Every finding on record at Wheatridge Park Care Center

The facility identified a census of 40 residents, with 12 residents sampled, and one resident reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Based on observations, interviews, and record review, the facility failed to provide a pressure reducing device on the bed to prevent a pressure injury for Resident (R) 2. On 07/11/24 the facility noted R2's previous pressure injuries were all closed. On 07/12/24, R2 was moved to a different room and the facility failed to move his air mattress for his bed to the new room. On 07/24/24, R2's left heal pressure injury re-opened and was identified as a stage three pressure injury (full thickness pressure injury extending through the skin into the tissue below). This placed the resident at risk to worsen his pressure ulcers and delayed healing. Findings included: - Resident (R) 2 's Electronic Health Record (EHR) revealed diagnoses of diabetes mellitus type two (DM2-when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin) and reduced mobility. The Significant Change Minimum Data Set (MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) of 99, indicating severely impaired cognition. The resident had a total mood severity score of 02, indicating no depression and R2 had no behaviors. R2 required total assistance with activities of daily living (ADLs), which included bed mobility, toileting, dressing, and bathing. R2 was always incontinent of bladder. R2 had a stage two pressure ulcer (partial-thickness skin loss into but no deeper than the dermis including intact or ruptured blisters) on admission. There was a pressure relieving device on the bed and the chair. The Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) did not trigger on the 10/25/23 MDS. The Pressure Ulcer CAA dated 11/02/23, documented an actual skin breakdown and R2 was at risk for further skin breakdown due to incontinence. Treatment and preventative measures were in place and the facility consulted a wound care physician. The facility would proceed with care planning to ensure that interventions were in place to heal an existing wound and prevent new skin breakdown. The Quarterly MDS dated [DATE], documented a BIMS of 99. R2 required total assistance of staff with ADLs. R2 had two stage three pressure ulcers, which were facility acquired and had pressure relieving devices on the bed and the chair. The 09/10/24 Care Plan documented interventions which included: On 08/04/22, staff were instructed to float R2's heels with pillows while in bed. Staff applied an air mattress to R2's bed. On 12/27/23, staff were instructed to apply podus boots (lightweight plastic shell with a liner to help treat and prevent lower extremity disorders) at all times. The Physician Orders dated 08/09/24 included instruction to staff not to provide whirlpool baths for R2 and if showers were done, they were to wrap the resident's left foot. The physician orders lacked any orders for treatment for R2's left foot pressure ulcers. Review of the Progress Notes from 01/01/24 to 09/10/24 documented the following: On 03/28/24 at 09:23 AM the Interdisciplinary Team (IDT) Wound Note revealed a stage three pressure wound to the left heel that measured 2.4 centimeter (cm) by 1.5 cm and 0.2 cm depth. The wound edges were irregular and noted a current treatment plan in place. On 04/16 /24, a Progress Note at 11:08 AM, wound care clinic staff had R2 admitted to a hospital for a worsened foot ulcer and noted the left heel wound required debridement (medical removal of dead, damaged, or infected tissue to improve the healing potential for the remaining healthy tissue). On 4/18/24, a Progress Note at 01:44 PM, R2 readmitted back to facility. On 05/07/24, a Wound Consult Note, revealed the left heel wound measured 1.9 cm by 2.6 cm by 0.4 cm, the left lateral (pertaining to the side, away from the middle) foot wound measured 1.2 cm by 1 cm by 0.3 cm. Staff were to maintain heel foam pad at all times. On 06/20/24 , a Wound Consult Note revealed the resident's left heel wound measured 1 cm by 1.5 cm by 0.5 cm. The area was debrided by the physician. On 07/11/24, a Wound Consult Note revealed all of the resident's wounds were closed. Staff were to continue to off load the resident's heel and remove the Podus boot to prevent pressure to dorsal (back) and lateral foot. The resident would have a heel foam pad in place at all times, which was to be changed every two weeks. Staff were to monitor the areas daily and call if worsening. On 07/11/24 at 09:08 AM, Social Services Designee (SSD) K spoke with R2's family member to move R2 into a new room with a roommate, and the family agreed. On 07/17/24 at 10:55 AM, six days after the wounds closed, a Skin/Wound Note revealed the left foot dorsum (upper surface of the foot) wound measured 5 cm by 4 cm, the left heel wound measured 2 cm by 1.5 cm, the left side of the foot with a scabbed area that measured 1 cm by 1.5 cm with redness to the surrounding area that measured 8.5 cm by 2 cm. On 07/22/24 at 07:39 AM, a Skin/Wound Note revealed the left foot dorsum wound measured 4 cm by 2.2 cm, the left heel measured 2.5 cm by 1.7 cm, the left side of foot wound measured 2 cm by 1.3 cm, with no redness noted. On 08/01/24 at 08:17 AM, a Skin/Wound Note revealed the left foot dorsum had redness that measured 4 cm by 2.2 cm by 0.1 cm, the left heel wound measured 3 cm by 3 cm by 0.3 cm with yellow drainage, the left side of the foot wound measured 1.8 cm by 1.5 cm by 0.1 cm with blood- tinged drainage. On 08/08/24 at 04:39 PM, a Wound Consultation Note revealed the resident's left heel re-opened and measured 2.5 cm by 2.5 cm by 0.7 cm, and the left lateral foot wound measured 1.5 cm by 2 cm. On 08/12/24 at 12:08 PM, a Skin/Wound Note revealed the left heel measured 2 cm by 1.7 cm by 0.2 cm and the wound to the left lateral foot measured 0.1 cm by 0.1 cm by 0.1 cm. There was moderate amount of purulent (producing or containing pus) drainage noted from the left heel. On 08/15/24 at 03:59 PM, a Wound Care Note revealed the left heel wound measured 2 cm by 2 cm by 0.3 cm and the wound to the left lateral foot wound measured 1.4 cm by 2 cm by 0.2 cm. Staff were to cleanse the wound with wound wash, pat dry and cover the heel and lateral foot with Aquacel Ag (dressing is indicated for the management of a variety of at risk/infected chronic and acute wounds) extra absorbent dressing. Staff would cover the top of the left foot with a foam pad and change the dressing two times a week. On 09/05/24 at 12:07 PM, a Wound Care Note revealed the left heel wound measured 1.7 cm by 1.8 cm by 0.1 cm and the left side of the foot wound measured 1 cm by 1 cm by 0.1 cm. The left dorsum wound measured 0.5 cm by 2 cm by 0.1 cm. Staff were to leave the dressing intact until the follow-up appointment. During an observation on 09/10/24 at 12:46 PM, R2 was in the dining room seated in wheelchair and had no seat cushion in the wheelchair. R2 had a blue foot bootie on his left foot with a brown dressing covering the foot, the right foot had a sock and both feet were placed in a foot cradle (cushioned back and side panels that are designed to help control foot drop). Observation revealed R2's bed lacked an air mattress. During an observation on 09/11/24 at 07:54 AM, R2 was in the dining room. R2 had a left heel bootie on his foot, a sock on the right foot and both feet were in a foot cradle. The wheelchair lacked a seat cushion and R2's bed lacked an air mattress. An interview on 09/11/24 at 08:00 AM revealed Licensed Nurse (LN) H confirmed R2's EHR lacked an order for the left foot wound received by the wound care clinic on 09/05/24. LN H revealed R2 should have both heels off loaded per physician's order and confirmed R2 had only a left foot bootie placed. An interview on 09/11/24 at 08:09 AM revealed Certified Nurse Aide (CNA) F confirmed R2 did not have a seat cushion under him on the wheelchair and stated that R2 only required a bootie on his left foot and never wore a right foot bootie. An interview on 09/11/24 at 10:20 AM revealed CNA F stated he assisted R2 to bed at approximately 10:00 AM and placed afoot bootie on the right foot and he placed the left foot bootie under the left heel. CNA F stated R2 did not have extra pillows in his room, and he placed R2's heel on the left bootie instead of in the bootie to off load the left heel, then CNA F confirmed that the bootie was not on correctly and was going to get pillows to off-load the heels. CNA F confirmed that R2 did not have an air mattress on his bed and stated that he had never seen one on R2's bed. An interview on 09/11/24 at 03:10 PM revealed Administrative Nurse B confirmed R2 should have had both heels off-loaded in the correct manner. Administrative Nurse B stated that R2's left heel wounds were chronic, non-pressure ulcers, that R2 had since admission. Administrative Nurse B was asked to clarify what stage, type of ulcer, and if the areas were facility acquired as documentation on the 07/28/24 MDS revealed two stage three facility acquired pressure ulcers. An interview on 09/11/24 at 03:43 PM revealed Administrative Nurse B confirmed R2 did not have an air mattress on his bed. Administrative Nurse B stated that R2's room had been changed a few weeks prior, and R2 always had an air mattress on his bed for at least a year. An interview on 09/11/24 at 04:00 PM revealed Administrative Nurse B confirmed R2 had facility acquired stage three pressure ulcers after she spoke to the wound care clinic nurse. Administrative Nurse B revealed that the areas were closed and healed on 07/11/24, and the pressure ulcers were facility acquired. On 09/11/24 at 04:40 PM, SSD K verified R2 moved to room his previous room on 07/12/24. Administrative Nurse B confirmed R2 did not have an air mattress when he moved to a different room and commented the facility had extra air mattresses and did not know why R2 was without an air mattress. The facility's policy Pressure Ulcer/Skin Breakdown dated April 2013 documented: Physicians shall help prevent and manage pressure ulcers, consistent with established guidelines. Incidence of new pressure ulcers will be minimized to the extent possible. Healing of existing pressure ulcers will be optimized to the extent as possible. The facility will be able to show failure of a pressure ulcer to heal was medically unavoidable. The facility failed to place interventions to prevent pressure injuries for R2, who developed two preventable, facility acquired, stage 3 pressure injuries. This placed the resident at risk to worsen his current pressure ulcer or develop more skin issues.

