Care Plan initiated on 12/19/23 indicated she was at risk for falls and required extensive to total assistance from staff for grooming, toileting, bathing, transfers, and repositioning. The plan instructed staff to follow her provided toileting plan, assist with ADLs, ensure her bed was in the lowest position, and encourage her to use her call light for assistance. The plan documented she had a positional rail (grab bar) mounted on the right side of her bed. The plan documented she had a low air-loss mattress to prevent pressure-related injuries. R33's EMR under Forms revealed an Assistive Device for Bed Screening form completed on 10/14/24. The screening documented that R33 had an ADL impairment and a history of falls. The screening documented she had poor trunk control, difficulty repositioning, and fluctuations in her level of consciousness. The screening documented she used the bed mobility device for transfers and repositioning. The screening failed not acknowledge the use of her low air-loss mattress. A review of the low air-loss mattress manufacturer's operation (Drive Model #14530 Series) manual indicated the usage of bed rails with the air mattress system should be assessed based on the risk of entrapment. On 12/10/24 at 11:03 AM, R33's mattress sat in the low position. Her Low air-loss mattress pump, Drive Model #14530 Series, was set at 80 pounds (lbs.) per her orders. Her bed had a right-sided hand-bar style side rail toward the head of her bed. On 12/11/24 at 11:30 AM, Licensed Nurse (LN) G stated staff looked at each resident's bed and attachment each shift to ensure the mattresses were set appropriately and each bed was safe. She stated that low air-loss mattresses were set by weight and that the bed rails should have no gaps. On 12/11/24 at 02:01 PM, Administrative Nurse D stated the facility did not assess side rails or handrails in relation to the use of low air-loss mattresses. She stated they look at the placement of the rails and ensure no gaps exist. The facility's Assistive Device Used for Bed policy revised 09/2024 indicated the facility would assess the need for the use of all assistive devices to ensure functionality, safety, and appropriate use. The policy indicated the facility would ensure identification of the risks and hazards associated with railing. The policy documented the use of low air-loss mattresses would be included in the evaluation of potential risks. The facility failed to ensure that R33 had a safety assessment for the use of side rails that acknowledged the risks when used with a low air-loss mattress. This placed R33 at risk for uninformed decisions and impaired safety related to the risks associated with the use of side rails.

The facility identified a census of 63 residents. The sample included 18 residents with five residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 41 had a Centers for Medicare and Medicaid (CMS) approved indication or the required physician-documented rationale including risk versus benefits and nonpharmocologcal attempts prior to the use of the antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medication Zyprexa. This placed R41 at risk for unnecessary medication administration and possible adverse side effects. Findings included: - R41's Electronic Medical Record (EMR) documented diagnoses of vascular dementia with irritation (a condition where a person experiences increased motor activity, restlessness, aggressiveness, and emotional distress), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and delirium (sudden severe confusion, disorientation, and restlessness). R41's Significant Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of three which indicated a severely impaired cognition. R41 had a limitation in range of motion with impairment on one side of the upper extremity. R41 required substantial assistance to complete dependence on staff for activities of daily living (ADLs) and functional abilities. R41 was receiving hospice services. The MDS documented R41 had a diagnosis of dementia (a progressive mental disorder characterized by failing memory and confusion). The MDS documented R41 had received antipsychotic medication, antidepressant (a class of medication used to treat mood disorders) medication, antianxiety (a class of medication that calms and relaxes people) medication, and opioid (a class of controlled drugs used to treat pain) medication during the observation period. The MDS documented no gradual dose reduction was completed and there was physician documentation that a gradual dose reduction was contraindicated for R41. R41's Quarterly MDS dated [DATE] documented a BIMS score of three which indicated a severely impaired cognition. R41 had a limitation in range of motion with impairment on both sides of the upper extremity. R41 required substantial assistance to complete dependence on staff for ADLs and functional abilities. R41 was receiving hospice services. The MDS documented R41 had a diagnosis of dementia. The MDS documented R41 had received antipsychotic medication, antidepressant medication, antianxiety medication, and opioid medication during the observation period. The MDS documented no gradual dose reduction was completed and there was physician documentation that a gradual dose reduction was contraindicated for R41. R41's Psychotropic Care Area Assessment (CAA) dated 06/24/24 documented he took antianxiety, antidepressant, and antipsychotic medications daily. He has a diagnosis of severe dementia with agitation, depression, and anxiety. R41 has had falls since the last review and scored high risk for falls. R41 was at risk for changes in mood/behaviors and the effects of medications. R41's Care Plan revised on 04/22/24 directed staff he took Zyprexa and needed to be monitored for side effects. Staff were directed to report any medication side effects to the charge nurse for further evaluation. R41's Orders tab of the EMR documented an order dated 08/12/24 for Zyprexa five milligrams (mg) by mouth daily for delirium and anxiety. R41's EMR lacked a physician documented rationale along with risks versus benefits and nonpharmacological interventions attempted and failed. On 12/10/24 at 07:12 AM, R41 sat in his Broda chair (specialized wheelchair with the ability to tilt and recline) in the hallway across from the nurse's station asleep. R41 had a dressing on his right temple and his hair was uncombed. On 12/10/24 at 01:56 PM, R41 sat in his Broda chair yelling out as staff walked by without addressing him. On 12/11/24 at 03:25 PM, Administrative Nurse D stated she expected the physician to document the risk versus benefit rationale for the use of antipsychotic medications. Administrative Nurse D stated that R41's restlessness had increased, and the resident was admitted to hospice services. The Psychoactive Psychopharmacological Medications policy revised 07/05/22 documented that psychoactive medications would not be used for discipline or for convenience and would not be used unless necessary to treat medical symptoms. Psychoactive medications would be monitored by the interdisciplinary team (IDT) through the care planning process. The benefits and side effects of these medications would be discussed with the primary care provider, so drug selection and dosages were adjusted as necessary to provide the best therapeutic effect for the resident. The facility failed to ensure R41 had a CMS-approved indication or the required physician documented rationale including risks versus benefits for the use of Zyprexa. This placed R41 at risk for unnecessary medication administration and possible adverse side effects.