The facility identified a census of 40 residents, which included 12 residents sampled and three reviewed for accidents and accident hazards. Based on interviews, observations, and record review, the facility failed to provide an environment free of accident hazards for the residents of the facility when the facility failed to properly store chemicals in an unlocked cabinet in an unlocked room and when the facility stored chemicals along a rail in the hallway. Additionally, the facility failed to ensure R26, who was identified by the facility as confused and independently mobile with aggressive and wandering behaviors, remained free of accident hazards when R26 put scissors in his pocket and wandered inside the facility. Furthermore, the facility failed to ensure that two residents, Resident (R) 22 and R8, remained free of accident hazards related to falls when the facility failed to appropriately investigate, develop, and implement appropriate interventions to prevent multiple falls for R22 related to continued use of a powered lift chair, or develop any new interventions for R8. These deficient practices resulted in R8 falling and sustaining a fracture (broken bone) to her left humerus (upper arm bone) and left fourth rib which required a hospitalization . Findings included: - Review of the Electronic Health Record (EHR) for Resident (R) 8 included diagnoses of osteoporosis (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk), history of falling, repeated falls, generalized muscle weakness, lack of coordination, and dementia (a progressive mental disorder characterized by failing memory, confusion). The Significant Change Minimum Data Set (MDS) dated [DATE], documented R8 as unable to complete the Brief Interview for Mental Status (BIMS) assessment and staff assessed R8 to have severely impaired cognition. The assessment documented R8 required substantial or maximal assistance from staff for cares. R8 was frequently incontinent of bladder and always incontinent of bowel. The assessment documented that R8 had no falls since the previous assessment. The Cognitive Loss / Dementia Care Area Assessment (CAA) dated [DATE], documented R8 as deceased ; however, the surveyor observed R8 in the facility on [DATE], [DATE], [DATE], and [DATE]. The Quarterly MDS dated [DATE], documented R8 as unable to complete a BIMS assessment and staff assessed R8 to have severely impaired cognition. The assessment documented R8 as dependent on staff for toileting, bathing, and all forms of hygiene and required substantial or maximal assistance for all other cares except eating, which was required supervision/setup. R8 was frequently incontinent of bowel and always incontinent of bladder. The assessment documented that R8 had a fall since the previous assessment. The [DATE] Care Plan documented R8 was at risk for falls and listed the following interventions: On [DATE], staff would monitor for changes in R8's condition that may warrant increased supervision or assistance and notify the charge nurse. On [DATE], staff would provide frequently used items within easy reach. On [DATE], family reported R8 was forgetful and would benefit from consistency in her room. She was unable to use a walker due to difficulty remembering to use it. On [DATE], staff would request physical/occupational therapy to evaluate and treat the resident as needed. On [DATE], staff would encourage the resident to visually survey the area prior to stepping away to walk. On [DATE], activities staff would provide mid-morning and mid-afternoon activities, one on one to keep R8 busy and mobile. On [DATE], staff placed a night light in R8's room so she was able to see after dark. Review of the EHR Safety Device Consent dated [DATE], documented a safety assessment for turn bars only and lacked safety assessment for a powered lift chair. Review of the EHR Fall Risk assessments revealed on [DATE], the facility documented a fall risk score of 22, which indicated R8 was a high risk for falls. The Progress Notes dated [DATE] documented R8 experienced a witnessed fall and landed on her left side, she then repositioned herself to her back. Review of the facility Fall Investigation revealed on [DATE] at 05:20 PM, R8 fell without injury. The facility's root cause analysis determined R8 had a lack of safety awareness, which caused the fall. The fall investigation report documented the immediate and permanent care plan interventions were that staff would provide a smaller recliner that was a better fit for R8. The resident's Care Plan documented on [DATE] staff would provide a smaller recliner that was a more appropriate fit for R8; however, the facility lacked evidence of the implementation of this intervention. The Progress Notes dated [DATE] documented R8 was found sitting on the floor near the bed with bed linens wrapped around her legs. The fall investigation report documented the immediate and permanent care plan interventions were that staff would provide more frequent rounding. Review of the facility Fall Investigation revealed on [DATE] at 10:06 PM, R8 fell and obtained a minor injury. The facility's root cause analysis lacked determination causal factors for the fall. The fall investigation report documented the immediate and permanent care plan interventions were that staff would provide more frequent rounding. The resident's Care Plan documented on [DATE] that staff would provide frequent rounding however, the facility lacked evidence of the implementation of this intervention. Review of the EHR Fall Risk assessments revealed [DATE], the facility documented a fall risk score of 15, which indicated R8 was a moderate risk for falls. The Progress Notes for R8 lacked an entry with a description related to fall on [DATE]. The fall investigation report lacked an immediate intervention to mitigate fall risk for the remainder of the shift. The fall investigation report documented the permanent care plan documented staff would cue and sit with R8 to ensure that R8 ate the meal or snack provided. Review of the facility Fall Investigation revealed on [DATE], R8 fell and obtained a minor injury. The facility's root cause analysis determined that R8 was hungry and attempted to ambulate without staff assistance. The fall investigation report lacked an immediate intervention to mitigate fall risk for the remainder of the shift. The fall investigation report documented the permanent care plan documented staff would cue and sit with R8 to ensure that R8 ate the meal or snack provided. The resident's Care Plan documented on [DATE] that staff would sit with R8 to provide cues and assistance with any snacks or meals provided. The Progress Notes dated [DATE] documented staff discovered R8 at approximately 05:30 AM, on the ground on her knees, and noted she had a minor injury to the left elbow. The facility's fall investigation report documented that the immediate intervention was that staff would close monitoring for remainder of shift. The facility's fall investigation report permanent care plan documented staff would unplug recliner and switch to a manual recliner when possible. Review of the facility Fall Investigation revealed on [DATE], R8 fell and obtained a minor injury. The facility's root cause analysis determined R8 raised a powered lift chair to its full height and fell . The facility's fall investigation report documented that the immediate intervention was that staff would closely monitor the resident for the remainder of the shift. The facility's fall investigation report permanent care plan documented staff would unplug recliner and switch to a manual recliner when possible. The resident's Care Plan documented manual recliner on [DATE]; however, the surveyor observed R8 resting in powered lift chairs on [DATE], [DATE], [DATE], and [DATE]. Review of the EHR Fall Risk assessments revealed the on [DATE], the facility documented a fall risk score of 25, which indicated R8 was a high risk for falls. The Progress Notes dated [DATE] at 09:25 PM documented staff discovered R8 on the ground on her left side in her doorway, with a minor injury to the left elbow. Review of the facility Fall Investigation revealed on [DATE], R8 fell and obtained a minor injury. The facility's root cause analysis determined R8 had limited safety awareness. The fall investigation report documented the immediate intervention was that staff would perform more close monitoring of the resident. The fall investigation report documented the permanent care plan intervention was staff would offer toileting with all bed checks. The resident's Care Plan documented on [DATE] staff would offer toileting with all bed checks to prevent the resident from attempting to ambulate without assistance from staff. Review of the EHR Fall Risk assessments revealed on [DATE], the facility documented a fall risk score of 22, which indicated R8 was a high risk for falls. The Progress Note dated [DATE] at 01:27 AM, documented R8 was given pain medication for the fall that occurred on [DATE] at 09:25 PM and lacked documentation of the location or severity of the pain. The Progress Note dated [DATE] at 03:24 PM, revealed an unknown Certified Nurse Aide (CNA) staff reported to the nurse R8 had pain and swelling to the left shoulder. The nurse assessed R8 and documented swelling and bruising from R8's shoulder to her elbow on the left arm, documented she notified R8's primary care physician (PCP), and noted she left a message for the PCP. The Progress Note dated [DATE] at 03:55 PM, revealed R8's PCP returned the phone message and gave a telephone order to obtain an x-ray of the resident's left upper arm and left shoulder. The Progress Note dated [DATE] at 09:14 PM, revealed the consultant x-ray provider notified the facility that R8 had a displaced fracture (a traumatic bone break where two ends of the bone separate out of their normal positions) of the left humerus and a fractured left fourth rib. The facility staff notified R8's PCP and received orders to maintain current treatment to maintain R8's comfort and notify the PCP if R8 became uncomfortable. Review of the Progress Note dated [DATE] at 05:48 PM, revealed staff called the hospital and were advised that R8 admitted to the medical floor due to a fracture of the left humerus. The Progress Notes lacked additional documentation related to how, when, or why the resident was transferred to the hospital. Review of the Progress Note dated [DATE] at 03:00 PM, revealed R8 arrived to the facility with a report from the hospital noting R8 was not a candidate for surgical repair of the left arm and orders to apply ice to the affected area as needed for pain or swelling, R8 was to wear a sling on the left side at all times for four weeks, and staff were not to use the left arm to assist the resident with cares. Review of the facility Fall Investigation revealed on [DATE], R8 fell and obtained a minor injury. The facility's root cause analysis determined that R8's limited safety awareness caused the fall. The fall report documented that the immediate intervention was that staff would perform more close monitoring with one-on-one supervision as much as possible. The fall investigation report documented the permanent care plan intervention was documented as staff asked R8's family to bring a TV to her room so staff would place the TV on a music channel then wait to see if she was willing to lay and watch television and sleep. The Progress Notes for R8 lacked documentation related to the [DATE] fall. The resident's Care Plan included an intervention dated [DATE], which documented family would bring R8 in a television and staff were to put it on a music channel which would allow her to watch, relax, and sleep. Review of the Progress Note dated [DATE] at 03:22 AM, staff documented a witnessed fall when R8 attempted to stand unassisted from a wheelchair without additional injuries; however, the facility lacked a fall investigation related to this fall. The resident's Care Plan included an intervention dated [DATE], which indicated staff had a meeting with family regarding additional interventions to prevent R8 from falling again with suggestions made that staff would implement with the goal to keep R8 calm; however, no additional information was provided. Review of the EHR Fall Risk assessments revealed on [DATE], the facility documented a fall risk score of 26, which indicated a high risk for falls. The resident's Care Plan included an intervention dated [DATE], which directed staff would offer to take R8 to the bathroom during all overnight bed checks to prevent her from self-ambulation attempts. The Progress Notes dated [DATE] at 04:19 PM, revealed staff documented a witnessed fall without injury when R8 attempted to stand from a recliner with the footrest in the up position. The fall investigation report documented the immediate and permanent care plan interventions were that staff would offer snacks/drinks frequently. Review of the facility Fall Investigation revealed on [DATE], R8 fell without injury. The facility's root cause analysis determined R8 attempted to stand without staff assistance. The fall investigation report documented the immediate and permanent care plan interventions were that staff would offer snacks/drinks frequently. The resident's Care Plan documented on [DATE] staff would frequently offer snacks/drinks to R8 however, the facility lacked evidence of the implementation of this intervention. Review of the EHR Fall Risk assessments revealed on [DATE], the facility documented a fall risk score of 23, which indicated a high risk for falls. The Progress Notes revealed on [DATE] at 05:28 PM, staff documented a fall without injury when R8 attempted to ambulate without staff assistance. Review of the facility Fall Investigation revealed on [DATE], R8 fell without injury. The facility's root cause analysis determined that R8 attempted to stand without staff assistance. The fall report lacked an immediate intervention performed by staff to mitigate the risk of falls for the remainder of the shift. The permanent care plan intervention was staff should monitor for items left on the floor or any items the resident may have dropped and assist with picking them up. Review of the resident's Care Plan revealed the following interventions: On [DATE], staff would perform rounds frequently and offer R8 toileting assistance. On [DATE], staff would maintain an environment that was clutter-free, provide adequate lighting, and ensure personal items were within reach. On [DATE], staff would provide assistive devices as needed. On [DATE], staff would review information on past falls to determine causes of falls. Review of the EHR Fall Risk assessments revealed on [DATE], the facility documented a fall risk score of 15, which indicated R8 was a moderate risk for falls. Observations on [DATE] at 12:50 PM, [DATE] at 07:40 AM, and [DATE] at 10:00 AM revealed R8 in a powered lift chair recliner in the common area near the nurses' station with her eyes closed. Observation on [DATE] at 12:00 PM, revealed R8 in a powered lift chair recliner in the common area near the nurses' station with her eyes closed. Two unknown CNA staff assisted R8 to an upright seated position using the powered mechanism of the lift chair, then performed a two-person pivot-transfer from recliner to R8's wheelchair and assisted R8 to the dining area for the noon meal. On [DATE] at 12:04 PM, CNA F stated when a resident fell , CNA staff should ensure the resident was safe, then alert other staff that assistance was required, and would notify the nurse. Upon the arrival of the nurse, then CNA staff would follow the instructions of the nurse. CNA F was unable to recall specific interventions for R8 and stated that they would refer to the CNA book at the nurses' station or R8's care plan on the EHR for guidance. On [DATE] at 12:14 AM, CNA E stated that when a resident fell , CNA staff would ensure the resident was safe and call for help, which included calling the nurse. Once the nurse arrived, then CNA staff would follow the instructions of the nurse. CNA E was unable to recall any information specific to R8's falls and stated that interventions to prevent falls for R8 could be found in the resident's care plan, which was accessible in the EHR on either the computers or tablets or in the CNA book in the nurses' station. On [DATE] at 12:24 PM, Licensed Nurse (LN) D stated after a fall, the CNA staff would ensure the resident was safe and call for help, which included the nurse. When the nurse arrived, they would assess the resident for injuries and give aid if appropriate. Immediately following the fall, the nurse would notify the PCP, the resident's representative, Administrative Nurse B and/or Administrative Staff A. Immediately after the required notifications were made, the nurse would fill out a fall report in the EHR and collect witness statements from all nursing (CNA, Certified Medication Aides [CMA], LN) personnel on duty at the time of the fall. The nurse would then hold a fall huddle with the staff to initiate an investigation to determine the root cause of the fall and develop an immediate intervention to mitigate the risk of falls for the remainder of the shift. The nurse would also perform and document ongoing assessments for fall follow up which may or may not include neurological (pertaining to the brain) assessments if needed for 72 hours (3 days) after the fall. On the next business day, Administrative Nurse B would review the documentation and add a permanent care plan intervention on the resident's care plan and place the update in the CNA book at the nurses' station. Additionally, LN D stated that she was unsure if residents were assessed for safety related to the safe operation of powered lift chairs. During an interview with Administrative Nurse B on [DATE] at 12:36 PM revealed after a resident fell , she expected staff to perform a huddle to discuss what happened, develop an immediate intervention to prevent further falls, then staff would complete a risk management module. All nursing staff were expected to fill out a witness statement, then make appropriate notifications. The Director of Nursing (DON) reviewed fall charting and added interventions to the individual resident care plans after a fall. Administrative Nurse B reported resident cares were driven by the care plan and stated it was her expectation the care plan would be revised with a new and unique intervention related to each specific fall. Administrative Nurse B further confirmed if the facility did not identify the cause of a fall they could not say if interventions in place for fall were appropriate. Administrative Nurse B stated duplicate or similar care plan interventions were unacceptable and confirmed the resident had duplicate/similar care planned interventions for multiple falls. Administrative Nurse B stated care planned interventions should be new, unique to the fall, and measurable. She also confirmed the facility lacked appropriate follow up for all falls in the resident's progress notes. The nurse should initiate and document ongoing assessments for 72 hours (3 days) for fall follow up and include neurological assessments if needed. Administrative Nurse B stated that the previous DON was responsible for the information prior to the [DATE] fall and she was unable to provide an explanation as to why the expectations were not met. Administrative Nurse B stated that all residents who use powered lift chairs should have a Safety Device Consent assessment in their EHR to determine whether they could safely utilize a piece of powered equipment. She confirmed R8 had severely impaired cognition and could not be assessed for safe use of a powered lift chair. Further, confirmed that the Safety Device Consent in R8's EHR, dated [DATE] lacked a safety assessment for a powered lift chair. The facility's undated Fall Guidelines - Assessing Falls and Their Causes documented staff were to observe a resident who fell for delayed complications for approximately forty-eight (72) hours and would document the findings in the resident's EHR. Additionally, staff would, in collaboration with the interdisciplinary team (IDT - a team of facility staff consisting of members of various departments including but not limited to; dietary, nursing, maintenance, therapy, etc.), identify possible or likely causes of the incident and lacked instructions for staff to follow to correct the causes of the incident. The facility failed to implement interventions after multiple falls to provide an environment free of accident hazards for a dependent resident with severely impaired cognition and a known history of repeated falls. R8 fell twice on [DATE] and was injured, fell on [DATE] and was injured, fell on [DATE] and was injured, fell on [DATE] and was injured (two fractures and a hospitalization ), fell on [DATE] and was injured, fell on [DATE] and was not injured, and fell on [DATE] and was not injured. This deficient practice resulted in actual harm to the physical and psychosocial well-being of R8. - Observation on [DATE] at 10:45 AM, revealed a container of sanitizer wipes for surfaces and reusable medical equipment sat on top of the handrail in the 200 hall. The sanitizer wipes container was labeled Keep out of reach of children. On [DATE] at 11:42 AM, Housekeeping Supervisor X, unknown housekeeper and unknown laundry aide observed walking past the container of sanitizer wipes stored on the top of the handrail in the 200 hall. On [DATE] at 12:10 PM, Licensed Nurse (LN) H identified the sanitizer wipes as hazardous chemicals since the manufacturer's label documented to keep out of reach of children and stated that the container of wipes should be stored in the medication room, in the supply room, or in a (unsecured) bag hanging from mechanical lifts. LN H then removed the container of wipes and placed it in an unsecured bag and hung it from a mechanical lift that was stored in the hallway. On [DATE] at 01:51 PM, during an environmental tour with Maintenance Director O in the activities room, a large metal cabinet with two full-length doors was unlocked and contained the following hazardous chemicals with Keep out of reach of children on the manufacturer's labels: 1. One container of Germicidal (sanitizing) wipes. 2. Two cans of paint plus primer. 3. One can of spray adhesive. 4. One can of extra hold hairspray. 5. One container of mosaic stone cement. 6. Two containers of nail polish remover. In addition, there was assorted nail care accessories which included nail polish, clippers and scissors. On [DATE] at 03:00 PM, Administrative Nurse B confirmed the above findings and stated that her expectation was for all chemicals and sharp objects to be secured behind a locked door or cabinet. Administrative Nurse B identified four residents who were independently mobile and had cognitive impairment that included confusion. The facility's undated Poisonous and Toxic Materials documented that all containers of poisonous and toxic materials would be prominently marked or labeled for easy identification and when not in use would be stored on shelves that were used for no other purpose. The policy lacked documentation related to keeping chemicals away from residents and/or secured behind a locked door or cabinet. The facility failed to provide an environment free of accident hazards when the facility failed to appropriately store hazardous chemicals. - Review of the Electronic Health Record (EHR) for Resident (R) 26 included diagnoses of altered mental status (state of awareness that was different from the normal awareness of a person), dementia (a progressive mental disorder characterized by failing memory, confusion) and Wernicke's encephalopathy (a brain and memory disorder that causes confusion, ataxia [impaired ability with muscle coordination], eye problems and memory loss). The Admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of seven, which indicated severely impaired cognition. The assessment documented that R26 had a PHQ-9 score of 0, which indicated no indications for depression and no behaviors documented. R26 required partial/moderate assistance of staff for dressing and footwear, and supervision for all other cares except eating which required setup and supervision. R26 performed toileting independently. The Cognitive Loss / Dementia Care Area Assessment (CAA) dated [DATE], documented that R26 had a diagnosis of dementia with cognitive loss. The [DATE] Care Plan documented R26 displayed wandering behaviors and included multiple interventions for staff to promote safety. The [DATE] Care Plan documented R26 had a history of inappropriate behaviors that included agitation and aggression and intermittent refusal of care and provided the following interventions: Staff would reorient and redirect R26 as needed, dated [DATE]. Staff would allow R26 time to calm down and reapproach at a later time, and monitor for and document each behavioral event, dated [DATE]. Staff would evaluate the need for a referral to psychological services and offer psychosocial support, dated [DATE]. Staff would interact in an empathetic and supportive manner, dated [DATE]. Staff would attempt to allow resident time then reapproach, regarding verbal aggression to staff, dated [DATE]. The Physician's Orders documented the following: Monitor the resident for target behaviors including yelling at staff, resisting cares, hitting others and inappropriate behaviors, two times per day for behavior monitoring, dated [DATE]. Monitor the resident for inappropriate behaviors, wandering, verbal aggression, two times per day for behavior monitoring, dated [DATE]. The Assessments reviewed and lacked safety assessment for R26 to keep or have access to sharp/dangerous objects. The [DATE] to [DATE] Medication Administration Record (MAR) and Treatment Administration Record (TAR) documented monitoring of behaviors. The Progress Notes reviewed [DATE] to [DATE] revealed multiple entries where staff documented rejection of cares, aggression, and agitation towards staff and wandering behavior that included wandering into other resident's rooms. On [DATE] at 11:45 AM, an observation revealed R26 in his room with scissors and nail clippers. R26 became verbally aggressive with survey team when an interview attempted. R26 placed the scissors in the front pocket of his trousers and walked angrily from the room down the hallway. On [DATE] at 07:46 AM, R26 wandered in the hallway with a furrowed brow and scowl expression. On [DATE] at 12:04 PM, Certified Nurse Aide (CNA) F stated that all dangerous items such as chemicals and sharp objects (knives, scissors, etc.) should be locked up and should not be accessible to residents. On [DATE] at 12:14 PM, CNA E stated that dangerous objects such as chemicals, knives or scissors should be locked up and inaccessible to residents. On [DATE] at 12:24 PM, Licensed Nurse (LN) D stated that dangerous items such as chemicals, knives or scissors should be secured in such a way that prevents residents from having access to them. On [DATE] at 03:00 PM, Administrative Nurse B stated that her expectation was for all dangerous items which included chemicals, knives, scissors, and nail clippers to be secured and not available to residents. Administrative Nurse B identified four residents in the facility that were independently mobile and confused, that included R26. Further, Administrative Nurse B identified R26 as a resident who displayed intermittently aggressive behaviors and should not have access to sharp objects. The facility lacked a policy related to securing potentially hazardous objects. The facility failed to ensure that R26, a resident that the facility identified as confused and independently mobile with aggressive and wandering behaviors when R26 put scissors in his pocket and wandered inside the facility. This put this resident at risk for self -injury as well as the residents of the facility at risk for potential of harm related to unsecured sharp objects. - Review of the Electronic Health Record (EHR) for Resident (R) 22 included diagnoses of history of falling, chronic obstructive pulmonary disease (COPD - a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing) and bipolar disorder (a major mental illness that caused people to have episodes of severe high and low moods). The Significant Change Minimum Data Set (MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The assessment documented that R22 utilized a walker or wheelchair for locomotion and required extensive assistance of all cares of two staff members except eating which was performed independently. R22 was always incontinent of urine and occasionally incontinent of bowel. R22 received opioid (class of drug used to treat moderate to severe pain) five of the seven days in the look-back-period and received oxygen. The assessment documented that R22 did not fall since the previous assessment. The Falls Care Area Assessment (CAA) dated [DATE], documented that R22 had a history of falls related to her need for assistance with transfers. The Quarterly MDS dated [DATE], documented a BIMS score of 10, which indicated moderately impaired cognition. The assessment documented R22 was dependent on staff for bathing and toileting and required substantial/maximal assistance for all other cares except eating, which required partial assistance. R22 was always incontinent of urine and occasionally incontinent of bowel and received an antidepressant (a class of medications used to treat mood disorders and relieve symptoms of depression) and oxygen. The assessment documented that R22 fell since the previous assessment. The [DATE] Care Plan documented R22 was at risk for falls related to poor safety awareness, unsteadiness, COPD and hospice/end-of-life care and listed the following interventions: On [DATE] documented staff should place non-skid surface in a chair to prevent her from sliding out of chair, initiated on [DATE] and revised date of [DATE]. Staff would maintain a clutter free environment; free from spills with adequate lighting and place personal items within reach, initiated on [DATE]. Staff would ensure items are within reach, initiated on [DATE]. Staff would ensure the call light was within reach and encourage the resident to call for help, initiated on [DATE]. On [DATE], staff educated to ensure that water pass performed on both shifts and placed within the reach of resident, initiated on [DATE]. Staff would provide appropriate footwear with transfers and ambulation, initiated on [DATE]. Staff would provide assistive devices as needed, initiated on [DATE]. Staff would refer R22 to physical/occupational therapy as needed, initiated on [DATE]. Staff would remind resident to use the call light for safety, initiated on [DATE]. Staff would review information on past falls and attempt to determine the cause of falls as indicated, initiated on [DATE]. Review of the EHR lacked a Safety Device Consent safety assessment for a powered lift chair for R22. Review of the EHR Fall Risk assessment on [DATE], revealed the facility documented a fall risk score of 15, which indicated R22 was a moderate risk for falls. Review of the EHR Fall Risk [TRUNCATED]

The facility reported a census of 40 residents. Based on interview and record review, the facility failed to complete an annual performance review at least once every 12 months for five Certified Nurse Aides (CNAs) reviewed, to ensure adequate appropriate cares and services provided to the residents of the facility. The facility identified five CNAs employed over 12 the month period. Findings included: - Review of employee files on 09/12/24 at 2:00 PM revealed a lack of performance evaluations signed by management for five of five Certified Nurse's Aides (CNAs), that had been employed over one year, that included Certified Nurse's Aide CNA P, CNA Q, CNA R, CNA S and CNA T. On 09/12/24 at 2:00 PM, Administrative Staff A reported that producing the requested performance evaluations for CNA staff would be difficult and stated that he did not know that annual performance evaluations for CNA staff was a requirement. The facility's In-Service Training, Nurse Aide policy dated 09/2022, documented that the facility completes a performance review of the nurse aides at least every 12 months. The facility failed to complete an annual performance review at least once every 12 months for five CNAs reviewed, to ensure adequate appropriate cares and services provided to the residents of the facility. This deficient practice had the potential to negatively affect the physical and psychosocial well-being of all the residents in the facility.

The facility census totaled 40 residents on three halls with a commons area where residents gathered for meals and activities. The facility had one medication cart and one nurse treatment cart that services the facility. Based on observation, interview, and record review, the facility failed to provide a safe environment by the failure to ensure a nurse treatment cart that contained insulin (a medication used to treat diabetes [a disease when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin]), topical ointments and creams, and narcotics that were in a locked box within the nurse's treatment cart, remained locked when not in direct line of vision of the nurse, in an area where residents could access it. Findings included: - Observation on 09/11/24 at 07:47 AM, revealed a treatment cart unlocked and unattended in the hallway where residents could access it. Observation on 09/11/24 at 02:20 PM, revealed a treatment cart in the residents' hallway, unlocked and unattended. On 09/11/24 at 07:50 AM, Licensed Nurse (LN) G identified the unlocked and unattended cart as the treatment cart and confirmed it contained insulins, topical ointments, medicated creams, wound care supplies and narcotics that were in a separate locked box within the cart. LN G verified the treatment cart should be locked when not within arms reach of staff. On 09/11/24 at 08:10 AM, Administrative Nurse B stated it was her expectation staff should lock all medication and treatment carts when not in line of sight of the staff responsible for the cart. On 09/11/24 at 2:20 PM, LN G confirmed the treatment cart was left unattended. LN G confirmed the treatment cart should be locked when unattended. On 09/11/24 at 02:30 PM, Administrative Nurse B confirmed that the Medication and treatment carts should be locked when not in the line of sight of the person responsible for the cart. The facility's Security of Medication Cart policy, revised 4/2007, documented the nurse must secure the medication cart during medication pass. The cart must be locked and parked in the doorway outside the resident's room during the medication pass. When the cart is out of view of the nurse, it must be locked and parked at the nurses' station. The facility failed to provide a safe environment for the residents by the failure to ensure a treatment cart remained locked when not in direct line of vision of the licensed nurse passing medications from their carts.

The facility reported a census of 40 residents. Based on observation, interview, and record review, the facility failed to provide sanitary conditions for food storage and dishes to prevent the spread of food borne illness to the residents of the facility. Findings included: - Initial tour of the kitchen on 09/10/24 at 08:32 AM with Dietary Manager L, revealed the following areas of concerns: 1. In the serving area, several stacks of bowls and plates stored in the upright position that had the potential to be exposed to splash, dust or other contamination. 2. In the dry storage area, a box of pancake mix opened to air and undated, a large bag of long grain rice opened to air and undated, a large container of Japanese breadcrumbs opened to air and undated, and a box of white cake mix opened to air and undated. 3. In an upright stand-alone refrigerator was a container of white cheese opened to air. 4. The facility utilized a three basin sink system for low-temp washing of dishes. Dietary Manager L was unable to provide current sanitation documentation and produced a package of testing strips to test appropriate concentration of sanitizer. Dietary Manager L placed the test strip in the sanitizer water but did not change color which indicated an insufficient amount of sanitizer present. 5. In the main kitchen there were two cutting boards that had deep gouges and were identified as an uncleanable surface by Dietary Manager L. 6. Upright stand-alone refrigerator temperature measured 50 degrees Fahrenheit (F) and contained a partially empty gallon of milk, several dozen eggs, one large tray of raw chicken, several packages of luncheon meats and other assorted foods. On 09/12/24 at 11:01 AM, a follow-up tour with Dietary Manager L, Dietary Staff M, and Resource Staff N revealed the following areas of concerns: 1. Multiple stacks of bowls and plates stored in the upright position that had the potential to be exposed to splash, dust or other contamination. 2. On 09/12/24 at approximately 11:15 AM, dietary staff M obtained food temperatures and poked a thermometer probe through the foil overwrap and into the mashed potatoes. Dietary Staff M stated it was acceptable to test food temperatures without removing the aluminum foil cover. Review of sanitization check logs for 07/01/24 thru 08/31/24 revealed the following: 1. Staff documented a water temperature of 300 degrees F for 56 out of 124 opportunities to document sanitization concentration in the sink (measured in parts per million [PPM - a measurement of the concentration of a substance in a larger solution]). 2. Staff left 56 out of 124 opportunities blank. 3. Staff documented 170 degrees F on seven out of 124 opportunities to document sanitization concentration in the sink in PPM. 4. Staff documented 200 degrees F on four out of 124 opportunities to document sanitization concentration in the sink in PPM. 5. The facility did not provide a sanitization log for 09/2024. Review of refrigerator temperature logs for 07/01/24 thru 08/31/24 revealed the following: 1. Staff failed to document 26 out of 124 opportunities to document the temperature in degrees F. 2. Staff documented 35 out of 124 opportunities to document the temperature in degrees F temperature readings between 42 degrees F and 56 degrees F and started on 07/27/24. 3. The facility did not provide a temperature log for the affected refrigerator for 09/2024. On 09/10/24 at 09:00 AM, Dietary Manager L stated sanitizer levels were to be checked before and after meals and could not recall the minimum sanitizer concentration to be considered safe. Stated that the facility would immediately begin to utilize the high-temperature dish washing machine located in a different room across the hall where the wash and rinse temperatures were 180 degrees F. Additionally, Dietary Manager L reported that his expectation that food should be dated and covered. Further, stated refrigerator temperature checks were to be performed by the staff twice daily and the staff should have reported to him when the refrigerator temperatures were above 41 degrees F. Additionally, confirmed findings discovered by survey team regarding the temperature log for the affected refrigerator. On 09/12/24 at 11:10 AM, Dietary Manager L stated that the correct procedure to obtain temperature readings of food was to remove a corner on the overwrap and not poke the thermometer through the overwrap as the overwrap could potentially be contaminated. The facility's undated Food Storage (Dry, Refrigerated, and Frozen) policy documented that all foods in the kitchen would be labeled and include the name of the food and expiration date. Additionally, all refrigerator temperature settings must ensure that internal food temperature is 41 degrees F or lower. Staff were to place thermometer in the warmest part of the refrigerator to monitor the air temperature and never leave food uncovered or unlabeled. The facility's Refrigerator and Freezer policy, dated 11/2022, documents that refrigerators and freezers will are maintained in good working condition. Refrigerators will keep foods at or below 41 degrees F. The facility failed to provide sanitary food preparation and storage of food. This deficient practice had the potential to cause the spread of food borne illness to the residents of the facility.

The facility reported a census 40 residents. Based on observation, interview, and record review, the facility failed to maintain and/or dispose of garbage and refuse properly in a sanitary condition to prevent the harborage and feeding of pests. Findings included: - Initial tour of the outside trash dumpsters on 09/10/24 at 08:32 AM with Dietary Manager L, revealed two dumpsters had the lids in the open position, one of which had trash debris that stuck out of the dumpster. Both lids were broken and failed to completely cover the trash cans. On 09/10/24 at 08:40 AM, Dietary Manager L revealed he was not aware of the requirement to have trash covered. On 09/10/24 at 10:29 AM, Administrative Staff A stated that the dumpsters belonged to the city. The facility lacked a policy related to garbage and refuse handling and disposal. The facility failed to provide sanitary garbage and refuse containers that were maintained with lids closed or otherwise covered. This deficient practice had the potential to lead to harborage and feeding of pest animals.

The facility identified a census of 40 residents. Based on observations, record reviews, and interviews, the facility failed to put in place an effective administration who ensured the facility was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident who resided at the facility. The outcome of these failures caused harm to Resident (R)2 and R8. Findings included: - The facility failed to provide Resident (R)10 care in a dignified manner during colostomy care. R10 was left lying in his bed for 40 minutes with his door open, undressed waist up and no colostomy (surgical creation of an artificial opening on the stomach wall to excrete feces from the body) bag covered his stoma. This deficient practice placed the resident at risk for decreased psychosocial well-being. The facility failed to include R7 to his care plan meetings. This deficient practice placed the residents at risk for inadequate care and services. This practice had the potential to lead to negative psychosocial effects related to safety and uncommunicated needs. The facility failed to ensure R7 received his monthly benefit in a timely manner. This deficient practice had the potential to have a negative effect on the overall physical and psychosocial well-being of the resident in the facility. The facility failed to ensure four residents had accurately completed advanced directives. Resident (R)2 had a Do Not Resuscitate (DNR- or no code, a legal document or order that means the person does not desire cardiopulmonary resuscitation [CPR is an emergency lifesaving procedure performed when the heart stops beating] in the event of cardiac arrest), only signed by a physician. R8 had two DNR's; one signed by the guardian only and the other one signed only by the physician. R10's DNR was not signed by a witness and R 20's DNR was only signed by a physician. The facility failed to ensure the correct and complete Beneficiary Protection Notification forms were issued to R146, as required. The facility failed to provide written notification to the representatives of Resident (R) 8, R26, R2, R10 and R21. Additionally, the facility also failed to notify the Office of the Long-Term Care Ombudsman (LTCO-a public official who works to resolve resident issues in nursing facilities). These deficient practices placed the residents at risk for impaired rights and uninformed care choices and had the potential to lead to uncommunicated needs related to continuity of care across the healthcare spectrum. The facility failed to provide a bed hold notice to R21 and/or their representative specifying the duration of the bed-hold policy, at the time of the resident's transfer to the hospital. The facility failed to complete Care Area Assessments that addressed the individual underlying causes, contributing factors and risk factors for five residents. Resident (R)7 and R21 had incomplete and repetitive documentation, Additionally R8 all the CAA notes documented R8 was deceased , when R8 was still a resident in facility on [DATE]. R144 had no CAA notes for two triggered categories. The facility failed to accurately complete the Minimum Data Set for two residents, Resident (R)7 and R8 related to falls. Additionally, R7 for dentition (the arrangement or condition of the teeth). This placed the resident at risk for uncommunicated care needs. The facility failed to review and revise the care plans with appropriate interventions for four of the sampled residents; Resident (R) 20 related to physician ordered interventions, R2 related to treatment of an area of pressure ulcer/injury, R22 and R8 related to development and implementation of appropriate interventions to prevent multiple falls for R22 related to continued use of a powered lift chair or develop any new interventions for R8. These deficient practices resulted in uncommunicated care needs. The facility failed to implement a discharge plan for Resident (R)144 being discharged from the facility. The discharge planner failed to involve R144 with the discharge planning process. The facility failed to provide a pressure reducing device on the bed to prevent a pressure injury for Resident (R) 2. On [DATE] the facility noted R2's previous pressure injuries were all closed. On [DATE], R2 was moved to a different room and the facility failed to move his air mattress for his bed to the new room. On [DATE], R2's left heal pressure injury re-opened and was identified as a stage three pressure injury (full thickness pressure injury extending through the skin into the tissue below). This placed the resident at risk to worsen his pressure ulcers and delayed healing. The facility failed to provide an environment free of accident hazards for the residents of the facility when the facility failed to properly store chemicals in an unlocked cabinet in an unlocked room and when the facility stored chemicals along a rail in the hallway. Additionally, the facility failed to ensure R26, who was identified by the facility as confused and independently mobile with aggressive and wandering behaviors, remained free of accident hazards when R26 put scissors in his pocket and wandered inside the facility. Furthermore, the facility failed to ensure that two residents, Resident (R) 22 and R8, remained free of accident hazards related to falls when the facility failed to appropriately investigate, develop, and implement appropriate interventions to prevent multiple falls for R22 related to continued use of a powered lift chair, or develop any new interventions for R8. These deficient practices resulted in R8 falling and sustaining a fracture (broken bone) to her left humerus (upper arm bone) and left fourth rib which required a hospitalization . The facility failed to properly clean, label and store the nebulizer (a device for administering inhaled medications) for Resident (R)7 in accordance with the standards of care and failed to follow up on a bilevel positive airway pressure (BiPAP-medical device which helps with breathing) physician order. In addition, the facility failed to date the oxygen tubing for R144. R7, R21, R22 and R144. The facility failed to complete an annual performance review at least once every 12 months for five Certified Nurse Aides (CNAs) reviewed, to ensure adequate appropriate cares and services provided to the residents of the facility. The facility identified five CNAs employed over 12 the month period. The facility failed to display accurate and identifiable staffing formation daily, for the 40 residents in the facility. The facility failed to provide a safe environment by the failure to ensure a nurse treatment cart that contained insulin (a medication used to treat diabetes [a disease when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin]), topical ointments and creams, and narcotics that were in a locked box within the nurse's treatment cart, remained locked when not in direct line of vision of the nurse, in an area where residents could access it. The facility failed to provide sanitary conditions for food storage and dishes to prevent the spread of food borne illness to the residents of the facility. The facility failed to maintain and/or dispose of garbage and refuse properly in a sanitary condition to prevent the harborage and feeding of pests. The facility failed to use Enhanced Barrier Precautions (EBP is a risk-based approach to use protective personal equipment to reduce the spread of multidrug resistant organism, consisting of gown and gloves). for Resident (R)39 during wound care and R26 during urinary catheter care. This placed the residents at risk for infection. The facility failed to provide proper documentation of vaccination or declination of vaccines for COVID-19 (vaccines designed to prevent COVID-19 [highly contagious respiratory virus]) or pneumococcal (vaccines designed to prevent pneumonia [inflammation of the lungs which can be debilitating or lethal in the elderly]) for one of the five residents reviewed, Resident (R)5. The facility failed to ensure the kitchen's double-door oven was in safe operating condition. The facility failed to develop, implement, and permanently maintain an in-service training program for Certified Nurse Aide (CNAs) with the required topics and no less than 12 hours per year. Two of the five nurse aides sampled lacked the required training topics. Two of five nurse aides sampled lacked the required 12 hours per year of in-service training. The facility failed to put in place an effective administration who ensured the facility was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident who resided at the facility. The outcome of these failures caused harm to Resident (R)2 and R8.