The facility identified a census of 63 residents. The sample included 18 residents with two residents reviewed for hospice. Based on observation, record review, and interviews, the facility failed to ensure coordinated care and services provided by the facility with the care and services provided by hospice for Resident (R) 43 and R38. This placed the residents at risk for inadequate end-of-life care. Finding Included: - R43's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), kidney failure (a condition where one or both kidneys no longer work on their own), chronic obstructive pulmonary disease (COPD - a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), hypertension (high blood pressure), major depressive disorder (major mood disorder that causes persistent feelings of sadness), Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness), and chronic respiratory failure with hypoxia (when there was not enough oxygen in the blood). The Significant Change in Status Minimum Data Set (MDS) dated [DATE] recorded a Brief Interview for Mental Status (BIMS) score of 12, which indicated moderately impaired cognition. The MDS documented R43 was dependent on staff for personal hygiene, toileting, and dressing. The MDS documented R43 received hospice services during the observation period. R43's Cognitive Loss/Dementia Care Area Assessment (CAA) dated 10/09/24 documented R43 had issues with recall ability at times. The CAA documented R43 was newly readmitted to hospice services and nursing would see R43's medication list, as-needed (PRN) medications, and ensure medicines were ordered for R43's mood state. The MDS documented staff would see the nurse practitioner's note for a diagnosis of dementia (a progressive mental disorder characterized by failing memory and confusion); R43 had an alteration in thought processes due to dementia. R43's Care Plan dated 07/11/22 documented R43 required maximum assistance of one staff with activities of daily living (ADL) such as eating, bathing transfers, bathing, and toileting. Nursing staff were to encourage R43 to wear footwear in the mornings. R43's plan of care dated 10/10/24 documented R43 would receive hospice services. R43's plan of care dated 10/11/24 documented the hospice provider would coordinate services with the facility. The care plan lacked instruction on the services provided by hospice; including the frequency and type of support visits, supplies and medical equipment provided by hospice, medications covered by hospice, and the hospice contact information. A review of the hospice-provided communication binder revealed R43 was admitted to hospice services on 10/15/24. On 12/09/24 at 09:44 AM, R43 sat in her chair in her room, covered with a blanket. On 12/10/24 at 11:42 AM, R43 sat at the dining room table, waiting for her lunch. On 12/11/24 at 11:15 AM, Licensed Nurse (LN) J stated anything hospice provided for a resident should be care planned, such as when the aid or nurse would come to the facility, equipment, medications, and supplies. LN J stated she does not do care plans and was unsure where staff would find the information if it was not in the resident's care plan. On 12/11/24 at 12:54 PM, Certified Nursing Aide (CNA) Q stated she did not know if the care plan stated what hospice provided for a resident. CNA Q stated when she charted her tasks, she was able to see the resident's needs. CNA Q stated she would ask her nurse about the specific equipment hospice provided or look at the tag on the back of the resident's chair. On 12/11/24 at 03:24 PM, Administrated Nurse D stated the resident's care plan should state what was provided by hospice, what medication, equipment, and supplies, and when the hospice staff would be in the building. Administrated Nurse D stated staff could find the information in the hospice-provided binder, but she did not believe this information was in the facility's care plan. The facility's Care Management policy reviewed on 10/11/21 documented that management of resident care was conducted systematically and comprehensively by an interdisciplinary team knowledgeable in current concepts of geriatric care. Management used the five steps of the nurse process: assessment, diagnosis, goal setting, implantation, and evaluation; and was always consistent with the medical plan of care. The facility failed to coordinate care between the facility and the hospice provider for R43, who received hospice services. This deficient practice placed the resident at risk for inadequate end-of-life care. 41037 - R38's Electronic Medical Record (EMR) documented diagnoses of respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood), chronic kidney disease (a long-term condition where the kidneys gradually lose their ability to filter blood properly), and hypertension (HTN - elevated blood pressure). R38's Significant Change Minimum Data Set (MDS) dated [DATE] documented that she had short and long-term memory problems. R38 had impairment on one side of her upper extremity. R38 was dependent on staff for activities of daily living (ADLs) and functional abilities. R38 received hospice services. R38's Cognitive Care Area Assessment (CAA) dated 11/19/24 documented she had impaired cognition and was non-verbal. R38 recently had a decline and was on hospice services. R38's Care Plan revised on 11/19/24 directed staff that hospice would provide durable medical equipment (DME) of a mattress, wheelchair, briefs, and oxygen. The care plan directed staff that hospice staff was to visit per the hospice plan of care (POC). The care plan lacked staff direction on what services the hospice staff would provide and when, as well as what medications were covered. R38's EMR under the Orders tab revealed the following physician orders: May consult hospice dated 11/08/24. On 12/10/24 at 07:11 AM, R38 sat in her recliner in her room. R38's TV was on, but the lights were turned off. On 12/11/24 at 11:15 AM, Licensed Nurse (LN) J stated anything hospice provided for a resident should be care planned, such as when the aid or nurse would come to the facility, equipment, medications, and supplies. LN J stated she does not do care plans and was unsure where staff would find the information if it was not located in the resident's care plan. On 12/11/24 at 12:54 PM, Certified Nursing Aide (CNA) Q stated she did not know if the care plan stated what hospice provided for a resident. CNA Q stated when she charted her tasks, she was able to see the resident's needs. CNA Q stated she would ask her nurse about the specific equipment hospice provided or look at the tag on the back of the resident's chair. On 12/11/24 at 03:24 PM, Administrated Nurse D stated the resident's care plan should state what was provided by hospice, what medication, equipment, and supplies, and when the hospice staff would be in the building. Administrated Nurse D stated staff could find the information in the hospice-provided binder, but she did not believe this information was in the facility's care plan. The facility's Care Management policy reviewed on 10/11/21 documented that management of resident care was conducted systematically and comprehensively by an interdisciplinary team knowledgeable in current concepts of geriatric care. Management used the five steps of the nurse process: assessment, diagnosis, goal setting, implantation, and evaluation; and was always consistent with the medical plan of care. The facility failed to coordinate care between the facility and the hospice provider for R38, who received hospice services. This deficient practice placed the resident at risk for inadequate end-of-life care.

The facility identified a census of 63 residents. The sample included 18 residents with five residents reviewed for influenza (a contagious respiratory illness that infects the nose, throat, and sometimes the lungs) and pneumococcal (a disease that refers to a range of illnesses that affect various parts of the body and are caused by infection) immunizations. Based on record review and interviews the facility failed to ensure Resident (R) 51 received the pneumococcal vaccine after consenting to the vaccination. This deficient practice placed R51 at risk for acquiring, transmitting, or experiencing complications from the pneumococcal disease. Findings included: - On 12/11/24 an review for influenza and pneumococcal immunizations was completed for R17, R27, R31, R43, and R51. R51's Immunization tab in the EMR revealed he received a pneumococcal (PPSV23) vaccination on 12/17/14 and a pneumococcal vaccination (PCV13) on 01/20/16. The EMR lacked documentation that other pneumococcal vaccinations (PCV20 or PCV21) were offered or given. On 12/10/24 at 08:05 AM, R51 stated he admitted to the facility in 2023 and had not received pneumococcal vaccinations since his admission. He stated someone talked to him a few months ago but he has not received any update on it. On 12/11/24 at 01:25 PM, Administrative Nurse D provided a Pneumococcal Consent Form for R51 completed on 08/28/24. The form indicated R51 consented to receive the newer PCV20 pneumococcal vaccination on 08/28/24 but never received the vaccination. On 12/11/24 at 02:01 PM, Administrative Nurse D stated she gave R51 his vaccination earlier in the morning (12/11/24). Administrative Nurse D was unable to explain why the vaccination had not been given since August. The facility's Immunization-Pneumococcal revised 07/2024 indicated all residents would be screened for pneumococcal vaccinations. The policy indicated the facility would assess each resident's history, health status, and preferences. The facility failed to ensure R51 received the pneumococcal vaccine after consenting to the vaccination. This deficient practice placed R51 at risk for acquiring, transmitting, or experiencing complications from the pneumococcal disease.