The facility reported a census of 40 residents. Based on observation, interview, and record review, the facility failed to ensure the kitchen's double-door oven was in safe operating condition. Findings included: - On 09/12/24 at 11:01 AM, observation revealed a double-door oven was held closed with a folding metal chair. Interview on 09/12/24 at 11:01 AM with Dietary Manager L, confirmed that the oven doors would not stay closed and must be propped closed with a metal folding chair. The facility failed to provide a policy related to maintaining properly functioning equipment. The facility failed to maintain mechanical equipment in safe operating condition.

The facility reported a census of 40 residents. Based on interview and record review, the facility failed to develop, implement, and permanently maintain an in-service training program for Certified Nurse Aide (CNAs) with the required topics and no less than 12 hours per year. Two of the five nurse aides sampled lacked the required training topics. Two of five nurse aides sampled lacked the required 12 hours per year of in-service training. Findings included: - On 09/12/24 at 12:30 PM, review of training records for five CNAs employed by the facility for more than one year revealed two CNAs had less than 12 hours of documented in-service training for the previous 12 months. CNA S had eight hours of documented training and CNA T had 10.5 of documented training. On 09/12/24 at 12:30 PM, review of training records for five CNAs employed by the facility for more than one year revealed two CNAs did not have the required topics for in-service training for the previous 12 months. CNA Q lacked dementia care training and CNA R lacked behavior health training. On 09/12/24 at 11:49 AM, Administrative Nurse E confirmed that CNAs were required to have 12 hours of training annually and stated that there were no records of additional training for those CNA's. The facility's In-Service Training, Nurse Aide policy revised August 2022, documented that annual in-services are to be no less than 12 hours a calendar year and are to include required training topics which included dementia care and behavioral health. The facility failed to develop, implement and permanently maintain an in-service training program for CNAs with the required topics and no less than 12 in-service training hours per year.

The facility reported a census of 40 residents, with 12 residents sampled, including review for advanced directives (a written document which indicated the medical decisions for health care professionals when the person could not make their own decisions). Based on interview and record review, the facility failed to ensure four residents had accurately completed advanced directives. Resident (R)2 had a Do Not Resuscitate (DNR- or no code, a legal document or order that means the person does not desire cardiopulmonary resuscitation [CPR is an emergency lifesaving procedure performed when the heart stops beating] in the event of cardiac arrest), only signed by a physician. R8 had two DNR's; one signed by the guardian only and the other one signed only by the physician. R10's DNR was not signed by a witness and R 20's DNR was only signed by a physician. Findings included: - Resident (R)2 's Electronic Health Record (EHR) revealed diagnoses of diabetes mellitus type two (DM2-when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin) and reduced mobility. The Significant Change Minimum Data Set (MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) of 99, indicating intact severely impaired cognition. The resident had a total mood severity score of two, indicating no depression and no behaviors. R2 required total assistance with activities of daily living (ADLs), which included bed mobility, toileting, dressing, and bathing. R2 was always incontinent of bladder. R2 had a stage two pressure ulcer (partial-thickness skin loss into but no deeper than the dermis including intact or ruptured blisters) on admission. There was a pressure relieving device on the bed and the chair. The Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) did not trigger on the [DATE] MDS. The Quarterly MDS dated [DATE], documented a BIMS of 99. The [DATE] Care Plan documented staff were not to perform cardiopulmonary resuscitation (CPR- emergency lifesaving procedure performed when the heart stops beating), dated [DATE]. The Physician's Order dated [DATE], documented a Do Not Resuscitate order. The review of the scanned DNR lacked a signature from the resident or durable power of attorney (DPOA- legal document that named a person to make healthcare decisions when the resident was no longer able to). The DNR was only signed by a physician, dated [DATE]. On [DATE] at 04:45 PM, Social Service Designee (SSD) K confirmed that R2's DNR lacked the resident or DPOA signatures. SSD K revealed that a DNR required a resident or DPOA signature and then signed by the physician. On [DATE] at 04:40 PM, Administrative Nurse B confirmed the advanced directives forms should be completed as per policy and contain all the required signatures. On [DATE] at 10:49 AM, Administrative Staff A confirmed there was an issue with advanced directives not being signed as required. The facility's Advanced Directives policy dated [DATE] documented the resident has the right to formulate an advanced directive, including the right to accept or refuse medical or surgical treatment. Advanced directives are honored in accordance with state law and facility policy. Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advanced directive if they choose to do so. DPOA for healthcare is a document delegating authority to a legal representative to make health care decisions in case the individual delegating the authority subsequently becomes incapacitated. The facility failed to ensure R2 had an accurately completed advanced directive. This deficient practice had the potential to lead to uncommunicated needs specifically to end-of-life care. - Resident (R)10 's Electronic Health Record (EHR) revealed diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion) and need for assistance with personal care. The Annual Minimum Data Set (MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) of 15, indicating intact cognition. The resident had a total mood severity score of 00, indicating no depression and no behaviors. R10 required total assistance with activities of daily living (ADLs), which included toileting, dressing, and transfers. R10 was frequently incontinent of bladder and bowel. The Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) dated [DATE], documented R10 required variable assistance with ADL function and mobility related to rheumatoid arthritis (chronic inflammatory disease that affected joints and other organ systems). Staff would continue with care plan and a goal to maintain current function. The Quarterly MDS dated [DATE], documented a BIMS of eight, indicating moderately impaired cognition. R10 required total assistance with ADL's, which included toileting, dressing, and transfers. Frequently incontinent of bladder. Not rated for bowels as R10 had a colostomy (surgical creation of an artificial opening on the stomach wall to excrete feces from the body). The [DATE] Care Plan documented staff were not to perform cardiopulmonary resuscitation (CPR- emergency lifesaving procedure performed when the heart stops beating), dated [DATE]. The Physician's Order dated [DATE], documented a Do Not Resuscitate order. The review of the scanned DNR lacked a witness signature on the [DATE] DNR form. On [DATE] at 04:45 PM, Social Service Designee (SSD) K confirmed that R10's DNR lacked the witness signature. SSD K revealed that a DNR required a witness signature. On [DATE] at 04:40 PM, Administrative Nurse B confirmed the advanced directives forms should be completed as per policy and contain all the required signatures. On [DATE] at 10:49 AM, Administrative Staff A confirmed there was an issue with advanced directives not being signed as required. The facility's Advanced Directives policy dated [DATE] documented the resident has the right to formulate an advanced directive, including the right to accept or refuse medical or surgical treatment. Advanced directives are honored in accordance with state law and facility policy. Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advanced directive if they choose to do so. DPOA for healthcare is a document delegating authority to a legal representative to make health care decisions in case the individual delegating the authority subsequently becomes incapacitated. The facility failed to ensure R10 had an accurately completed advanced directive. This deficient practice had the potential to lead to uncommunicated needs specifically to end-of-life care. - Resident (R)20 's Electronic Health Record (EHR) revealed diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion) and osteoporosis (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk). The Annual Minimum Data Set (MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) of 99, indicating intact severely impaired cognition. The resident had a total mood severity score of 00, indicating no depression and no behaviors. R20 required total assistance with activities of daily living (ADLs), which included bed mobility, toileting, dressing, and bathing. R20 was always incontinent of bladder. The Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA), dated [DATE] lacked analysis of findings documented. The Quarterly MDS dated [DATE], documented a BIMS of 99. The [DATE] Care Plan documented staff were not to perform cardiopulmonary resuscitation (CPR- emergency lifesaving procedure performed when the heart stops beating), dated [DATE]. The Physician's Order dated [DATE], documented a Do Not Resuscitate order. The review of the scanned DNR lacked a signature from the resident or durable power of attorney (DPOA- legal document that named a person to make healthcare decisions when the resident was no longer able to) and lacked a witness signature. The DNR was only signed by a physician, dated [DATE]. On [DATE] at 04:45 PM, Social Service Designee (SSD) K confirmed that R20's DNR lacked the resident or DPOA signatures and witness signature. SSD K revealed that a DNR required a resident or DPOA signature, then a witness signature and then signed by the physician. On [DATE] at 04:40 PM, Administrative Nurse B confirmed the advanced directives forms should be completed as per policy and contain all the required signatures. On [DATE] at 10:49 AM, Administrative Staff A confirmed there was an issue with advanced directives not being signed as required. The facility's Advanced Directives policy dated [DATE] documented the resident has the right to formulate an advanced directive, including the right to accept or refuse medical or surgical treatment. Advanced directives are honored in accordance with state law and facility policy. Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advanced directive if they choose to do so. DPOA for healthcare is a document delegating authority to a legal representative to make health care decisions in case the individual delegating the authority subsequently becomes incapacitated. The facility failed to ensure R20 had an accurately completed advanced directive. This deficient practice had the potential to lead to uncommunicated needs specifically to end-of-life care. 46960 - Review of the Electronic Health Record (EHR) for Resident (R)8 included the diagnoses of osteoporosis (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk), history of falling, repeated falls, generalized muscle weakness, lack of coordination and dementia (a progressive mental disorder characterized by failing memory, confusion). The Significant Change Minimum Data Set (MDS) dated [DATE], documented R8 was unable to complete the Brief Interview for Mental Status (BIMS) assessment and staff assessed R8 to have severely impaired cognition. The assessment documented R8 required substantial or maximal assistance from staff for cares. R8 was dependent on staff to perform oral hygiene. R8 required supervision and setup for eating. R8 was frequently incontinent of bladder and always incontinent of bowel. The Cognitive Loss / Dementia Care Area Assessment (CAA) dated [DATE], documented R8 as deceased . The Quarterly MDS dated [DATE], documented R8 was unable to complete the BIMS assessment and staff assessed R8 to have severely impaired cognition. The assessment documented R8 was dependent on staff for toileting, bathing and all forms of hygiene and required substantial or maximal assistance for all other cares except eating which was required supervision/setup. R8 was frequently incontinent of bowel and always incontinent of bladder. The [DATE] Care Plan documented the following: 1. On [DATE], two interventions documented staff were not to perform cardiopulmonary resuscitation (CPR- emergency lifesaving procedure performed when the heart stops beating). 2. On [DATE], staff were to honor the resident's wishes. 3. On [DATE], staff were to notify the physician and family of the resident's passing. 4. On [DATE], staff were to provide comfort to the resident's family during a time of loss. The Physician's Order dated [DATE], documented a Do Not Resuscitate order. The review of the EHR scanned documents revealed the following: 1. A DNR order, dated [DATE], lacked a signature from the resident or durable power of attorney (DPOA- legal document that named a person to make healthcare decisions when the resident was no longer able to). Additionally, the document lacked a witness signature. The DNR was signed by R8's guardian/conservator, dated [DATE], and a physician, dated [DATE]. 2. A DNR order, dated [DATE], lacked a signature from the resident or DPOA or witness. The DNR was only signed by a physician dated [DATE]. On [DATE] at 08:22 AM, Social Service Designee (SSD) K that residents DNR should have a resident or DPOA signature and a witness, and a physician signature. SSD K confirmed that some residents DNR orders were missing signatures. SSD K also confirmed that guardians/conservators cannot sign a resident's DNR order without a court order. On [DATE] at 04:40 PM, Administrative Nurse B confirmed the advanced directives forms should be completed as per policy and contain all the required signatures and cannot be signed by a resident's guardian/conservator. On [DATE] at 10:49 AM, Administrative Staff A confirmed there was an issue with advanced directives not being signed as required. The facility's Advanced Directives policy dated [DATE] documented the resident has the right to formulate an advanced directive, including the right to accept or refuse medical or surgical treatment. Advanced directives are honored in accordance with state law and facility policy. Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advanced directive if they choose to do so. DPOA for healthcare is a document delegating authority to a legal representative to make health care decisions in case the individual delegating the authority subsequently becomes incapacitated. The facility failed to ensure R8 had an accurately completed advanced directive. This deficient practice had the potential to lead to uncommunicated needs specifically to end-of-life care.

The facility identified a census of 40 residents which included 12 residents sampled, that included five residents reviewed for notification of discharge to residents' representative and the Office of the State Long-Term Care Ombudsman. The facility failed to provide written notification to the representatives of Resident (R) 8, R26, R2, R10 and R21. Additionally, the facility also failed to notify the Office of the Long-Term Care Ombudsman (LTCO-a public official who works to resolve resident issues in nursing facilities). These deficient practices placed the residents at risk for impaired rights and uninformed care choices and had the potential to lead to uncommunicated needs related to continuity of care across the healthcare spectrum. Findings included: - Review of the Electronic Health Record (EHR) for Resident (R) 8 revealed a hospitalization from [DATE] to 05/06/24. Review of the EHR Progress Notes lacked documentation that R8's representative was notified of the hospitalization by the facility. Review of the EHR scanned documents lacked documentation that the facility notified the LTCO regarding the hospitalization of R8. On 09/12/24 at 09:40 AM, Social Services Designee (SSD) K stated she did not know of the requirement to contact the LTCO when a resident was transferred or discharged . On 09/12/24 at 10:49 AM, Administrative Staff A stated that he was unsure about the bed hold policy and would need to look at the policy. Administrative Staff A reported that the LTCO should be notified once a month regarding transfers or discharges to a hospital. The facility lacked a policy related to notifications of residents' representatives or LTCO upon transfer or discharge. The facility failed to provide written notification to the representatives of R8 or the LTCO when this resident required hospitalization . This deficient practice placed R8 at risk for impaired rights and uninformed care choices and had the potential to lead to uncommunicated needs related to continuity of care across the healthcare spectrum. - Review of the Electronic Health Record (EHR) for Resident (R) 26 revealed a hospitalization from [DATE] to 08/06/24. Review of the EHR Progress Notes lacked documentation that R26's representative was notified of the hospitalization by the facility. Review of the EHR scanned documents lacked documentation that the facility notified the LTCO regarding the hospitalization of R26. On 09/12/24 at 09:40 AM, Social Services Designee (SSD) K stated she did not know of the requirement to contact the LTCO when a resident was transferred or discharged . On 09/12/24 at 10:49 AM, Administrative Staff A stated that he was unsure about the bed hold policy and would need to look at the policy. Administrative Staff A reported that the LTCO should be notified once a month regarding transfers or discharges to a hospital. The facility lacked a policy related to notifications of residents' representatives or LTCO upon transfer or discharge. The facility failed to provide written notification to the representatives of R26 or the LTCO when this resident required hospitalization . This deficient practice placed R26 at risk for impaired rights and uninformed care choices and had the potential to lead to uncommunicated needs related to continuity of care across the healthcare spectrum. 50659 - Resident (R) 2's Electronic Health Record (EHR) revealed diagnoses of diabetes mellitus type two (DM2-when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin) and reduced mobility. The Significant Change Minimum Data Set (MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) of 99, indicating severely impaired cognition. The resident had a total mood severity score of two, indicating no depression and R2 had no behaviors. R2 required total assistance with activities of daily living (ADLs), which included bed mobility, toileting, dressing, and bathing. R2 was always incontinent of bladder. R2 had a stage two pressure ulcer (partial-thickness skin loss into but no deeper than the dermis including intact or ruptured blisters) on admission. The Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) did not trigger on the 10/25/23 MDS. The Pressure Ulcer CAA dated 11/02/23, documented an actual skin breakdown and R2 was at risk for further skin breakdown due to incontinence. Treatment and preventative measures were in place and the facility consulted a wound care physician. The facility would proceed with care planning to ensure that interventions were in place to heal an existing wound and prevent new skin breakdown. The Quarterly MDS dated [DATE], documented a BIMS of 99. R2 required total assistance of staff with ADLs. R2 had two stage three pressure ulcers (full thickness pressure injury extending through the skin into the tissue below), which were facility acquired and had pressure relieving devices on the bed and the chair. Review of the Progress Notes from 01/01/24 to 09/10/24 documented the following: On 04/16/24, a Progress Note at 11:08 AM, wound care clinic staff had R2 admitted to a hospital for a worsened foot ulcer and noted the left heel wound required debridement (medical removal of dead, damaged, or infected tissue to improve the healing potential for the remaining healthy tissue). Family notified. On 4/18/24, a Progress Note at 01:44 PM, R2 readmitted back to the facility. Review of the EHR scanned documents lacked documentation that the facility notified the Office of the Long-Term Care Ombudsman (LTCO-a public official who works to resolve resident issues in nursing facilities) regarding the hospitalization of R2. On 09/12/24 at 09:40 AM, Social Services Designee (SSD) K stated she did not know of the requirement to contact the LTCO when a resident was transferred or discharged . On 09/12/24 at 10:49 AM, Administrative Staff A stated that he was unsure about the bed hold policy and would need to look at the policy. Administrative Staff A reported that the LTCO should be notified once a month regarding transfers or discharges to a hospital. The facility lacked a policy related to notifications of residents' representatives or LTCO upon transfer or discharge. The facility failed to provide written notification to the LTCO when R2 required hospitalization . This deficient practice placed R2 at risk for impaired rights and uninformed care choices and had the potential to lead to uncommunicated needs related to continuity of care across the healthcare spectrum. - Resident (R)10 's Electronic Health Record (EHR) revealed diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion) and need for assistance with personal care. The Annual Minimum Data Set (MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) of 15, indicating intact cognition. The resident had a total mood severity score of 00, indicating no depression and no behaviors. R10 required total assistance with activities of daily living (ADLs), which included toileting, dressing, and transfers. R10 was frequently incontinent of bladder and bowel. The Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) dated 12/05/23, documented R10 required variable assistance with ADL function and mobility related to rheumatoid arthritis (chronic inflammatory disease that affected joints and other organ systems). Staff would continue with care plan and a goal to maintain current function. The Quarterly MDS dated [DATE], documented a BIMS of eight, indicating moderately impaired cognition. R10 required total assistance with ADL's, which included toileting, dressing, and transfers. Frequently incontinent of bladder. Not rated for bowels as R10 had a colostomy (surgical creation of an artificial opening on the stomach wall to excrete feces from the body). On 09/10/24 11:37 AM, R10 reported he had been in the hospital in March 2024 for his stomach pain and had to have a colostomy completed. Review of the EHR scanned documents lacked documentation that the facility notified the Office of the Long-Term Care Ombudsman (LTCO-a public official who works to resolve resident issues in nursing facilities) regarding the hospitalization of R10. On 09/12/24 at 09:40 AM, Social Services Designee (SSD) K stated she did not know of the requirement to contact the LTCO when a resident was transferred or discharged . On 09/12/24 at 10:49 AM, Administrative Staff A stated that he was unsure about the bed hold policy and would need to look at the policy. Administrative Staff A reported that the LTCO should be notified once a month regarding transfers or discharges to a hospital. The facility lacked a policy related to notifications of residents' representatives or LTCO upon transfer or discharge. The facility failed to provide written notification to the LTCO when this R10 required hospitalization . This deficient practice placed R10 at risk for impaired rights and uninformed care choices and had the potential to lead to uncommunicated needs related to continuity of care across the healthcare spectrum. - Resident (R)21 's Electronic Health Record (EHR) revealed diagnoses of chronic obstructive pulmonary disease (COPD- progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing) and sleep apnea (disorder of sleep characterized by periods without respirations). The 05/20/24 Admission Minimum Data Set (MDS), documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The resident had a total mood severity score of 00, indicating no depression and no behaviors. R21 required total assistance with activities of daily living (ADLs), with toileting hygiene. Maximal assistance dressing and transfers. The 05/27/24 Care Area Assessment (CAA) lacked analysis of findings documented. The 08/05/24 Quarterly MDS, documented a BIMS score of 15, indicating intact cognition. R21 required total assistance with most ADLs. R21 required oxygen. Review of the EHR for Resident (R)21 revealed a hospitalization from [DATE] to 06/27/24, a hospitalization from [DATE] to 07/08/24 and a hospitalization from [DATE] to 07/31/24. Review of the EHR scanned documents lacked documentation that the facility notified the Office of the Long-Term Care Ombudsman (LTCO-a public official who works to resolve resident issues in nursing facilities) regarding the hospitalization of R21. On 09/12/24 at 09:40 AM, Social Services Designee (SSD) K stated she did not know of the requirement to contact the LTCO when a resident was transferred or discharged . On 09/12/24 at 10:49 AM, Administrative Staff A stated that he was unsure about the bed hold policy and would need to look at the policy. Administrative Staff A reported that the LTCO should be notified once a month regarding transfers or discharges to a hospital. The facility lacked a policy related to notifications of residents' representatives or LTCO upon transfer or discharge. The facility failed to provide written notification to the LTCO when this R21 required hospitalization . This deficient practice placed R21 at risk for impaired rights and uninformed care choices and had the potential to lead to uncommunicated needs related to continuity of care across the healthcare spectrum.

The facility had a census of 40 residents. The sample included 12 residents with five residents reviewed for hospitalization . Based on observation, interview, and record review, the facility failed to provide a bed hold notice to Residents, (R)2, R10, R21 and R26 and/or their representative with a written notice specifying the duration of the bed-hold policy, at the time of the residents' transfers to the hospital. Findings included: - Resident (R) 2's Electronic Health Record (EHR) revealed diagnoses of diabetes mellitus type two (DM2-when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin) and reduced mobility. The Significant Change Minimum Data Set (MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) of 99, indicating severely impaired cognition. The resident had a total mood severity score of two, indicating no depression and R2 had no behaviors. R2 required total assistance with activities of daily living (ADLs), which included bed mobility, toileting, dressing, and bathing. R2 was always incontinent of bladder. R2 had a stage two pressure ulcer (partial-thickness skin loss into but no deeper than the dermis including intact or ruptured blisters) on admission. The Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) did not trigger on the 10/25/23 MDS. The Pressure Ulcer CAA dated 11/02/23, documented an actual skin breakdown and R2 was at risk for further skin breakdown due to incontinence. Treatment and preventative measures were in place and the facility consulted a wound care physician. The facility would proceed with care planning to ensure that interventions were in place to heal an existing wound and prevent new skin breakdown. The Quarterly MDS dated [DATE], documented a BIMS of 99. R2 required total assistance of staff with ADLs. R2 had two stage three pressure ulcers, which were facility acquired and had pressure relieving devices on the bed and the chair. The 09/10/24 Care Plan lacked any documentation regarding a bed hold. Review of the Progress Notes from 01/01/24 to 09/10/24 documented the following: On 04/16/24, a Progress Note at 11:08 AM, wound care clinic staff had R2 admitted to a hospital for a worsened foot ulcer and noted the left heel wound required debridement (medical removal of dead, damaged, or infected tissue to improve the healing potential for the remaining healthy tissue). On 4/18/24, a Progress Note at 01:44 PM, R2 readmitted back to facility. Review of EHR on 09/10/24 lacked any documentation for a bed hold. On 09/12/24 at 09:30 AM, Social Service Designee (SSD) K reported she did not provide R2 or representative with a written bed-hold policy, because she would have documented that in the progress notes. On 09/12/24 at 09:57 AM, Administrative Nurse B reported charge nurses do not complete a bed hold form when a resident transferred to a hospital. She reported that Administrative Staff I or SSD K would be responsible to complete the bed hold form. On 09/12/24 at 10:42 AM, Administrative Staff I reported she would not complete any bed hold forms for residents or representative when a resident would be transferred to the hospital. On 09/12/24 at 10:49 AM, Administrative Staff A reported he was unsure about the bed hold policy and would need to read the policy. The facility's policy Bed-Holds and Returns dated October 2022, documented residents and or representatives are informed in writing of the facility and staff (if applicable) bed-hold policies. All residents and or representatives are provided written information regarding the facility and state bed-hold policies, which address holding or reserving a resident's bed during periods of absence (hospitalization s). Residents, regardless of payer source, are provided written notice about these policies. At the time of transfer (or, if the transfer was an emergency, within 24 hours). The facility failed to provide a bed-hold notice to R2 and/or their representative specifying the duration of the bed hold policy, at the time of the resident's transfer to the hospital. - Resident (R)10 's Electronic Health Record (EHR) revealed diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion) and need for assistance with personal care. The Annual Minimum Data Set (MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) of 15, indicating intact cognition. The resident had a total mood severity score of 00, indicating no depression and no behaviors. R10 required total assistance with activities of daily living (ADLs), which included toileting, dressing, and transfers. R10 was frequently incontinent of bladder and bowel. The Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) dated 12/05/23, documented R10 required variable assistance with ADL function and mobility related to rheumatoid arthritis (chronic inflammatory disease that affected joints and other organ systems). Staff would continue with care plan and a goal to maintain current function. The Quarterly MDS dated [DATE], documented a BIMS of eight, indicating moderately impaired cognition. R10 required total assistance with ADL's, which included toileting, dressing, and transfers. Frequently incontinent of bladder. Not rated for bowels as R10 had a colostomy (surgical creation of an artificial opening on the stomach wall to excrete feces from the body). The 09/10/24 Care Plan lacked any documentation regarding a bed hold. On 03/01/24, a Progress Note at 04:25 PM, physician updated on R10 abdominal pain, had not voided and was lethargic. Physician had ordered a straight catheter yesterday (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid). R10 refused the catheter. The physician ordered an indwelling catheter to be placed, and if unable to place in house, send R10 to the hospital. On 03/01/24, a Progress Note at 04:42 PM, R10 was transferred to the hospital as resident refused the indwelling catheter to be placed. On 03/13/24, a Progress Note at 12:20 AM, R10 remained in hospital, On 03/15/24, a Progress Note at 06:30 PM, R10 readmitted back to facility. On 09/10/24 at 11:37 AM, R10 reported he had been in the hospital in March 2024 for his stomach pain and had to have a colostomy. Review of EHR on 09/10/24 lacked any documentation for a bed hold. On 09/12/24 at 09:30 AM, Social Service Designee (SSD) K reported she did not provide R10 or representative with a written bed-hold policy, because she would have documented that in the progress notes. On 09/12/24 at 09:57 AM, Administrative Nurse B reported charge nurses do not complete a bed hold form when a resident transferred to a hospital. She reported that Administrative Staff I or SSD K would be responsible to complete the bed hold form. On 09/12/24 at 10:42 AM, Administrative Staff I reported she would not complete any bed hold forms for residents or representative when a resident would be transferred to the hospital. On 09/12/24 at 10:49 AM, Administrative Staff A reported he was unsure about the bed hold policy and would need to read the policy. The facility's policy Bed-Holds and Returns dated October 2022, documented residents and or representatives are informed in writing of the facility and staff (if applicable) bed-hold policies. All residents and or representatives are provided written information regarding the facility and state bed-hold policies, which address holding or reserving a resident's bed during periods of absence (hospitalization s). Residents, regardless of payer source, are provided written notice about these policies. At the time of transfer (or, if the transfer was an emergency, within 24 hours). The facility failed to provide a bed hold notice to R10 and/or their representative specifying the duration of the bed-hold policy, at the time of the resident's transfer to the hospital. - Resident (R)21 's Electronic Health Record (EHR) revealed diagnoses of chronic obstructive pulmonary disease (COPD- progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing) and sleep apnea (disorder of sleep characterized by periods without respirations). The 05/20/24 Admission Minimum Data Set (MDS), documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The resident had a total mood severity score of 00, indicating no depression and no behaviors. R21 required total assistance with activities of daily living (ADLs), with toileting hygiene and required maximal assistance with dressing and transfers. The 05/27/24 Care Area Assessment (CAA) lacked analysis of findings documented. The 08/05/24 Quarterly MDS, documented a BIMS score of 15, indicating intact cognition. R21 required total assistance with most ADLs. R21 required oxygen. The 09/10/24 Care Plan lacked any documentation regarding a bed hold. Review of the Progress Notes from 01/01/24 to 09/10/24 documented the following: On 06/20/24, a Progress Note at 03:54 PM, R21 transferred to a hospital with altered mental status and functional decline. R21 admitted to hospital for alerted level of consciousness and elevated laboratory results. The responsible party notified. On 06/27/24, a Progress Note at 05:29 PM, R21 readmitted back to the facility. On 07/05/24, a Progress Note at 08:53 AM, R21 transferred to a hospital for altered mental status. The responsible party notified. On 07/05/24, a Progress Note at 12:44 PM, R21 was admitted to the hospital for respiratory failure (results from inadequate gas exchange by the respiratory system). On 07/08/24, a Progress Note at 11:40 PM, R21 readmitted back to facility. On 07/28/24, a Progress Note at 06:33 PM, R21 transferred to a hospital for shortness of breath and altered mental status. The responsible party notified. On 07/28/24, a Progress Note at 08:40 PM, R21 admitted to hospital for chronic kidney disease (a condition that occurs when the kidneys are damaged and can't filter blood properly) and a urinary tract infection (UTI-an infection in any part of the urinary system). On 07/31/24, a Progress Note at 03:20 PM, R21 readmitted back to the facility. Review of EHR on 09/10/24 lacked any documentation for a bed hold. On 09/12/24 at 09:30 AM, Social Service Designee (SSD) K reported she did not provide R21 or representative with a written bed-hold policy, because she would have documented that in the progress notes. On 09/12/24 at 09:57 AM, Administrative Nurse B reported charge nurses do not complete a bed hold form when a resident transferred to a hospital. She reported that Administrative Staff I or SSD K would be responsible to complete the bed hold form. On 09/12/24 at 10:42 AM, Administrative Staff I reported she would not complete any bed hold forms for residents or representative when a resident would be transferred to the hospital. On 09/12/24 at 10:49 AM, Administrative Staff A reported he was unsure about the bed hold policy and would need to read the policy. The facility's policy Bed-Holds and Returns dated October 2022, documented residents and or representatives are informed in writing of the facility and staff (if applicable) bed-hold policies. All residents and or representatives are provided written information regarding the facility and state bed-hold policies, which address holding or reserving a resident's bed during periods of absence (hospitalization s). Residents, regardless of payer source, are provided written notice about these policies. At the time of transfer (or, if the transfer was an emergency, within 24 hours). The facility failed to provide a bed hold notice to R21 and/or their representative specifying the duration of the bed-hold policy, at the time of the resident's transfer to the hospital. 46960 - Resident (R) 26's Electronic Health Record (EHR) revealed diagnoses of altered mental status, infection and inflammatory reaction due to catheter, Wernicke's encephalopathy (an acute neurological condition marked by mental confusion and unsteady gait), sepsis (systemic reaction that develops when the chemicals in the immune system release into the blood stream to fight an infection which cause inflammation throughout the entire body instead. Severe cases of sepsis can lead to the medical emergency, septic shock.) and hypertension (HTN- elevated blood pressure) Review of Discharge Minimum Data Set (MDS) dated [DATE] documented R26 had an unplanned discharge with a return anticipated. Review of Quarterly MDS dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of nine, which indicated moderate cognitive impairment. R26 was independent with all cares. R26 had behaviors of wandering one to three days in the look back period and other behavioral symptoms not directed towards others one to three days during the look back period. The 09/10/24 Care Plan lacked any documentation regarding a bed hold. Review of Progress Notes revealed the following: On 08/04/24 at 02:41 PM, a Progress Note documented R26 had blood from his penis. R26 transferred to the hospital at 01:40 PM. The progress note lacked evidence that the responsible party was notified, or a bed hold given to the resident and/or responsible party. On 08/04/24 at 06:26 PM, a Progress note documented R26 was admitted to the hospital for elevated white blood cell count and fever. The progress note lacked evidence that a responsible party was notified or bed hold given to the resident/responsible party. Review of a Census Log in the EHR revealed R26 discharged on [DATE] and returned to the facility on [DATE]. Review of EHR on 09/10/24 lacked any documentation for a bed hold. On 09/12/24 at 09:30 AM, Social Service Designee (SSD) K reported she did not provide R26 or representative with a written bed-hold policy, because she would have documented that in the progress notes. On 09/12/24 at 09:57 AM, Administrative Nurse B reported charge nurses do not complete a bed hold form when a resident transferred to a hospital. She reported that Administrative Staff I or SSD K would be responsible to complete the bed hold form. On 09/12/24 at 10:42 AM, Administrative Staff I reported she would not complete any bed hold forms for residents or representative when a resident would be transferred to the hospital. On 09/12/24 at 10:49 AM, Administrative Staff A reported he was unsure about the bed hold policy and would need to read the policy. The facility's policy Bed-Holds and Returns dated October 2022, documented residents and or representatives are informed in writing of the facility and staff (if applicable) bed-hold policies. All residents and or representatives are provided written information regarding the facility and state bed-hold policies, which address holding or reserving a resident's bed during periods of absence (hospitalization s). Residents, regardless of payer source, are provided written notice about these policies. At the time of transfer (or, if the transfer was an emergency, within 24 hours). The facility failed to provide a bed hold notice to R26 and/or their representative specifying the duration of the bed-hold policy, at the time of the resident's transfer to the hospital.