The facility identified a census of 60 residents. The sample included three residents reviewed for accidents. Based on record review, interviews, and observations, the facility failed to ensure Resident (R)1 remained free from avoidable accident hazards when staff failed to provide safe transfers using the required number of staff and the required equipment per the resident's plan of care. Subsequently, R1 sustained fractures to both her ankles/lower legs. This deficient practice also placed R1 at risk for increased pain and impaired well-being. Findings include: - R1's Electronic Medical Record (EMR), under the Diagnosis tab, recorded diagnoses of malignant neoplasm (tumor) of the lower right lung, chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), age-related osteoporosis (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk), thrombocytopenia (abnormally low number of platelets, the parts of the blood that help blood to clot, sometimes associated with abnormal bleeding), long term use of anticoagulants (a class of medications sued to prevent the blood from clotting), and hypertension (elevated blood pressure). The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 11, which indicated mildly impaired cognition. R1 had no impairment to the upper or lower extremities and used a wheelchair for mobility. R1 required partial to moderate assistance for upper body dressing. R1 required substantial to maximal assistance for showers, lower body dressing, sitting-to-standing, and all transfers. R1 was dependent on staff assistance for putting on and taking off her footwear. R1 displayed no mood concerns or behaviors. The Cognitive Loss/Dementia Care Area Assessment (CAA) dated 02/14/24 documented R1 had some issues with orientation and recall ability at times. R1 was able to make her needs known verbally and could hear the speaker with no issues noted. The Activities of Daily Living [ADL] CAA dated 02/14/24 documented R1 required limited to extensive assistance with ADLs, transfers, and mobility. R1 transferred with a sit-to-stand lift and used a wheelchair with the assistance of one staff member for mobility. The Falls CAA dated 02/14/24 documented R1 scored a moderate risk for falls. R1's left leg was shorter than her right leg after hip surgery. R1 required transfers with extensive assistance and the sit-to-stand lift. R1's speech was clear, and she was able to make her needs known. The Quarterly MDS dated [DATE] documented a BIMS score of 13 which indicated intact cognition. R1 had no impairment to the upper or lower extremities and used a wheelchair for mobility. R1 required substantial to maximal assistance for showers, upper body dressing, and transfers. R1 was dependent on staff assistance for lower body dressing and putting on and taking off footwear. R1 displayed no mood concerns or behaviors. R1's Care Plan implemented 02/28/23 documented R1 used the sit-to-stand lift with extensive assistance of two staff members for transfers. On 09/03/24 at 06:55 AM a Social Service Note documented R1 was tearful regarding her feet and ankles. Hospice care was notified and requested to check on R1's ankles and feet during the next visit. On 09/03/24 at 10:33 AM a Registered Nurse Note documented staff received orders for X-rays of R1's bilateral ankles related to pain and swelling. On 09/03/24 at 03:34 PM the Xray Report documented R1 had significant findings of the left ankle with the impression of osteoarthritic (degenerative changes to one or many joints characterized by swelling and pain) changes, bones were osteopenic (reduced bone density), and there was acute fractures (broken bones) of the distal (away from the farthest point of origin or attachment) tibia (bone of the lower leg) and fibula (one of the two bones of the lower leg) with associated soft tissue swelling. On 09/03/24 at 03:42 PM the Xray Report documented R1 had significant findings of the right ankle with the impression of a spiral fracture (a type of complete fracture that occurs when a long bone is broken by a twisting force) across the distal tibial shaft, a nondisplaced fracture (type of fracture where the bone cracks in only one place and does not move to change alignment) of the fibular shaft, arthrosis (joint or articulation) across the hindfoot (posterior portion of the foot), midfoot (the anterior part of the foot), Achilles calcific tendinopathy (deterioration of the Achilles tendon in the heel), generalized osteoporosis (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk), atherosclerotic disease (buildup of fats, cholesterol, and other substances in and on the artery walls), and a calcaneal (the bone that forms the heel of the foot) spur (bony projections that develop along bone edges). On 09/03/24 at 04:55 PM Registered Nurse Note documented Administrative Nurse D requested to transfer R1 to the hospital due to R1's fractured ankles. On 09/03/24 at 09:23 PM a Registered Nurse Note documented R1 was ready to return to the facility. R1's legs were splinted. The Facility Investigation dated 09/11/24 documented, according to a staff interview, R1 required a pivot transfer on 09/01/24. Certified Nurse Aide (CNA) M entered R1's room and found R1 had her legs dangling over the side of the bed. CNA M reported R1 was adamant about getting up. The investigation documented two CNAs transferred R1 from the bed to R1's wheelchair, at R1's request, to prevent R1 from falling. The facility investigation documented R1 reported bilateral ankle pain, with R1's left ankle showing mild edema on 09/03/24. R1's physician obtained X-ray orders. The portable X-ray results received on 09/03/24 at 03:30 PM and identified a fracture. R1's physician gave orders to send R1 out to the emergency room for further evaluation. The investigation documented CNA M but lacked identification of any other staff who assisted in the transfer. A notarized Witness Statement dated 09/11/24 documented an interview obtained from CNA M via a phone conversation with Administrative Nurse D. CNA M reported that on 09/01/24 at approximately 10:00 AM while walking by R1's room, R1 had swung her legs out of the bed. CNA M went into R1's room and attempted to have R1 lay back down in bed, but R1 refused. CNA M reported an unidentified CNA helped CNA M stand and pivot R1 into her wheelchair because CNA M was afraid R1 would fall on the floor. The Facility Investigation lacked further staff interviews or statements from the unidentified CNA related to R1's transfer or care on 09/01/24. Review of the facility's staffing schedule for 09/01/24 indicated staff on duty were Licensed Nurse (LN) G, CNA M, CNA N, CNA O, and Certified Medication Aide (CMA) R. On 09/12/24 at 11:10 AM R1 did not respond to a knock on her door or her name. R1 lay in bed on her back with a blanket covering her midsection; her head and feet were uncovered. R1's feet were at a 90-degree angle and wrapped with braces on both feet. On 09/12/24 at 02:30 PM R1 laid in bed on her back with her feet elevated. R1 had family at her bedside. R1's feet were uncovered, and braces were visible on both feet. On 09/12/24 at 01:41 PM CNA O stated she did not help with transferring R1 on 09/01/24. On 09/12/24 at 01:58 PM CNA N stated no one helped CNA M get R1 up into the wheelchair. CNA N observed CNA M leave R1's room and R1 was up in her wheelchair with no sling underneath her to assist with getting R1 back into bed. CNA N stated she assisted CNA M in transferring R1 back into bed. CNA N stated that the transfer was an arm-in-arm transfer she did with CNA M. CNA N said CNA M and she stood on either side of R1 and lifted and pivoted R1 into bed. CNA N confirmed they did not use a gait belt or the lift. On 09/12/24 at 02:05 PM CNA M was unavailable for interview. On 09/12/24 at 02:05 PM LN G stated that she did not know who had helped CNA M transfer R1 out of bed. On 09/12/24 at 02:18 PM CMA R stated she had not helped CNA M transfer R1 out of bed. CMA R revealed that she arrived at R1's room to administer medications and observed CNA M pushing R1 out of her room in her wheelchair with no gait belt (belt used to help transfer or stabilize during activity), no sling. CMA R stated there were no other staff members in the room nor had one just exited R1's room when CMA R approached to administer R1's medication. On 09/12/24 at 03:35 PM Administrative Nurse D stated that she had completed a thorough investigation and felt she knew the cause of R1's injuries. Administrative Nurse D revealed that she only interviewed CNA M even after it was reported that the transfer was done with two staff members, but the second staff member was not identified. After learning of the statements provided by the other staff who worked with R1 on 09/01/24, Administrative Nurse D revealed she had more questions about the event but still felt she knew the cause of the injuries and that there was no abuse or neglect. Administrative Nurse D stated that if R1 was transferred with only one staff, it was to keep R1 safe and that would be acceptable if R1 was about to fall off the bed. Administrative Nurse D confirmed that in the statement received from CNA M appeared that R1 was not unsafe or about to fall off the bed. Administrative Nurse D also confirmed that an arm-in-arm transfer without the use of a gait belt was not a safe transfer for R1. The facility's policy Lifting & Transferring Residents revised 10/25/23 documented a safe work environment for resident care areas by providing and requiring the use of safety materials, equipment, and training designed to prevent injury. The policy directed that staff would utilize the proper transfer procedure for each resident. This included the use of the resident transfer devices or other lifting equipment and applying proper body mechanics. The facility did not provide a policy on accidents. The facility failed to ensure R1 remained free from avoidable accidents resulting in bilateral ankle and/or lower leg fractures. This also placed R1 at risk for increased pain and impaired well-being.

The facility identified a census of 62 residents. The sample included three residents reviewed for accidents. Based on record review, interview, and observation, the facility failed to provide an environment free from safety hazards when staff left Resident (R) 1 in a mechanical recliner, with the footrest raised, without assessing R1's ability to lower the footrest. On 01/10/24 R1 attempted to get out of the recliner by climbing over the footrest and fell . As a result, R1 sustained a fractured sternum (breastbone) and left fourth rib. This also placed R1 at risk for pain, decreased mobility, and impaired quality of life. Findings included: - R1's Electronic Medical Record (EMR), under the Diagnosis section, recorded diagnoses of fracture of the coccyx (small triangular bone at the base of the spine), fall, acute posthemorrhagic anemia (type of anemia that occurs when a person loses a large amount of blood quickly), Parkinson's disorder (a slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness), personal history of malignant (the tendency of a medical condition, especially tumors, to become progressively worse, most familiar as a characteristic of cancer) neoplasm (tumor) of brain, and overactive bladder. The Admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of nine, which indicated moderately impaired cognition. R1 required substantial to maximum assistance with supervision or touching assistance with sit to stand transitions, and chair/bed to chair transfer. The Activities of Daily Living (ADL) Care Area Assessment (CAA) dated 01/10/24 documented R1 required limited to extensive assistance