The facility reported a census of 40 residents. The sample included 12 residents. Based on record review and interviews, the facility failed to complete Care Area Assessments that addressed the individual underlying causes, contributing factors and risk factors for five residents. Resident (R)7 and R21 had incomplete and repetitive documentation, Additionally R8 all the CAA notes documented R8 was deceased , when R8 was still a resident in facility on [DATE]. R144 had no CAA notes for two triggered categories. Findings included: - Resident (R)7's medical diagnoses included chronic respiratory failure (a long-term condition that occurs when the body's respiratory system is unable to exchange oxygen and carbon dioxide properly) and morbid obesity (excessive body fat). The [DATE] Admission Minimum Data Set (MDS), documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. R7 required total assistance with activities of daily living (ADLs), with toileting hygiene, bathing, dressing, personal care, and transfers. R7 required oxygen and dialysis (procedure where impurities or wastes were removed from the blood). The [DATE] Functional Abilities Care Area Assessment, Nutritional, Urinary Incontinence and the Pressure Ulcer CAAs were all documented as the same note for analysis and care plan consideration for R7. admitted for skilled services. Dialysis patient and diagnosis of morbid obesity. Needed assistance with ADL's and transfers related to impaired mobility. R7 was at risk for falls and skin breakdown related to impaired mobility and incontinence. Weights as indicated. The [DATE] Quarterly MDS, documented a BIMS score of 15, indicating intact cognition. R7 required total assistance with ADLs, .R7 required oxygen and dialysis. On [DATE] at 03:20 PM, Administrative Nurse C reported the MDS's are completed off site by Consultant Nurse J. Administrative Nurse C reported the Consultant Nurse J calls the facility every day at the morning meeting and a tele-conference completed with the Interdisciplinary team. On [DATE] at 09:57 AM, Administrative Nurse B revealed she expected the MDS information to be completed correctly. On [DATE] at 03:02 PM, Consultant Nurse J was called on her phone number provided and did not answer the call. Review of facility's policy Resident Assessment Instrument Completion of the RAI dated [DATE] documented: The MDS completion is comprised of many individuals known as the Interdisciplinary Team and that there are many sections that are completed. The policy lacked any documentation about the CAAs. The facility failed to accurately complete the CAAs for (R)7 related to functional abilities, urinary incontinence, nutritional status and pressure ulcer/injury. This placed the resident at risk for uncommunicated care needs. - Resident (R)144's medical diagnoses included sleep apnea (disorder of sleep characterized by periods without respirations) and chronic respiratory failure (a condition that results in the inability to effectively exchange carbon dioxide and oxygen). The [DATE] Admission Minimum Data Set (MDS), documented a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. The resident had a total mood severity score of four, indicating no to minimal depression and R144 had no behaviors. R144 required total assistance with activities of daily living (ADLs), with transfers and wheelchair mobility. Maximal assistance with toileting, dressing and bed mobility. Frequently incontinent of bladder. R144 required oxygen. discharge date is more than three months away. The [DATE] Functional Abilities Care Area Assessment, Nutritional, Urinary Incontinence and the Pressure Ulcer CAAs were all documented as the same note for analysis and care plan consideration for R144. He admitted to the facility for skilled services. R144 required assistance with ADL's and transfers related to impaired mobility. R7 was at risk for falls and skin breakdown related to impaired mobility and incontinence. The Psychosocial Well-Being and Activities CAA that triggered lacked any documentation. On [DATE] at 03:20 PM, Administrative Nurse C reported the MDS's are completed off site by Consultant Nurse J. Administrative Nurse C reported the Consultant Nurse J calls the facility every day at the morning meeting and a tele-conference completed with the Interdisciplinary team. On [DATE] at 09:57 AM, Administrative Nurse B revealed she expected the MDS information to be completed correctly. On [DATE] at 03:02 PM, Consultant Nurse J was called on her phone number provided and did not answer the call. Review of facility's policy Resident Assessment Instrument Completion of the RAI dated [DATE], documented: The MDS completion is comprised of many individuals known as the Interdisciplinary Team and that there are many sections that are completed. The policy lacked any documentation about the CAAs. The facility failed to accurately complete the CAAs for (R)144 related to functional abilities, urinary incontinence, nutritional status and pressure ulcer/injury. This placed the resident at risk for uncommunicated care needs. - Resident (R)21 's Electronic Health Record (EHR) revealed diagnoses of chronic obstructive pulmonary disease (COPD- progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing) and sleep apnea (disorder of sleep characterized by periods without respirations). The [DATE] Admission Minimum Data Set (MDS), documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The resident had a total mood severity score of 00, indicating no depression and no behaviors. R21 required total assistance with activities of daily living (ADLs), with toileting hygiene. Maximal assistance dressing and transfers. The [DATE] Functional Abilities Care Area Assessment, Nutritional, Urinary Incontinence Falls Psychotropic Drug Use and the Pressure Ulcer CAAs were all documented as the same note for analysis and care plan consideration for R21. She was admitted for skilled services fall with pelvic fracture she required assistance with ADL's and transfers related to impaired mobility. R21 was at risk for falls and skin breakdown related to impaired mobility and incontinence. Received antipsychotic (class of medications used to treat major mental conditions which cause a break from reality) medication. The [DATE] Quarterly MDS, documented a BIMS score of 15, indicating intact cognition. R21 required total assistance with most ADLs. R21 required oxygen. On [DATE] at 03:20 PM, Administrative Nurse C reported the MDS's are completed off site by Consultant Nurse J. Administrative Nurse C reported the Consultant Nurse J calls the facility every day at the morning meeting and a tele-conference completed with the Interdisciplinary team. On [DATE] at 09:57 AM, Administrative Nurse B revealed she expected the MDS information to be completed correctly. On [DATE] at 03:02 PM, Consultant Nurse J was called on her phone number provided and did not answer the call. Review of facility's policy Resident Assessment Instrument Completion of the RAI dated [DATE], documented: The MDS completion is comprised of many individuals known as the Interdisciplinary Team and that there are many sections that are completed. The policy lacked any documentation about the CAAs. The facility failed to accurately complete the CAAs for (R)21 related to functional abilities, urinary incontinence, nutritional status and pressure ulcer/injury. This placed the resident at risk for uncommunicated care needs. 46960 - Review of the Electronic Health Record (EHR) for Resident (R)8 included the diagnoses of osteoporosis (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk), history of falling, repeated falls, generalized muscle weakness, lack of coordination and dementia (a progressive mental disorder characterized by failing memory, confusion). The Significant Change Minimum Data Set (MDS) dated [DATE], documented R8 was unable to complete the Brief Interview for Mental Status (BIMS) assessment and staff assessed R8 to have severely impaired cognition. The assessment documented R8 required substantial or maximal assistance from staff for cares. R8 was dependent on staff to perform oral hygiene. R8 required supervision and setup for eating. R8 was frequently incontinent of bladder and always incontinent of bowel. The assessment documented R8 had no falls since the previous assessment. The Cognitive Loss / Dementia Care Area Assessment (CAA) dated [DATE], documented R8 as deceased although resident was observed in the facility on [DATE], [DATE], [DATE] and [DATE]. The Visual Function CAA dated [DATE], documented R8 as deceased although resident was observed in the facility on [DATE], [DATE], [DATE] and [DATE]. The Communication CAA dated [DATE], documented R8 as deceased although resident was observed in the facility on [DATE], [DATE], [DATE] and [DATE]. The Urinary Incontinence and Indwelling Catheter (a hollow flexible tube that collects urine and leads to a drainage bag) CAA dated [DATE], documented R8 as deceased although resident was observed in the facility on [DATE], [DATE], [DATE] and [DATE]. The Psychosocial Well-Being CAA dated [DATE], documented R8 as deceased although resident was observed in the facility on [DATE], [DATE], [DATE] and [DATE]. The Behavioral Symptoms CAA dated [DATE], documented R8 as deceased although resident was observed in the facility on [DATE], [DATE], [DATE] and [DATE]. The Falls CAA dated [DATE], documented R8 as deceased although resident was observed in the facility on [DATE], [DATE], [DATE] and [DATE]. The Pressure Ulcer/Injury CAA dated [DATE], documented R8 as deceased although resident was observed in the facility on [DATE], [DATE], [DATE] and [DATE]. The Psychotropic Drug Use CAA dated [DATE], documented R8 as deceased although resident was observed in the facility on [DATE], [DATE], [DATE] and [DATE]. The Pain CAA dated [DATE], documented R8 as deceased although resident was observed in the facility on [DATE], [DATE], [DATE] and [DATE]. The Quarterly MDS dated [DATE], documented R8 was unable to complete the BIMS assessment and staff assessed R8 to have severely impaired cognition. The assessment documented R8 was dependent on staff for toileting, bathing and all forms of hygiene and required substantial or maximal assistance for all other cares except eating which was required supervision/setup. R8 was frequently incontinent of bowel and always incontinent of bladder. The assessment documented that R8 had fallen since the previous assessment. Review of the facility Fall Investigation revealed on [DATE], R8 fell and obtained a minor injury. The facility's root cause analysis determined R8's limited safety awareness caused the fall. The fall report documented that the immediate intervention was that staff would perform more close monitoring with one-on-one supervision as much as possible. The fall investigation report documented the permanent care plan intervention was to ask R8's family to bring a television to her room so staff would place the television on a music channel, then wait to see if she was willing to lay and watch television and/or sleep. The Progress Notes for R8 lacked documentation related to this fall. The resident's Care Plan included an intervention dated [DATE], which documented family would bring R8 in a television and staff were to put it on a music channel which would allow her to watch, relax, and sleep. Review of the Progress Note dated [DATE] at 03:22 AM, staff documented a witnessed fall when R8 attempted to stand unassisted from a wheelchair without additional injuries; however, the facility lacked a fall investigation related to this fall. The resident's Care Plan included an intervention dated [DATE], which indicated staff had a meeting with family regarding additional interventions to prevent R8 from falling again with suggestions made that staff would implement with the goal to keep R8 calm; however, no additional information was provided. Observation on [DATE] at 12:50 PM, revealed R8 in a powered lift chair recliner in the common area near the nurses' station with her eyes closed. Observation on [DATE] at 07:40 AM, revealed R8 in a powered lift chair recliner in the common area near the nurses' station with her eyes closed. Observation on [DATE] at 10:00 AM, revealed R8 in a powered lift chair recliner in the common area near the nurses' station with her eyes closed. Observation on [DATE] at 12:00 PM, revealed R8 in a powered lift chair recliner in the common area near the nurses' station with her eyes closed. Two unknown CNA staff assisted R8 to an upright seated position using the powered mechanism of the lift chair, then performed a two-person pivot-transfer from recliner to R8's wheelchair and assisted R8 to the dining area for the noon meal. On [DATE] at 03:20 PM, Administrative Nurse C reported the MDS's are completed off site by Consultant Nurse J. Administrative Nurse C reported the Consultant Nurse J calls the facility every day at the morning meeting and a tele-conference completed with the Interdisciplinary team. On [DATE] at 09:57 AM, Administrative Nurse B revealed she expected the MDS information to be completed correctly. On [DATE] at 03:02 PM, Consultant Nurse J was called on phone number provided and did not answer the call. Review of facility's Resident Assessment Instrument Completion of the RAI dated [DATE] documented: The MDS completion is comprised of many individuals known as the Interdisciplinary Team and that there are many sections that are completed. An accurate assessment requires collecting information from multiple sources, some of which are mandated by regulations. The facility failed to accurately complete the CAAs for (R)8 related to cognitive loss / dementia, visual function, communication, urinary incontinence and indwelling catheter, psychosocial well-being, behavioral symptoms, pressure ulcer/injury, psychotropic drug use or pain. This placed the resident at risk for uncommunicated care needs.

The facility reported a census of 40 residents with 12 residents sampled, including five residents reviewed for respiratory care. Based on observations, record reviews, and interviews, the facility failed to properly clean, label and store the nebulizer (a device for administering inhaled medications) for Resident (R)7 in accordance with the standards of care and failed to follow up on a bilevel positive airway pressure (BiPAP-medical device which helps with breathing) physician order. In addition, the facility failed to date the oxygen tubing for R144. R7, R21, R22 and R144. Findings included: - Resident (R)7's medical diagnoses included chronic respiratory failure (a long-term condition that occurs when the body's respiratory system is unable to exchange oxygen and carbon dioxide properly) and morbid obesity (excessive body fat). The 04/29/24 Admission Minimum Data Set (MDS), documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. R7 required total assistance with activities of daily living (ADLs), with toileting hygiene, bathing, dressing, personal care, and transfers. R7 required oxygen and dialysis (procedure where impurities or wastes were removed from the blood). The 05/06/24 Functional Abilities Care Area Assessment (CAA), documented R7 admitted to the facility for skilled services. R7 required assistance with ADLs and transfers related to impaired mobility and was at risk for falls and skin breakdown related to incontinence. The CAA lacked any documentation regarded to respiratory. The 07/29/24 Quarterly MDS, documented a BIMS score of 15, indicating intact cognition. R7 required total assistance with ADLs. R7 required oxygen and dialysis. The 09/10/24 Care Plan documented interventions which included: On 04/24/24, staff were instructed to administer oxygen as ordered, monitor for signs and symptoms of upper respiratory infection. Provide aerosol treatments as per orders. Apply BiPAP as ordered, ensure settings followed per physician orders. Staff were instructed to educate the resident to use breathing techniques: purse lips, cough and deep breathing. Staff were instructed to notify the physician of increased complaints of difficulty in breathing. The Physician Orders reviewed on 09/10/24 included the following: Ipratropium-Albuterol (a combination is used to help control the symptoms of lung diseases, such as asthma, chronic bronchitis, and emphysema) Inhalation Solution 0.5-2.5 (3) milligram (mg)/3 milliliter (ml). Administer 3 ml four times a day inhale orally for shortness of breath, ordered on 04/24/24. Pulmicort Inhalation Suspension (medication used to manage and treat inflammatory diseases, mainly affecting the airways) administer 0.25 mg/2 ml, two times a day, inhale orally for shortness of breath, ordered on 04/24/24. Change nebulizer mask and tubing one time a day, for one day, every month, date ordered 05/05/24. To have Bi-PAP to be placed on hold. To have new sleep study and arterial blood gases (a test measures the oxygen and carbon dioxide levels in your blood) to determine the need for bi-pap and or non-invasive ventilator (a machine that helps you breathe by delivering oxygen into your lungs), dated 06/06/24. Change oxygen tubing and bags monthly and as needed, date ordered 08/27/24. Clean oxygen filters twice a month, once on the first, and once on the 15th of each month, date ordered 08/27/24. Administer oxygen via nasal cannula at three liters per minute continuously, to maintain oxygen saturation above 90 percent, date ordered 08/27/24. Review of the Progress Notes from 04/17/24 to 09/10/24 documented the following: On 05/29/24 a Progress Note at 10:55 PM, physician contacted as R7 requested a BiPAP. The physician was updated that R7 had used that device years ago and his last sleep study (is a test used to diagnose sleep disorders) was completed five years ago. Received order for a sleep study to be performed. On 06/28/24 a Progress Note at 04:58 PM, nurse to physician communication form faxed on 06/19/24 for a sleep study to determine the need for a BiPAP or non-invasive ventilator. The Physician signed. On 09/10/24 at 08:52 AM, observed R7's nebulizer mask with clear liquid substance in the chamber draped over the positioning bar on the bed by the tubing, the nebulizer mask touched the floor. Additionally, no date or label on the tubing or the mask. R7 had an oxygen nasal cannula noted on the wheelchair seat in the bathroom that was connected to the portable tank and oxygen tubing connected to the oxygen concentrator, and neither nasal cannula tubing was labeled with a date. The prefilled humidifier bottle was empty and not labeled. On 09/10/24 at 08:52 AM, R7 stated he was not sure when the oxygen supplies are changed out. R7 stated he had never seen the nebulizer mask or chamber rinsed after medication administered. R7 commented he had not received a BiPAP that the physician at the facility gave an order and the facility has not assisted with obtaining one. On 09/11/24 at 10:46 AM, R7 was in his room preparing to leave for dialysis. Observed new oxygen prefilled humidified bottle, bag for oxygen tubing and oxygen tubing dated 09/10/24. On 09/11/24 at 01:30 PM, Administrative Nurse B confirmed R7 had not completed a sleep study, and no appointment had been made for the sleep study. On 09/12/24 at 10:35 AM, Licensed Nurse (LN) G reported that the oxygen tubing and supplies should be changed out the first of every month, and all the tubing and supplies are to be labeled with the date. Additionally, LN G reported a black bag is to be taped to the oxygen concentrator and on the back of residents' wheelchairs, labeled with a date for nasal cannula and mask to be placed when not in use. LN G confirmed it was not acceptable to place nasal cannulas and nebulizer masks on the floor or on the residents' wheelchairs. LN G was unsure of the policy for nebulizer care after medication was administered. LN G reported the treatment administration record (TAR) did not have any direction to check the humidified bottles on the concentrator, she stated the bottles should be changed and dated when emptied. On 09/12/24 at 11:15 AM, Administrative Nurse B confirmed all oxygen supplies and nebulizer supplies should be labeled with a date, and the nasal cannulas should be placed in the black bag to keep the items clean. Additionally, the nebulizer masks and medication chambers should be rinsed out and air dried after each use. Administrative Nurse B expected nurses to change the humidified bottles on the concentrators when they were close to being empty and verified that is not on the TAR as an order. The facility lacked a policy for respiratory care supplies. The facility failed to provide respiratory care consistent with professional standards of care for R7, regarding the use and cleaning of the nebulizer equipment and oxygen supplies were not labeled. - Resident (R)21 's Electronic Health Record (EHR) revealed diagnoses of chronic obstructive pulmonary disease (COPD- progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing) and sleep apnea (disorder of sleep characterized by periods without respirations). The 05/20/24 Admission Minimum Data Set (MDS), documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The resident had a total mood severity score of 00, indicating no depression and no behaviors. R21 required total assistance with activities of daily living (ADLs), with toileting hygiene. Maximal assistance dressing and transfers. The 05/27/24 Care Area Assessment (CAA) lacked analysis of findings documented for respiratory. The 08/05/24 Quarterly MDS, documented a BIMS score of 15, indicating intact cognition. R21 required total assistance with most ADLs. R21 required oxygen. The 09/10/24 Care Plan documented interventions which included: On 05/15/24 staff were instructed to administer oxygen as ordered, apply continuous positive airway pressure (CPAP- ventilation device that blows a gentle stream of air into the nose to keep airway open during sleep) as ordered. Staff were instructed to educate the resident to use breathing techniques: purse lips, cough, and deep breathing. Staff were instructed to notify the physician of increased complaints of difficulty in breathing and head of bed to be elevated due to shortness of breath when lying flat. Staff were instructed to notify the physician of increased complaints of difficulty in breathing. The Physician Orders reviewed on 09/10/24 included the following: Oxygen check and replace or refill distilled water bottle as needed, dated 07/08/24. Apply CPAP at three liters of oxygen at bedtime for sleep apnea, date ordered 08/01/24. Administer oxygen via nasal cannula at three liters per minute at all times, date ordered 08/26/24. CPAP humidifier cleaning to be done once weekly. Cleanse the humidifier with warm soapy water, rinse thoroughly and dry with a clean cloth or allow to air dry, date ordered 08/27/24. Clean the CPAP tube with mild detergent that is not anti-bacterial (a substance that kills bacteria or stops them from growing and causing disease) in warm water. Dry the interior of the hose, connect it to the CPAP machine and allow it to run for approximately 15 minutes or until moisture has evaporated weekly, dated ordered 08/27/24. For the CPAP humidifier water- empty the distilled water each morning from the CPAP machine. After cleaning, refill with distilled water, dated ordered 08/27/24. CPAP mask and nasal pillows must be cleaned in the morning. Clean CPAP mask using warm water and a cloth daily. Place mask in bag, date ordered 08/27/24. Change the nebulizer mask and tubing monthly, date ordered 08/27/24. Change the oxygen tubing and bags monthly and as needed, date ordered 08/27/24. Clean oxygen filters monthly, dated ordered 08/27/24. On 09/10/24 at 09:46 AM, observed R21's oxygen tubing not date or labeled. R21 had an oxygen nasal cannula noted over the positioning bar on the bed by the tubing, the nasal cannula touched the floor. The CPAP mask laid face down on the nightstand and the prefilled humidifier bottle was empty and labeled with a date of 09/01/24. On 09/10/24 at 09:46 AM, R21 stated she was not sure when the oxygen supplies were to be changed out and the CPAP mask is usually placed on the nightstand. On 09/12/24 at 10:35 AM, Licensed Nurse (LN) G reported that the oxygen tubing and supplies should be changed out the first of every month, and all the tubing and supplies are to be labeled with the date. Additionally, LN G reported a black bag is to be taped to the oxygen concentrator and on the back of residents' wheelchairs, labeled with a date for nasal cannula and mask to be placed when not in use. LN G confirmed it was not acceptable to place nasal cannulas and nebulizer masks on the floor or on the residents' wheelchairs. LN G was unsure of the policy for nebulizer care after medication was administered. LN G reported the treatment administration record (TAR) did not have any direction to check the humidified bottles on the concentrator, she stated the bottles should be changed and dated when emptied. On 09/12/24 at 11:15 AM, Administrative Nurse B confirmed all oxygen supplies and nebulizer supplies should be labeled with a date, and the nasal cannulas should be placed in the black bag to keep the items clean. Additionally, the nebulizer masks and medication chambers should be rinsed out and air dried after each use. Administrative Nurse B expected nurses to change the humidified bottles on the concentrators when they were close to being empty and verified that is not on the TAR as an order. The facility lacked a policy for respiratory care supplies. The facility failed to provide respiratory care consistent with professional standards of care for R21, regarding the use and cleaning of the CPAP equipment and oxygen supplies were not labeled. - Resident (R)144's medical diagnoses included sleep apnea (disorder of sleep characterized by periods without respirations) and chronic respiratory failure (a condition that results in the inability to effectively exchange carbon dioxide and oxygen). The 09/03/24 Admission Minimum Data Set (MDS), documented a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. The resident had a total mood severity score of four, indicating no to minimal depression and R144 had no behaviors. R144 required total assistance with activities of daily living (ADLs), with transfers and wheelchair mobility. Maximal assistance with toileting, dressing and bed mobility. Frequently incontinent of bladder. R144 required oxygen. The 09/05/24 Functional Abilities Care Area Assessment (CAA), documented R144 admitted to the facility for skilled services. R144 required assistance with ADLs and transfers related to impaired mobility and was at risk for falls. The CAA lacked any documentation regarded to respiratory. The 09/10/24 Care Plan documented interventions which included: On 08/28/24, staff were instructed to administer oxygen as ordered and elevate had of bed due to shortness of breath. Staff were instructed to educate the resident to use breathing techniques: purse lips, cough and deep breathing and monitor for signs and symptoms of upper respiratory infection Staff were instructed to notify the physician of increased complaints of difficulty in breathing. The Physician Orders reviewed on 09/10/24 included the following: Head of bed elevated, resident is unable to lay flat due to shortness of breath every shift to promote ease of breathing, date ordered 08/26/24. Change the oxygen tubing monthly and as needed, date ordered 08/28/24. Check and replace or refill the distilled water bottle as needed, date ordered 08/28/24. Oxygen at two liters per nasal cannula at all times, date ordered 08/28/24. Clean the oxygen filters twice a month, once on the first, and once on the 15th of each month, date ordered 08/28/24. 09/10/24 at 07:15 AM, R144 laid in his bed with eyes shut, the prefilled humidifier bottle was empty and dated 09/01/24. R144 had an oxygen nasal cannula positioned on the wheelchair footrest on the wheelchair seat that was connected to the portable tank and oxygen tubing connected to the oxygen concentrator, and neither nasal cannula tubing was labeled with a date. On 09/11/24 at 07:30 AM, observed new oxygen prefilled humidified bottle, bag for oxygen tubing and oxygen tubing dated 09/10/24. On 09/12/24 at 10:35 AM, Licensed Nurse (LN) G reported that the oxygen tubing and supplies should be changed out the first of every month, and all the tubing and supplies are to be labeled with the date. Additionally, LN G reported a black bag is to be taped to the oxygen concentrator and on the back of residents' wheelchairs, labeled with a date for nasal cannula to be placed when not in use. LN G confirmed it was not acceptable to place nasal cannulas on the floor or on the residents' wheelchairs. LN G reported the treatment administration record (TAR) did not have any direction to check the humidified bottles on the concentrator, she stated the bottles should be changed and dated when emptied. On 09/12/24 at 11:15 AM, Administrative Nurse B confirmed all oxygen supplies and nebulizer supplies should be labeled with a date, and the nasal cannulas should be placed in the black bag to keep the items clean. Administrative Nurse B expected nurses to change the humidified bottles on the concentrators when they were close to being empty and verified that is not on the TAR as an order. The facility lacked a policy for respiratory care supplies. The facility failed to provide respiratory care consistent with professional standards of care for R144, regarding the use of oxygen supplies that were not labeled. 46960 - Review of the Electronic Health Record (EHR) for Resident (R) 22 included diagnoses of history of falling, chronic obstructive pulmonary disease (COPD - a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing) and bipolar disorder (a major mental illness that caused people to have episodes of severe high and low moods). The Significant Change Minimum Data Set (MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The assessment documented that R22 received oxygen. The Care Area Assessment (CAA) dated 09/13/23, lacked documentation related to oxygen use. The Quarterly MDS dated [DATE], documented a BIMS score of 10, which indicated moderately impaired cognition. The assessment documented that R22 received oxygen. The 09/11/24 Care Plan documented R22 received oxygen and listed the following interventions: Staff would administer oxygen as ordered at two liters per minute ( LPM), dated 07/01/21. Staff would monitor the resident and inform the physician if R22 complained of increased difficulty breathing, dated 07/01/21. Staff would administer oxygen as ordered via nasal cannula at 3 LPM, dated 12/14/22. The Physician Orders documented the following: Check and replace or refill distilled water bottle as needed, every 12 hours as needed for oxygen therapy maintenance, dated 01/16/24. Oxygen via nasal cannula at 2 LPM continuously, every day and night shift, dated 09/04/24. Clean oxygen filters, every day shift on the first and 15th of the month, dated 09/01/24 Change oxygen tubing and black bags monthly, every day shift on the first of the month, dated 09/01/24. Change nebulizer (device which changes liquid medication into a mist easily inhaled into the lungs) mask and tubing, every day shift on the first of the month, dated 09/01/24. On 09/10/24 at 11:04 AM, R22 was observed resting in her recliner with her eyes closed, oxygen tubing lacked date and distilled water bottle that was connected inline with the oxygen tubing contained no water. On 09/11/24 at 07:42 AM, R22 was observed resting in bed with her eyes closed, oxygen tubing lacked a date. On 09/11/24 at 08:30 AM, R22 was observed in the dining area seated at a table with her peers and staff, oxygen tubing lacked a date. On 09/12/24 at 10:35 AM, Licensed Nurse (LN) G reported that the oxygen tubing and supplies should be changed out the first of every month, and all the tubing and supplies are to be labeled with the date. Additionally, LN G reported a black bag is to be taped to the oxygen concentrator and on the back of residents' wheelchairs, labeled with a date for nasal cannula and mask to be placed when not in use. LN G confirmed it was not acceptable to place nasal cannulas on the floor or on the residents' wheelchairs. LN G reported the treatment administration record (TAR) did not have any direction to check the humidified bottles on the concentrator, she stated the bottles should be changed and dated when emptied. On 09/12/24 at 11:15 AM, Administrative Nurse B confirmed all oxygen supplies and nebulizer supplies should be labeled with a date, and the nasal cannulas should be placed in the black bag to keep the items clean. Administrative Nurse B expected nurses to change the humidified bottles on the concentrators when they were close to being empty and verified that is not on the TAR as an order. The facility lacked a policy for respiratory care supplies. The facility failed to provide respiratory care consistent with professional standards of care for R22, regarding oxygen supplies that were not labeled.