with wheelchair mobility. R1 had some memory and decision-making difficulties. The Falls CAA dated 01/10/24 documented R1 scored at moderate risk for falls. R1's Interdisciplinary Admit and Baseline Care Plan dated 01/05/24 documented R1 required extensive assistance from two staff members with transferring, bed mobility, and toileting. R1 required extensive assistance from one staff member to walk in the room or corridor and for locomotion on and off the unit. R1 was at risk for falls and had a history of falls with an injury of a fractured tailbone. R1's Admission Fall Risk assessment dated [DATE] documented a score of 12, which indicated R1 had a moderate fall risk. R1's EMR lacked evidence the staff assessed R1's ability to lower the footrest on the manual recliner. An Interdisciplinary Team (IDT) Nurse's Note dated 01/10/24 at 11:33 PM documented at the beginning of shift change, Certified Nurse Aide (CNA) M stated R1 was on the floor. Licensed Nurse (LN) G assessed R1 and then LN G and CNA M assisted R1 up to her wheelchair. CNA M assisted R1 to the bathroom and then back to bed. The IDT Nurse's Note dated 01/11/24 at 12:48 AM documented R1 sustained an unwitnessed fall at approximately 10:10 PM (on 01/10/24). When asked what happened, R1 reported she was trying to get out of the recliner. The note documented R1's recliner footrest was extended. The IDT Nurse's Note dated 01/11/24 at 03:05 AM documented R1 stated her right shoulder hurt. R1's shoulder was assessed with no noted discoloration or raised areas; the skin was intact. The IDT Nurse's Note dated 01/11/24 at 09:27 AM documented R1's primary care physician (PCP) was aware of R1's fall and R1 reported pain in her left rib and chest area. R1's PCP gave an order for a portable two-view chest X-ray due to physical limitations secondary to pain after a fall. Staff notified the X-ray technician of the order. The IDT Nurse's Note dated 01/11/24 at 12:24 PM documented R1's X-ray was obtained, and staff awaited a response of results. The IDT Nurse's Note dated 01/11/24 at 02:22 PM documented that R1's X-ray revealed no acute process. R1's lungs were adequately expanded and clear without suspicious mass lesions (lesions greater than three centimeters in length) or infiltration (the diffusion or acclimation of foreign substances in amounts excess of the normal). The mediastinal structures (space within your chest that contains your heart and both lungs) and heart were noted to be within normal limits. Staff notified R1's PCP with no new orders noted. The facility investigation dated 01/31/24 documented CNA M observed R1 laying on the floor to the left of R1's recliner on 01/10/24 at 10:20 PM. The recliner footrest was extended. CNA M immediately notified LN G who assessed R1 with no injuries identified. When asked what happened, R1 stated she was getting out of the recliner and fell . When asked if she knew where she was, R1 replied she was at home and when asked the day of the week, R1 replied Saturday though the day was Wednesday. R1 was incontinent at the time of the event. R1 had her call pendant in reach but failed to activate it. R1 reported pain in her right shoulder during the night after the fall. Staff offered R1 as-needed pain medication to which R1 declined. R1's PCP ordered a bone scan related to continued chest wall pain. R1's bone scan was completed on 01/22/24 and revealed a fractured sternum and left fourth rib. CNA M's Witness Statement dated 01/10/24 documented on 01/10/24 at 10:10 PM CNA M found R1 on the floor in R1's room while doing room checks. R1 lay on her left side and to the left side of her recliner. The footrest for R1's recliner was in the raised position. LN H's Witness Statement dated 01/10/24 documented on 01/10/24 at 10:10 PM LN H went to R1's room and observed R1 on the floor to the left of the recliner. The recliner footrest was extended. LN G's Witness Statement dated 01/10/24 documented on 01/10/24 at 10:00 PM CNA M alerted LN G that R1 was on the floor, to the left of R1's recliner. R1 laid on her left lateral side. R1's EMR and the facility's investigation lacked information related to when R1 was last checked, assisted to the bathroom, or observed in her recliner before the fall on 01/10/24. On 02/01/24 at 02:45 PM, CNA N stated she thought R1 was not strong enough to maneuver the manual recliner and put the footrest down. CNA N stated she doubted R1 could have lowered the footrest on her own. On 02/01/24 at 02:55 PM Administrative Nurse D stated that R1 had a manual recliner before the fall and afterwards, R1's family brought in an electric recliner. Administrative Nurse D stated she was unable to determine when R1 was last toileted or checked because CNA P refused to give a statement. Administrative Nurse D said CNA P stopped coming to work after R1's fall and refused to give a statement of what happened the evening R1 fell . On 02/01/24 at 03:10 PM, Consultant GG stated that R1 may have had the strength to maneuver the manual recliner handle but R1 had a lot of pain related to her fractured tailbone. Consultant GG revealed that R1 was working on repetitive motions with therapy and required a lot of cues to complete tasks including cueing to use the call light. Consultant GG stated R1 was forgetful. On 02/01/24 at 03:51 PM, CNA O stated that she assisted R1 into the recliner the day R1 had the fall (01/11/24). CNA O estimated the time she assisted R1 to the recliner was approximately 06:00 PM. CNA O further stated that R1 requested the footrest be raised. CNA O stated the footrest was lifted for R1 and she asked R1 if the resident could lower the footrest, and the resident said she could. CNA O admitted she never saw R1 raise or lower the footrest. CNA O further revealed she later asked CNA P to assist R1 to bed. CNA O told CNA P that R1 was in the recliner and that R1 liked to go to bed around 09:00 PM or 09:30 PM. CNA O believed that CNA P was the staff member assigned to assist R1 to bed. The facility's policy Falls revised 10/12/22 documented residents would be identified for risk of falls and interventions would be implemented to reduce risk. The Fall Prevention Reference Sheet by Type of Fall Appendix B lacked reference to recliner evaluations to assess resident safety. The facility failed to provide R1 with adequate supervision or evaluation of the ability of R1 to safely lower the footrest of the manual recliner, which resulted in a fall. R1 sustained a fractured sternum and fourth left rib as a result of the deficient practice.

The facility identified a census of 62 residents. The sample included three residents. Based on observations, record review, and interviews, the facility failed to ensure Resident (R) 1 remained free from abuse when Certified Nurse Aide (CNA) M struck R1 on her arm after R1 had physical behaviors towards her. This deficient practice resulted in impaired psychosocial well-being and placed R1 at risk for continued abuse. Findings included: - R1's Electronic Medical Record (EMR) documented diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure) and encounter for palliative care (treatment designed to relieve or reduce intensity of uncomfortable symptoms). The Annual Minimum Data Set (MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) was not conducted due to R1 was rarely/never understood. R1 had physical behaviors directed towards others one to three days in the assessment period. R1 required extensive assistance with two staff for bed mobility, transfers, dressing, and toileting; extensive assistance with one staff for personal hygiene; and total dependence with one staff for locomotion. The Quarterly MDS dated [DATE], documented a BIMS was not conducted due to R1 rarely/never understood. R1 had physical and verbal behaviors directed towards others and other behavioral symptoms not directed towards others one to three days in the assessment period. R1 required extensive assistance with two staff for bed mobility, dressing, and toileting; extensive assistance with one staff for personal hygiene; and total dependence with one staff for locomotion. The Cognitive Loss/Dementia [progressive mental disorder characterized by failing memory, confusion] Care Area Assessment [CAA] dated 04/03/23 documented R1 was unable to answer BIMS questions and staff assessment for cognition and showed problems with orientation and recall ability. The Activities of Daily Living [ADL] Functional/Rehabilitation Potential CAA dated 04/03/23, documented R1 required extensive assistance with ADL and transfers. R1's speech was clear, and she had difficulty finding words or finishing thoughts. The Behavioral Symptoms CAA dated 03/31/23, documented R1 had physical behaviors in the last week. R1's Care Plan dated 04/12/22 documented R1 had the physical behavior of swinging at staff when resisting cares at times and verbally resisting cares related to her diagnosis of dementia. The Care Plan directed staff were to be alert to R1's triggers such as coaxing her to eat and waking her and to avoid them as much as possible by allowing her to feed herself and allowing her to wake naturally. The Care Plan documented an intervention dated 09/18/23 that directed if R1 became agitated or unsettled, staff were to try these interventions to de-escalate: allow her time to settle, look at her family album with her, give her plenty of time to respond to staff, make sure her hearing aides were in, and explain procedures in advance. The facility's Investigative Report, dated 11/15/23, documented on 11/08/23 CNA N reported to Administrative Nurse D that she assisted CNA M to get R1 dressed for the day. As CNA N and CNA M transferred R1 to her Broda (specialized wheelchair with the ability to tilt and recline) chair, R1 suddenly struck CNA M, a behavior that was not uncommon and was care planned. CNA N described that CNA M quickly released her contact with R1, dropping her into her chair and proceeded to slap R1 twice on each arm while yelling at her to not hit people. R1 had no further aggression and did not react to CNA M's aggression. CNA M left the room and CNA N finished seating R1 in her preferred position in the Broda chair. The report documented CNA M was familiar with R1 and had provided ADL care to her many times. The report documented CNA M was immediately escorted out of the building and placed on suspension pending completion of the investigation. Administrative Nurse D assessed R1, who rested quietly in her recliner with her eyes closed. R1 did not react to Administrative Nurse D touching her arms and her arms were pink and warm without bruising. In a signed Witness Statement obtained by the facility on 11/08/23, CNA M stated she and CNA N went into R1's room to get her changed and R1 was in her Broda chair, ripping up her incontinence brief. She stated she told R1 they were going to change her and when CNA M grabbed R1 to stand, R1 swung at her face and tried to kick her. CNA M stated she gently pushed R1's legs and hands away and told her not to hit people then R1 pinched CNA M on her buttocks. In a signed Witness Statement obtained by the facility on 11/08/23, CNA N stated she was helping CNA M get R1 up and dressed for the day and R1 hit CNA M when she picked R1 up. CNA N stated CNA M dropped R1 back in her chair and slapped R1 twice on each arm and yelled at her. In a signed Witness Statement on 11/27/23, CNA N stated she and CNA M were in R1's room to get her up for the day and R1 had ripped up her incontinence brief which upset CNA M. She stated CNA M told her she was going to lift R1 while CNA N pulled her pants up. When CNA M picked R1 up, R1 pinched and hit CNA M and CNA M dropped R1 back into her Broda chair and hit R1 for sure on the left arm. CNA N stated she heard two slaps. CNA N stated R1 grabbed her left arm, rubbed it, and stated ow . On 11/27/23 at 11:02 AM, R1 laid in her bed with her eyes closed and appeared to be resting comfortably. On 11/27/23 at 11:16 AM, CNA N stated on 11/08/23, she and CNA M went into R1's room to get her ready and when CNA M picked her up from her Broda chair so CNA N could pull up her pants, R1 pinched and hit CNA M. She stated CNA M dropped R1 back into her chair then slapped R1. CNA N stated she was not sure if it was two separate arms or just her left arm, but it was loud slapping and R1 rubbed her left arm and said ow quietly. CNA N stated there was no way CNA M's actions could have been mistaken as anything other than a slap. On 11/27/23 at 11:37 AM, CNA M was unavailable for interview. On 11/27/23 at 11:45 AM, CNA N stated her statement differed from her original statement because on the morning of 11/08/23, she was under a lot of pressure and in her head, it was both arms that were slapped because it was two slaps. She stated she actually saw CNA M make contact with R1's left arm. On 11/27/23 at 11:46 AM, Licensed Nurse (LN) G stated she worked on 11/08/23 but was told about the incident the next day. She stated she did not witness any injuries on R1. On 11/27/23 at 12:44 PM, CNA N stated the charting system listed behavior triggers and interventions. She stated right now, R1's trigger was anything to do with her foot because of wounds. CNA N stated if R1 hit staff, staff were to calm her down and talk to her. She stated the care plan does not direct staff to slap or push R1's arms or hands. On 11/27/23 at 01:13 PM, LN G stated she was not sure if the CNAs had access to the care plans, but the care plans had behavior triggers and interventions on them. She stated R1's behaviors included swinging at staff, yelling out, and sometimes crying. LN G stated if R1 had behaviors, staff were to gently calm her and talk to her. She stated if R1 was hitting staff, staff could have stopped what they were doing and gave her time to calm down along with general reassurance and staying out of her space. On 11/27/23 at 01:18 PM, Administrative Nurse D stated on 11/08/23, CNA N came into her office shortly after 08:00 AM and stated she saw CNA M hit R1. She had CNA N stay in her office while she got CNA M to write a witness statement then escorted CNA M out of the building. Administrative Nurse D stated CNA M wrote in her witness statement that they were changing R1 and R1 swung at CNA M's face, so she gently pushed her hands and legs away. Administrative Nurse D stated the facility substantiated the abuse and education was conducted on abuse, neglect, and exploitation (ANE) but not on behavior management. She stated CNAs had access to the care plans which contained what behaviors residents typically exhibited and how staff were to intervene. Administrative Nurse D stated R1's care plan directed during behaviors, staff were to let her be and reapproach which did not happen on 11/08/23. She stated she expected if R1 had behaviors, staff allowed time for her to settle down, look at her family album, give her plenty of time, make sure she had her hearing aids in, and explained procedures in advance. Administrative Nurse D stated CNA N reported to her that she and CNA M had went in to change R1 and when CNA M lifted R1 up, R1 started hitting CNA M. CNA N stated to Administrative Nurse D that CNA M then dropped R1 back into her chair, slapped her twice on each arm, and yelled at her. Administrative Nurse D stated CNA N did not report that R1 said ow after the slap. The facility's ANE: Abuse Prevention, Intervention, Reporting, and Investigation- Staff Treatment of Residents policy, last revised 09/07/22, directed residents had the right to be free from verbal, sexual, physical, mental abuse, corporal punishment, exploitation, and involuntary seclusion. The policy directed prevention measures were in place which provided residents, families, and staff information related to reporting and handling concerns and grievances and included identifying, correcting, and/or intervening in situations in which abuse was more likely to occur. The facility failed to prevent physical abuse when CNA M hit R1 on 11/08/23. The scope and severity were determined to be actual harm based on the reasonable person concept due to the circumstances of R1's impaired cognitive status and inability to self-identify and express her feelings.

The facility identified a census of 63 residents. The sample included 16 residents with five residents reviewed for falls. Based on observation, interview, and record review the facility failed to respond to falls, assess, and identify injury, and apply standards of care for fall follow up for Resident (R)28. On 07/02/23 at 01:30 AM R28, who had severe cognitive impairment, had an unwitnessed fall in her room. Licensed Nurse (LN) K found R28 on the floor at which time R28 stated she was trying to get to her recliner. LN K assessed the resident and noted an abrasion to the left shoulder. R28 complained of left hip pain at that time. LN K assisted R28 to the recliner but failed to notify R28's physician and representative of the incident. LN K failed to follow up immediately after the occurrence with neurological checks and post fall assessments to identify changes and or injuries and failed to treat the reported pain in R28's left hip. Several hours later, Administrative Nurse E assessed R28, noted a deformity to the residents left leg and sent the resident to the acute hospital where R28 was diagnosed with a left hip fracture. The facility failure to provide post fall assessment and treatments per the standard of care, including neurological checks, vital sign assessment, and assessment and treatment of reported pain caused a delay in identification and treatment of a fall related fracture and placed R28 at risk for prolonged pain. Findings Included: - R28's Electronic Medical Record (EMR) documented diagnosis of generalized muscle weakness, difficulty walking, cognitive communication deficit, homonymous bilateral field defects (condition in which a person sees only one side of the visual field of each eye), senile degeneration of the brain (dementia - progressive mental disorder characterized by failing memory and confusion), and hallucinations (sensing things while awake that appear to be real, but the mind created). The Significant Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of seven, which indicated severe cognitive impairment. The MDS further documented R28 required limited assistance of one staff for bed mobility, transfers, dressing, toileting, and personal hygiene. She required extensive assistance of one staff for locomotion on and off the unit. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 03/01/23, documented R28 had a BIMS of seven and noted she had some confusion, but could answer questions. The Falls CAA, dated 03/06/23 documented R28 had a moderate risk for falls, required limited to extensive assistance from staff, and had poor memory and decision-making difficulty. The Care Plan with an intervention dated 06/22/23, documented R28 had a risk for falls, had senile degeneration of the brain, and hallucinations. The Care Plan intervention dated 06/22/23 documented as R28's senile degeneration progressed, her safety awareness was decreasing and noted she would attempt to do things that she had always done, but could no longer accomplish. It directed staff to do frequent visual checks and offer assistance as needed. A Registered Nurse Note dated 07/02/23 at 02:03 AM documented staff found R28 seated on the floor when LN K entered the room at 01:30 AM. The note further documented the resident stated she fell while attempting to get to her recliner. The note documented R28 showed no changes in alertness or orientation and vital signs were obtained. The note further documented R28 had an abrasion to the outer left shoulder the nurse cleaned the area and applied a dressing. The note documented R28 complained of left hip pain at that time and that no redness or bruising was noted to the left hip area. R28's EMR lacked evidence that LN K contacted R28's provider or representatives of the incident when it occurred. The EMR further lacked evidence that LN K conducted neurological checks or completed a post fall physical assessment. R28's EMR lacked evidence LN K assessed and treated the left hip pain reported by the resident immediately after the fall. The Medication Record dated 07/2023 documented R28 received morphine (medication used to treat moderate to severe pain) concentrate 20 milligrams per milliliter (mg/ml) with a dose of 0.25 ml at 05:43 AM and a dose of Tylenol (medication used to treat pain) 650mg at 05:47 AM on 07/02/23, four hours after the fall. A Registered Nurse Note dated 07/02/23 at 07:42 AM documented LN K notified Administrative Nurse E that R28 fell at approximately 01:30 AM. The note documented an abrasion/bruising to R28's left upper arm and notes staff assisted R28 back into bed. The note documented R28 had a pulse of 160 beats per minute (bpm) while taking morning vitals. Administrative Nurse E notified the provider of R28's severe left hip pain, pulse of 160 bpm and received an order for tramadol (medication used to treat moderate to severe pain) but the medication was unable to be obtained at that time. The note further documented LN K gave R28 morphine with no pain relief noted. Administrative Nurse E assessed R28 and a noted slight shortening of her left leg and R28 stated that she could not move her leg at all without severe pain. It also documented R28 complained of severe pain in left hip that radiated into R28's groin when she attempted to move her left knee. Administrative Nurse E notified R28's hospice nurse, and family. The hospice nurse arrived at approximately 07:15 AM and assessed R28, the on-call provider was updated on R28's status and agreed to send R28 to the ER. A Registered Nurse Note dated 07/02/23 at 11:32 AM documented the emergency room (ER) provider contacted the facility and requested information on R28. The note further documented the ER provider reported R28 had a left hip fracture. The note documented the facility was waiting for a response from R28's family regarding further care and an orthopedic consult. A Registered Nurse Note dated 07/06/23 at 12:44 PM documented staff sent R28 to the hospital due to a left hip fracture that occurred on 07/02/23 and was returning to the facility. It further documented that R28 had received a hemiarthroplasty (a surgical procedure where half of the hip is replaced. This procedure is typically used to repair a broken or fractured hip) on 07/03/23. An observation on 07/25/23 at 01:41 PM R28 sat in Broda chair (specialized wheelchair with the ability to tilt and recline) at nurse's station. Staff sat next to R29 for safety observations. R28 had a large bruise noted around her right eye. On 07/26/23 at 11:26 AM Administrative Nurse D stated she was not able to locate the neurological checks related to R28's fall on 07/02/23. She stated the facility did not have any record of the checks and she was only able to find the vital signs that were entered at that time. She stated LN K was an agency nurse and was not permitted to return/work at the facility in the future. On 07/26/23 at 01:30 PM LN K reported R28 was found on 07/02/23 around 01:30 AM by Certified Nurse Aide (CNA) MM and he was called in to assist. He stated R28 reported pain on her left side and must have rubbed against the wall during her fall because she had an abrasion on her left side hip. He stated he completed neurological checks, pain assessments, and evaluated R28, but did not know where to document the information due to not being trained properly. He stated he did give R28 oxycodone (medication used to treat pain) or some narcotic that evening. He stated he and CNA MM assisted R28 into the resident's bed, but R28 continued to have pain throughout the shift. He stated no other nurses were around to help him that evening and he did not know how to document assessments or complete medication entries into the medical records. He stated the medical doctor was notified upon the next shift arriving and R28 was sent out later in the morning. LN K stated he was not sure of a facility protocol for injuries or falls so he did what he thought was right. He stated R28 was very confused at the time of the fall but reported pain. On 07/26/23 at 01:45PM CNA MM reported she found R28 around 01:30AM on the floor. She stated R28 complained of pain in her left hip. She stated LN K followed her into R28's room. She stated R28 was assessed by the nurse but did not receive pain medication until sometime later. She stated R28 continued to complain about pain after the pain medication was administered and while performing cares later in the morning. She stated she offered R28 an ice pack or heat for the pain, but LN K declined to give it to her. On 07/26/23 at 02:12 PM Administrative Nurse E stated she worked on 07/02/23 after R28 fell . She stated LN K was concerned about R28's racing pulse of 160 bpm. Administrative Nurse E stated R28 had a history of atrial fibrillation (irregular heart rhythm) and racing pulse. She stated the only way to slow R28's pulse was to have her bear down (having a bowel movement). Administrative Nurse E stated she went to R28's room to assist her to the bathroom. She reported R28 stated she could not get up, as she was in pain. Administrative Nurse E stated neurological checks should be entered into the computer. She stated when the nurse enters a fall investigation into the computer, it created a notification for staff to start neurological checks. On 07/26/23 at 04:11 PM Administrative Nurse D stated she discussed the lack of neurological checks with the quality assurance nurse. She stated when entering a fall incident report, neurological checks should have been initiated and that LN K would have received a notice that they needed to be completed. She stated that when staff log in it shows them the tasks that need to be done and neurological checks would have been on that list. A review of the facility's Fall policy revised 10/2022 indicated all residents at risk for falls received review by the facility's interdisciplinary team. The policy noted each resident will be routinely assessed and provided individualized interventions to reduce the risk of falls. The policy indicated staff were to ensure each resident's care needs were provided and followed per the plan of care. The policy indicated the facility's quality assurance (QA) nurse would review fall interventions and update the plans as needed. The facility failure to provide post fall assessment and treatments per the standard of care, including neurological checks, ongoing vital sign assessment, and assessment and treatment of reported pain which caused a delay in identification and treatment of a fall related fracture and placed R28 at risk for prolonged pain.

The facility identified a census of 64 residents. The sample included one resident reviewed for cardiopulmonary resuscitation ((CPR) emergency medical procedure for restoring normal heartbeat and breathing). Based on record review and interview, the facility failed to provide CPR when staff observed resident #1 without a heartbeat or respirations. Resident #1 desired to be resuscitated if his/her heart stopped or he/she lacked respirations. This deficient practice placed the resident in immediate jeopardy. The facility further failed to ensure CPR qualified staff were available 24-hours a day to provide basic life-saving measures to residents who desired full-code status. Findings included: - The electronic medical record for resident #1 included [DIAGNOSES REDACTED]. The admission Minimum Data Set ((MDS) dated [DATE] documented staff assessed the resident with severely impaired decision-making ability. The resident was totally dependent on staff for Activities of Daily Living (ADLs), such as bathing and personal hygiene. The Care Area Assessment (CAA) dated [DATE] for cognition documented the resident had memory impairment from a previous 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) and did not respond to verbal cues. The care plan dated [DATE] documented the resident did not speak or write to communicate. The care plan directed staff to provide assistance with ADLs and documented the resident desired to be a full code (a technique of basic life support for the purpose of oxygenating the brain and heart until appropriate medical treatment can restore normal heart and ventilation action). The physician's orders [REDACTED]. The nurse's note dated [DATE] at 9:41 PM documented at 8:30 PM, licensed nursing staff G entered the resident's room and found the resident without a heartbeat or respirations. Staff notified the provider on call for the resident's physician and the resident's sister. Review of the staffing schedule for (MONTH) (YEAR) revealed 8 shifts out of 93 in which staff worked without CPR certification. On [DATE] at 11:01 AM, direct care staff M stated staff designated the resident's code status (full code or no CPR) on the resident's name plate outside of the resident's room. On [DATE] at 11:28 AM, licensed nursing staff G stated he/she and licensed nursing staff H provided care to the resident at 7:00 PM on [DATE]. Staff G said he/she reentered the resident's room at 8:30 PM and found the resident to be purple in color and without a heartbeat. He/she stated he/she summoned staff H and checked the resident's name plate for his/her code status. Staff G stated the name plate did not have the resident's code status designated. He/she said when staff H arrived, they decided not to perform CPR due to the resident's condition. On [DATE] at 11:56 AM, licensed nursing staff H stated at 8:30 PM on [DATE], direct care staff N reported that staff G requested his/her assistance with the resident. Staff G said when he/she arrived at the resident's room, the resident's skin was cool and mottled (changes occurring to the skin, especially to the hands and feet, near the end of life caused by slow blood circulation, skin may look blue and blotchy). Staff H further stated he/she and staff G decided not to perform CPR due to the resident's condition. On [DATE] at 12:52 PM, administrative staff D stated when staff found a resident without a heartbeat, he/she expected staff to check the resident's code status and follow the facility's policy. Staff D stated if a resident desired to be a full code, then he/she expected staff to perform CPR until emergency medical personnel arrived. The facility's policy CPR/Emergency Medical Care, revised [DATE], documented when staff found a resident without a heartbeat and without a do not resuscitate order ((DNR) - or no code, a written legal order to withhold CPR, in respect of the wishes of a person in case his/her heart stopped or he/she stopped breathing), CPR would be provided. The facility failed to provide CPR for this resident when staff found the resident without a heartbeat on [DATE]. The facility further failed to ensure CPR qualified staff were available 24-hours a day, to residents who desired full-code status, to provide basic life-saving measures. This deficient practice placed the resident in immediate jeopardy. The facility abated the immediate jeopardy on [DATE] when the facility initiated the following: Suspended the two nurses involved in the situation; requested from the agency one of the nurses not return to the facility; provided the agencies the facility contracts with the facility's policy on CPR Emergency Care; staff will audit all residents' records to ensure the presence of a code status; staff audited the residents' name plates to ensure their code status was designated; administrative staff D or designee will monitor the residents' name plates to ensure the residents' code statuses are identified; in-service all licensed nursing staff on Advance Directives (a written document which indicated the medical decisions for health care professionals when the person could not speak) and Ethics; in-service for all staff on CPR Emergency Care by [DATE] and any staff unavailable will not work with residents until they received the education; executive director and administrative staff D will report the status of this plan to risk management meetings weekly for 4 weeks, then monthly for 3 months, and then quarterly. The deficiency remained at a scope and severity of a G.

The facility reported a census of 83 residents and there were 18 residents in the sample. Based on interview and record review the facility failed to thoroughly assess, develop, and implement timely interventions to prevent the development of 3 stage 2 pressure ulcers (a localized injury to the skin as a result of pressure, or pressure in combination with shear and/or friction) for 1 of 2 residents sampled for pressure ulcers. (#114) Findings Included: - Review of resident #114's signed physician order [REDACTED]. Review of the admission MDS (Minimum Data Set) dated 8/31/2015 documented a BIMS (Brief Interview for Mental Status) score of 13, which indicated intact cognition. The resident required extensive assistance of 2 staff with transfers, locomotion on and off the unit; extensive assistance of one staff with bed mobility, dressing, toileting, and bathing; and walked with assistance of one staff in his/her room once or twice during the 7 day observation period. The resident used a walker and wheelchair for mobility. The resident was occasionally incontinent of urine and bowel and had a toileting plan. The resident was at risk for the development of pressure ulcers, had 3 stage 2 pressure ulcers and had a pressure ulcer device for his/her chair and bed and received pressure ulcer care. The resident did not receive a turning and repositioning program Review of a discharge MDS dated [DATE] documented the resident had an unplanned discharge to the hospital on [DATE]. The resident required extensive assistance from staff with bed mobility, transfers, movement on and off the unit and he/she walked in room once or twice during the 7 day observation period. The resident was occasionally incontinent of urine and continent of bowel. The resident had 3 unhealed stage 2 pressure ulcers. Review of an ADL (Activities of Daily Living) CAA (Care Area Assessment) dated 9/4/2015 documented the resident required extensive assistance with all ADL, to include transfers and mobility, wore oxygen at all times, and reported shortness of breath with activity and at rest. Review of a Pressure Ulcer CAA dated 9/4/2015 documented the resident was at risk for pressure ulcers, had occasional episodes of urinary incontinence, and required more assistance with transfers and mobility. The resident acquired 3 shearing (skin breakdown as a result of friction) ulcers on the sacral (large bone between to the two hip bones) area of his/her buttocks. Review of a Braden Skin Risk Assessment (an assessment used to determine a resident's risk for skin breakdown) dated 8/25/2015 documented a score of 17, which indicated no risk was present. Review of the score indicated the resident's mobility was slightly limited, which indicated the resident made frequent though slight changes in body or extremity position independent. Review of a physical therapy evaluation dated 8/26/2015 documented the resident required 25-50% staff assistance with bed mobility. Review of the care plan dated 8/25/2015 did not identify the resident at risk for skin breakdown, he/she had no skin breakdown, and no interventions were implemented by staff to prevent the resident's skin from breakdown. The care plan documented the resident required assistance of 2 staff with transfers, toileting, and ambulation and assistance of one staff with other ADL. The resident was usually continent of bowel and bladder. Staff revised the care plan on 9/1/2015 and documented the resident had impaired ADL due to muscle weakness, he/she frequently slid down in his/her bed and chair, and he/she developed stage 2 pressure ulcers on his/her right buttock, left buttock, and left of the sacral area. The care plan directed staff to use a foam type mattress to reduce pressure on the bed and in the chair, assist with repositioning every 2 hours and as needed, use one staff assistance with transfers, educate the resident on the importance of repositioning, and apply sensi-care with zinc (a protective barrier ointment) with all routine pericare and as needed every shift to both buttocks. Review of the resident-data collection assessment dated [DATE] at 4:30 PM documented the resident had no skin breakdown, required extensive assistance with transfers, 2 person assist with ambulation and had no supportive device used on his/her bed or chair. Review of nursing progress notes documented the following: On 8/25/2015 at 4:55 P.M. the resident required 2 staff to ambulate and transfers and he/she had 3+ [MEDICAL CONDITION] (measurement of fluid buildup) to both his/her legs and feet. On 9/1/2015 at 8:10 A.M. staff documented the resident had 3 shearing ulcers to both buttocks. The first ulcer was on the right side of the buttock, which measured 0.4 cm (centimeters) x 0.3 cm with no depth, swelling, inflammation, odor or drainage. The second ulcer was on his/her left side buttock, which measured 0.5 cm x 0.4 cm with no depth, swelling, inflammation, odor or drainage. The third ulcer was below the second ulcer on the left side of buttock, which measured 0.7 cm x 0.5 cm with no depth, swelling, inflammation, odor or drainage. Staff documented the resident used his/her heels to push him/herself up in the bed and staff educated the resident to ask for assistance with repositioning. During an interview on 11/05/2015 at 10:16 A.M. direct care staff O said he/she relied on the nurse to tell him/her if a resident was at risk for skin breakdown on admission. Staff O did not recall this resident. During an interview on 11/05/2015 at 3:33 P.M. direct care staff Q said the charge nurse let staff know if a resident was at risk for skin breakdown. Staff Q did not recall the resident. During an interview on 11/05/2015 at 3:38 P.M. licensed nursing staff H said he/she gathered information to include nutrition, activity level, incontinence, and information received from the hospital to determine if a resident was at risk for skin breakdown. Staff H said the facility frequently used sensi-care as a barrier to prevent skin breakdown and confirmed the facility did not start sensi-care until after the resident developed 3 stage 2 pressure ulcers. Staff H said the resident required staff assistance with all ADL, was weak, and had no pressure ulcers present on admission. Staff H stated he/she was not aware of any interventions to prevent the development of pressure ulcers. During an interview on 11/09/2015 at 8:59 A.M. administrative nursing staff C said administrative nursing staff F completed the initial care plan and administrative nursing staff G completed the skin portion of the care plan. Staff C said he/she did not review or revise the skin portion of the care plan. During an interview on 11/09/2015 at 11:10 A.M. administrative nursing staff F said he/she completed the initial care plan for residents and used hospital notes, a head to toe assessment, assessed mobility, nutrition, incontinence, and completed a Braden Skin Risk Assessment to determine if a resident was at risk for skin breakdown on admission. Staff F said the resident required 1-2 staff assistance with ADL and the assessment did not include bed mobility needs. Staff F said he/she did not assess the resident's bed mobility. Staff F said he/she completed the Braden Risk Assessment on admission based on information the resident gave. Staff F said after admission day it was the responsibility of other staff to to determine the resident's risk for skin breakdown and review and revise the care plan. Staff F said the initial care plan did not address bed mobility. During an interview on 11/09/2015 at 11:22 A.M. administrative nursing staff G said staff notified him/her if a resident's skin broke down and he/she updated the care plan. He/she said if the resident had no skin impairment he/she did not review or revise the care plan. Staff G said staff notified him/her on 8/31/2015 and he/she assessed the resident's wounds on 9/1/2015. Staff G said the resident had a stage 2 shearing wound on his/her right buttock, left buttock, and left sacral area. He/she said every resident had a pressure reducing mattress and he/she was not aware if any other interventions were in place prior to the development of the pressure ulcers. Staff G said he/she did not review the therapy evaluation dated 8/26/2015 to determine the resident's bed mobility needs and staff started a repositioning schedule after the wounds developed. During an interview on 11/09/2015 at 11:48 A.M. therapy consultant HH said physical therapy assessed the resident on 8/26/2015 and determined the resident needed 50% staff assistance with bed mobility. Staff HH said the facility maintained a copy of the evaluation in the medical record for nursing to review and nursing staff were responsible for the development of a repositioning program. During an interview on 11/09/2015 at 2:27 P.M. administrative nursing staff E said staff used a Braden Skin Risk Assessment, nutritional status, and mobility to determine a resident's risk for skin breakdown. He/she confirmed the initial care plan and the nursing admission assessment did not address bed mobility. Staff E said if the resident required extensive assistance with bed mobility and was incontinent the resident was at risk for skin breakdown and he/she expected staff to implement a toileting plan and reposition every 2 hours when in bed or in his/her chair. He/she expected staff to review therapy evaluations and implement interventions as appropriate and said all nurses were responsible for revising the resident's care plan. Staff E reviewed the Braden Skin Risk Assessment Score dated 8/25/2015 and said he/she expected staff to observe the resident's activity level and through record review he/she confirmed the may have been very limited. Staff E expected staff to consider documented [MEDICAL CONDITION] to the resident's legs and shortness of air with activity and at rest risk factors when risk for development of skin breakdown was determined and said the development of skin breakdown may be avoided if bed mobility interventions were in place prior to the development of the pressure ulcers. During an interview on 11/09/2015 at 3:27 P.M. physician consultant KK stated the resident had been in and out of hospitals prior to his/her admission to the facility and he/she had end stage heart failure. Consultant KK said the resident was at risk for skin breakdown on admission, had [MEDICAL CONDITION], shortness of air, needed assistance with bed mobility, and facility staff should have implemented a turning schedule to prevent skin breakdown. Review of the facility's revised Skin Integrity policy dated 7/2013 documented the facility assessed skin integrity, implemented preventative measures as indicated, and included incontinence, [MEDICAL CONDITION], exposure to friction/shearing forces, shortness of breath, and alterations in mobility as major risk factors for the development of pressure ulcers. The facility failed to thoroughly assess, develop, and implement timely interventions to prevent the development of 3 stage 2 pressure ulcers for this resident who needed assistance with bed mobility, had shortness of air, and [MEDICAL CONDITION] to both lower legs.

The facility reported a census of 74 residents. The sample included 3 residents for advanced directives (a written document which indicated the medical decisions for health care professionals when the resident could not speak). Based on interview and record review the facility failed to assess the resident and initiate cardiopulmonary resuscitation (CPR) for 1 (#1) of 1 resident reviewed who was a full code (staff to provide CPR) when staff found the resident was not breathing and died in the facility which placed the resident in immediate jeopardy. Findings included: - Resident #1 was admitted to the facility on [DATE]. The Admission Minimum Data Set (MDS) 3.0 dated [DATE] revealed a Brief Interview for Mental Status score of 15 which indicated no cognitive impairment. The resident could understand others and could be understood by others. Review of the comprehensive care plan dated [DATE] lacked documentation regarding the resident's code status. Review of the signed physician orders [REDACTED]. Review of the Social Service note dated [DATE] at 1:38 P.M. social services staff X revealed he/she discussed the code status in detail and the resident chose to be a full code. The nurses notes dated [DATE] at 10:16 P.M. by licensed staff I revealed a Certified Nurse Aide (CNA) called him/her to resident #1's room at 9:45 P.M. the resident was in the recliner with absence of vital signs, no response, skin cool to touch, last known staff contact was at 7 P.M. when staff provided ice water for the resident, at that time the resident was awake and without complaint and sat in the chair. Staff contacted the provider and explained the situation and received order to release body. Staff contacted the resident's family and advised him/her of the situation. Staff explained that no attempt was made to revive the resident due to coolness of skin and the length of time since staff's last contact with the resident. The nurses notes dated [DATE] at 4:20 A.M. by licensed staff J revealed the funeral home personnel were there to receive the body on [DATE] at 11:21 P.M. Review of the witness statement dated [DATE] by direct care staff N revealed on [DATE] at approximately 9:30 P.M. he/she walked into the resident's room, saw the resident was not breathing and ran to get the nurse. Review of the witness statement dated [DATE] by direct care staff O revealed on [DATE] at 9:30 P.M. he/she was informed by direct care staff N the resident was no longer with us, then the licensed staff I was informed. Review of the witness statement dated [DATE] by licensed staff I revealed on [DATE] around 9:30 P.M. a CNA came to get him/her from the desk and he/she went to the resident's room. Licensed staff I stated he/she knew the resident was a full code but decided against resuscitation attempts, as he/she looked so peaceful and the thought of putting him/her on the floor and starting chest compressions seemed cruel. In retrospect, the safer decision would have been to have started CPR and called 911. Review of the facility's investigation report revealed the nurse's emotions may have inhibited him/her to initiate CPR because the resident looked so peaceful and the nurse did not want to brutalize the body. Interview on [DATE] at 2:20 P.M. direct care staff N stated on [DATE] he/she did rounds around 9:30 P.M., noticed the resident was not breathing and left the room to get assistance, the first person observed was direct care staff O and informed him/her of the resident's status, direct care staff O went into the room and he/she went to find the nurse. Interview on [DATE] at 12:10 P.M. direct care staff O stated he/she was informed of the resident not breathing and went into the room and checked for a pulse and found none. At around 9:30 P.M. the nurse came in and assessed the resident and then left to call the family and the physician. Direct care staff O overheard the nurse on the phone state the resident was a full code. Interview on [DATE] at 4:20 P.M. licensed staff I stated he/she did not attempt to take the resident's vital signs when the resident was found not breathing. Interview on [DATE] at 4:45 P.M. licensed staff I stated the witness statement was accurate. The resident had a slack face, hands were cool to touch, the skin had a waxy appearance and the eyes were shut. He/she regretted the decision to not do CPR; it was the resident's decision to be a full code. Interview on [DATE] at 5:15 P.M. administrative licensed staff D stated he/she expected for the nurse to start CPR on this resident who was a full code. The death in healthcare policy provided by the facility dated ,[DATE] revealed the lack of direction for staff when death was apparent and the resident was a full code. The facility failed to assess and provide CPR for this resident who was a full code and was not breathing. The facility abated the immediate jeopardy on [DATE] at 4:00 P.M. when the facility: Developed a policy on CPR in accordance with the CMS memo dated [DATE]. Completed inservice of all staff with duties in the Health Care Unit regarding the CPR policy and their role. This inservice will be completed on [DATE] at 4:00 P.M. This training will be provided during new staff orientation, and annually. Residents with a Full Code Status will be identified with an asterisk on their room name plates and a purple dot on their chart. Only licensed nurses with a current CPR certification will be hired. All licensed staff and the transportation driver with be CPR certified. Human Resources will monitor the current status of CPR certified staff. The Quality Assurance (QA) Committee has formed a performance improvement team to address this issue and monitor with a monthly report and at the quarterly QA meeting. This deficiency practice remains at the scope and severity of a D.

The facility identified a census of 93 residents. Sample size included 3 residents. Based on record review and staff interview the facility, failed to follow the care plan for 1 (#2) resident of the sample, resulting in a fall with injury. Findings included: - Review of the physician's orders [REDACTED]. The Quarterly Minimum Data Set 3.0 dated 03/16/11 revealed the resident had adequate hearing, no speech, rarely/never understood/understands, required total assistance of one to two plus persons for all activities of daily living, impairment on both sides lower and upper extremity, only able to stabilize with human assistance for surface to surface transfers, always incontinent of bowel and bladder, one fall since admission or prior assessment, with injury, no weight loss, feeding tube, no pressure ulcers, at risk for developing pressure ulcers, no other wounds or skin problems, pressure reducing device for chair, pressure reducing device for bed, and turning/repositioning program. The Care Plan dated 03/17/11 identified potential for falls due to dementia, with the following approaches; the staff to do a fall risk assessment quarterly and as necessary (PRN), the staff are to ensure the resident's durable power of attorney and his/her physician were notified of any falls, abnormal laboratory (LAB) results or seizure activity. Labs as ordered by the physician, the staff should use a sling lift with assist of 2 persons for transfers, a beveled mat on the floor at the beside, the bed in the low position and against the wall, the staff should position the resident in the center of the bed, with the head of the bed (HOB) elevated at 30-45 degrees, and my physician would review my medications for any that could increase my fall risk. Review of the Interdisciplinary Notes dated 02/18/11 at 3:00 A.M. revealed this nurse heard a thud and went to investigate, and found the resident on the floor, face down with his/her mattress on top of him/her. Staff observed a pool of blood under his/her head, his/her head was very near the nightstand, the resident was assessed for additional injuries prior to placing the resident in the bed, staff stopped the bleeding to the forehead with direct pressure, he/she was noted to have a 3 centimeter laceration to the forehead, the staff re-approximated the skin applying 6 steri strips. Neurological examination appeared intact as the resident was able to blink his/her eyes, pupils equal, round, and reactive to light accommodation (PERRLA) and the resident could move his/her mouth and lips. He/she was softly crying, staff returned the resident to his/her bed, the staff notified the doctor via phone and the staff sent the resident to the local hospital emergency room for evaluation and treatment. Interdisciplinary Notes dated 02/18/11 at 8:39 A.M., the staff received a call from the emergency room which stated the resident was ready to return to the facility, with 4-5 sutures to the forehead, the head scan was negative, and had the following orders, the staff should apply triple antibiotic ointment to the area twice a day and remove the sutures in 8 days. At this time licensed staff A reiterated to the staff to have the fall mat in place by the bed. An interview on 04/13/11 at 4:10 P.M. licensed nursing staff B stated he/she had done the resident's tube feeding, the resident was positioned on his/her left side facing the wall, and I left him/her in that position because I knew the aid would come and turn him/her shortly. I returned to the nurses' station and heard a noise down the hall, I thought it was his/her roommates recliner foot support had drop but when I checked he/she was okay. I looked around the curtain and found the resident on the floor with the air mattress on top of him/her and he/she had a laceration on his/her right forehead, I figured he/she had hit the dresser from the looks of things. I assessed him/her and applied steri strips to the laceration, called the doctor, and obtained an order to send to hospital emergency room . To my knowledge he/she had not fell prior to this, he/she was new to this unit, I did instruct the aid on positioning the resident in the middle of the bed. An interview on 04/14/11 at 11:05 A.M. licensed nursing staff A stated he/she did not think the mat was in place by the bed the night the resident had his/her fall. I did reeducate staff regarding fall precautions and I usually don't re-educate unless there was a problem. The facility failed to follow the care plan for this dependent resident to prevent an injury from a fall.