The facility reported 40 residents with 12 residents included in the sample. Based on observation, interview, and record review the facility failed to use Enhanced Barrier Precautions (EBP is a risk -based approach to use protective personal equipment to reduce the spread of multidrug resistant organism, consisting of gown and gloves). for Resident (R)39 during wound care and R26 during urinary catheter care. This placed the residents at risk for infection. Findings Included: - R39's Electronic Medical Record (EMR) recorded the following diagnosis: acquired absence of left leg below the knee (BTKA), infection of the amputation stump of the left lower extremity, and Methicillin Resistant Staphylococcus Aureus Infection (MRSA, bacteria that is resistant to many treatments and can cause very serious and life-threatening infections). The 08/02/24 Admission Minimum Data Set (MDS), revealed the resident had a Brief Interview for Mental Status score of 15, which indicated intact cognition. R39 utilized a walker/wheelchair for transportation, required substantial to maximum assistance with toileting. R39 had an amputation with a diagnosis of osteomyelitis (local or generalized infection of the bone and bone marrow). The 08/02/24 Care Area Assessment (CAA) for pressure ulcer revealed R39 had a below the knee amputation and required assistance with Activities of Daily Living (ADL) related to impaired mobility and the resident was at risk for pain, falls and skin breakdown related to impaired mobility. R39's Care Plan dated 07/30/24 revealed staff were to use Personal Protective Equipment (PPE- clothing and equipment that is worn or used in order to provide protection against hazardous substances or environments) when interacting with the resident, to follow physician order, place signage on the door. The care plan indicated staff and resident were educated on EBP. The EMR documented the following orders: 08/05/24 revealed EBP due to surgical wounds with a history of MRSA, two times a day. 08/16/24 revealed R39 had a left BTKA. Staff were to cleanse wound, pat dry, apply Medi honey (medical grade honey used to aid wound healing), and wrap with gauze and Coban daily. 09/11/24 indicated that R39 was to utilize EBP with PPE when high direct care activities were provided to the resident. Indications were listed as wounds, indwelling medical devices, due to infection and or Multidrug-resistant Organism (MDRO) status, to be utilized day and night. During an observation on 09/11/24 at 07:40 AM, R39 rested in bed and watched television. Further observation revealed lack of visual evidence of PPE for the EBP in F39's room. During an observation on 09/11/24 at 09:24 AM, Licensed Nurse (LN) G gathered supplies from the treatment cart, performed hand hygiene and donned gloves. LN G did not utilize appropriate PPE for EBP. LN G entered the resident's room and placed supplies on a clean paper towel on the over the bed table. R39 lifted his leg to provide access to LN G. LN G removed gloves, performed hand hygiene, and donned new gloves. LN G removed the ace wrap and old dressing to both surgical wounds. LN G cleansed both wounds with wound cleanser. LN G did not remove dirty gloves, perform hand hygiene, and don new gloves prior to cleansing wounds. After cleansing the wounds, LN G removed gloves and performed hand hygiene. LN failed to bring scissors into the room to do the wound care dressing, so she removed gloves, performed hand hygiene and left the room. R39 lowered his leg to the pillow he had previously utilized and placed the cleansed wound on the dirty surface. LN G returned to the room, performed hand hygiene, and donned gloves. LN G did not cleanse the wounds again prior to placing clean dressing on them after they had encountered a dirty surface. LN G placed Medi honey ointment into the wound beds with a cotton tipped applicator. LN G then places the dressing over the wounds, Coban and ace wrap coverings. Interview 09/11/24 at 09:40 AM, LN G confirmed the EBP PPE should have been worn for the dressing change. She further confirmed she should have removed gloves and performed hand hygiene when moving from dirty to clean phases of the dressing change. LN G confirmed she should have cleansed the wound after it encountered the pillow when she left the room. During an interview on 09/11/24 at 02:57 PM, Administrative Nurse B stated that residents who require EBP should have a yellow sticker on the sign outside their room to alert staff to wear the proper PPE before providing direct cares. Administrative Nurse B revealed the PPE should be stored inside the resident's room, but not necessarily within the first six feet of the entering a room. She confirmed the PPE for EBP included gowns, gloves, and face shield or goggles. Administrative Nurse B said she expected staff to change gloves and perform hand hygiene when transitioning between dirty and clean phase of wound care, and to recleanse if the wound became contaminated during the wound care. The undated Enhanced Barrier Precautions Policy revealed Enhanced Barrier Precautions (EBP) referred to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities. The policy further revealed the EBP is used in conjunction with standard precautions and would be required for all residents with a MDRO and wounds regardless of MDRO colonization status. The facility failed to utilize the proper PPE for EBP for R39 who had a history of a MDRO during wound care. - R26's EMR revealed diagnoses of infection and inflammatory reaction due to urethral catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid). The 11/28/23 Admission Minimum Data Set (MDS) revealed the resident had a Brief Interview for Mental Status (BIMS) score of seven, which indicated severe cognitive impairment. R26 was independent with toileting and had an indwelling catheter. The 11/28/2023 Urinary Care Area Assessment (CAA) revealed R26 had a long-term catheter in place and had recently been treated for a catheter associated infection and was prone to further infections. The Care Plan dated 11/27/23 documented the resident required catheter care each shift and as needed. Staff were to change the catheter monthly and as needed per physician order. Staff should change R26 to a leg bag during the day and ensure tubing was kept free from kinks. Staff were to report to the physician any signs or symptoms of urinary tract infection such as burning, pain, blood-tinged urine, cloudy urine, no output, increased pulse or temperature, urinary frequency, foul smelling urine, fever, chills or change in mental status, behavior or eating patterns. A Care Plan revision on 04/18/24 revealed Enhanced Barrier Precautions (EBP) for R26. The staff were to utilize PPE when interacting with the resident, place signage on the resident's door, and educate both the resident and staff on EBP. A Physician's Order dated 05/14/24 included Enhanced Barrier Precautions and PPE required for high direct care resident contact activities for R26, indicated by wounds, indwelling medical devices related to infection and/or MDRO status. During an observation on 09/11/24 at 02:46 PM, Licensed Nurse H requested to provide catheter care to the resident. R26 ambulated into the spa room and stood over the commode. R26 lowered his pants and began to empty the leg bag into the commode. Hand hygiene was not performed by either the resident or LN H. LN H donned gloves and cleaned R26's genitals with wipes. LN H cleansed the catheter tubing, removed gloves and then both the resident and LN H performed hand hygiene. LN H did not don PPE for EBP. During an interview on 09/11/24 at 02:50 PM, LN H confirmed she did not wear the PPE for EBP and further confirmed neither she nor the resident performed hand hygiene. During an interview on 09/11/24 at 02:57 PM, Administrative Nurse B stated that residents who require EBP should have a yellow sticker on the sign outside their room to alert staff to don the proper PPE before providing direct cares. Administrative Nurse B revealed the PPE should be stored inside the resident's room, but not necessarily within the first six feet of the entering a room. She confirmed the PPE for EBP included gowns, gloves, and face shield or goggles. The undated Enhanced Barrier Precautions Policy revealed Enhanced Barrier Precautions (EBP) referred to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities. The policy further revealed the EBP is used in conjunction with standard precautions and would be required for all residents with a MDRO and urinary catheter regardless of MDRO colonization status. The facility failed to utilize the proper PPE for EBP for R26 who had a history of a MRSA during catheter care.

The facility reported a census of 40 residents. The sample included 12 residents. Based on interview and record review, the facility failed to provide Resident (R)10 care in a dignified manner during colostomy care. R10 was left lying in his bed for 40 minutes with his door open, undressed waist up and no colostomy (surgical creation of an artificial opening on the stomach wall to excrete feces from the body) bag covered his stoma. This deficient practice placed the resident at risk for decreased psychosocial well-being. Findings included: - Resident (R)10 's Electronic Health Record (EHR) revealed diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion) and need for assistance with personal care. The Annual Minimum Data Set (MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) of 15, indicating intact cognition. The resident had a total mood severity score of 00, indicating no depression and no behaviors. R10 required total assistance with activities of daily living (ADLs), which included toileting, dressing, and transfers. R10 was frequently incontinent of bladder and bowel. The Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) dated 12/05/23, documented R10 required variable assistance with ADL function and mobility related to rheumatoid arthritis (chronic inflammatory disease that affected joints and other organ systems). Staff would continue with care plan and a goal to maintain current function. The Quarterly MDS dated [DATE], documented a BIMS of eight, indicating moderately impaired cognition. R10 required total assistance with ADL's, which included toileting, dressing, and transfers. Frequently incontinent of bladder. Not rated for bowels as R10 had a colostomy. The 09/10/24 Care Plan documented R10 had a colostomy related to a fistula (abnormal passage from an internal organ to the body surface or between two internal organs). Staff were instructed to provide ostomy care each shift and as needed. Staff were to encourage R10 to discuss any concerns, fears, issues related to ostomy use or care as indicated, dated 03/18/24. The Physician's Order dated 03/19/24, colostomy care every shift and as needed. On 06/15/24, a Progress Note at 12:17 PM, two unidentified Certified Nurse Aides notified Licensed Nurse (LN) W that R10's ostomy bag required changing. R10 was angry that he had to wait to get his ostomy changed, yelled, and cursed at staff. Family member called and spoke with LN W, family member concerned R10 had to wait 40 minutes to receive ostomy care. LN W explained to family member that she went as soon as she was able to. On 09/10/24 at 11:37 AM, R10 stated that staff members left him lying in his bed undressed from waist up with no ostomy bag covering his stoma for 40 minutes sometime in June. R10 stated that his door to his room was left open and the curtains were closed. R10 stated he called his family member as he was angry. He stated that the next day he spoke to the Administrative Staff A and was satisfied with the outcome of the nurse being discharged . On 09/11/24 a Grievance dated 06/16/24, revealed LN W was removed from the schedule as R10 had to wait 40 minutes for a new colostomy bag. R10 was satisfied with the outcome and the grievance form was signed by Administrative Staff A on 06/17/24. On 09/11/24 at 01:25 PM, Administrative Staff A confirmed that LN W was no longer employed at the facility after R10 had to wait for a long period of time for care that was required. Administrative Staff A revealed that R10 was satisfied with the outcome. The facility's policy Dignity dated February 2021 documented: Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Staff to promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. Promptly responding to a resident's request for toileting assistance. The facility failed to provide Resident (R)10 care in a dignified manner during colostomy care. R10 was left lying in his bed for 40 minutes with his door open, undressed waist up and no colostomy bag covered his stoma. This deficient practice placed the resident at risk for decreased psychosocial well-being.

The facility reported a census of 40 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to include Resident (R)7 for the development and continued planning of the resident's care plan quarterly. This deficient practice placed the residents at risk for impaired care and services. This practice had the potential to lead to negative psychosocial effects related to safety and uncommunicated needs. Findings included: - Resident (R)7's medical diagnoses included diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin), end stage renal disease (ESRD-a terminal disease of the kidneys) and anxiety. The 04/29/24 Admission Minimum Data Set (MDS), documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. R7 had a total mood severity score of 00, indicating no depression and there were no behaviors. R7 required total assistance with activities of daily living (ADLs), with toileting hygiene, bathing, dressing, personal care, and transfers. R7 required set up for eating. R7 was occasionally incontinent of bladder. R7 required oxygen and dialysis (procedure where impurities or wastes were removed from the blood). The 05/06/24 Functional Abilities Care Area Assessment (CAA), documented R7 admitted to the facility for skilled services. R7 required assistance with ADLs and transfers related to impaired mobility and was at risk for falls and skin breakdown related to incontinence. The 07/29/24 Quarterly MDS, documented a BIMS score of 15, indicating intact cognition. R7 required total assistance with ADLs, and he had no falls. The 09/10/24 Care Plan documented staff were to invite R7 to review and discuss suggested or recommended treatments or interventions to allow individual preferences and choices. Review of the Progress Notes from 04/24/24 to 09/10/24 lacked documentation regarding R7's care plan meeting, or if R7 had been invited to or attended a meeting. On 09/10/24 at 07:49 AM, R7 stated that he had never been invited to a care plan meeting or attended a care plan meeting since he was admitted at the end of April 2024. On 09/12/24 at 09:30 AM, Social Service Designee (SSD) K confirmed that R7 had not attended a care plan meeting since admitted on [DATE]. SSD K revealed she had no documentation in the EHR or in non-medical file of R7 to verify that she had a care plan meeting scheduled. SSD K revealed R7's care plan meeting had to be canceled for an unknown reason. SSD K confirmed she did not have a copy of the care plan meeting invitation that she would give to residents. SSD K stated that all residents should have a care plan meeting quarterly and/or if there was a significant change in a resident's condition. On 09/12/24 at 09:57 AM, Administrative Nurse B revealed residents care plan meetings were to occur every three months or if a significant change occurred. Administrative Nurse B was unsure how the SSD invited residents. On 09/12/24 at 10:49 AM, Administrative Staff A confirmed that a resident, family member, and/or responsible party should be invited to their care plan meeting quarterly and as needed. Administrative Staff A revealed that the SSD should send a written invitation to the resident, family member and responsible party. He confirmed it was a concern that R7 had not attended a care plan meeting since admission. The facility's Comprehensive Care Plan policy dated 12/2016 documented: A comprehensive, person -centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed, implemented and reviewed quarterly, annually and with significant change for each resident. Each resident's comprehensive person-centered care plan will be consistent with the residents' rights to participate in the development and implementation of his or her plan of care, including the right to request meetings, participate in the planning process and see the care plan. The facility failed to include R7 to his care plan meetings. This deficient practice placed the residents at risk for inadequate care and services. This practice had the potential to lead to negative psychosocial effects related to safety and uncommunicated needs.

The facility reported a census of 40 residents. The sample included 12 residents. Based on interview and record review, the facility failed to ensure Resident (R)7 received his monthly benefits when he requested the funds. Findings included: - On 09/10/24 at 07:45 AM, R7 stated he requested his monthly benefits of 62.00 dollars on 09/06/24 in the morning prior to him leaving the facility for his dialysis (procedure where impurities or wastes were removed from the blood) appointment. R7 stated when he returned to facility in the afternoon, there was no check waiting for him and Administrative Staff I was gone for the day. On 09/12/24 at 09:25 AM, Certified Medication Aide (CMA) V reported she was not aware of any money for residents to have available when the business office was closed. On 09/12/24 at 09:26 AM, Licensed Nurse (LN) U reported he was unaware of any money being available for residents that requested money from staff if the business office was closed. LN U stated he would not know the policy on how residents could receive money at night or on the weekends. On 09/12/24 at 09:30 AM, Social Service Designee (SSD) K reported she was unaware if residents had access to their personal funds on weekends, evening, or night shift when the business office was closed. SSD K reported that residents were encouraged to request their funds from Administrative Staff I or Administrative Staff A on Fridays. Additionally, SSD K stated that Administrative Staff I or Administrative Staff A would have to come to the facility on off hours to ensure a resident received the money requested. On 09/12/24 at 10:42 AM, Administrative Staff I reported that the facility is R7's payee and R7 requested his monthly benefit of 62.00 dollars on 09/06/24 prior to R7 being transported to dialysis. Administrative Staff I confirmed R7 had not received his monthly benefits as of 09/12/24, as R7 did not come back down to the business office to request the money. Administrative Staff I reported she should have delivered the requested funds to R7 the day he requested the funds. Administrative Staff I reported that there was 100.00 dollars in a locked box in the medication room for the residents with personal funds handled by facility for residents to request if the business office was closed. On 09/12/24 at 10:45 AM, Administrative Staff A confirmed the above concern was an issue. The facility's policy Management of Residents' Personal Funds dated March 2021 documented our facility manages personal funs of residents who request to do so. Should the facility be appointed the resident's payee, and directly receive monthly benefits to which the resident is entitled, such funds are managed in accordance with established policies and federal/state requirements. The facility failed to ensure R7 received his monthly benefit in a timely manner. This deficient practice had the potential to have a negative effect on the overall physical and psychosocial well-being of the resident in the facility.

The facility reported a census of 40 residents. The sample included 12 residents. Based on interview and record review, the facility failed to ensure the correct and complete Beneficiary Protection Notification forms were issued to one of three residents reviewed, Resident (R)146. Findings included: - On 09/11/24 review of the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage Form CMS-20052 (SNFABN) and the Notification of Medicare Non-Coverage Form 10123(NOMNC- the form used to notify Medicare A participants of their rights to appeal and the last covered date of service) both forms lacked Resident (R)146's signature before her discharge home on 03/08/24. Option three checked to reflect I don't want the care listed above. I understand that I'm not responsible for paying, and I can't appeal to see if Medicare would pay. The box was marked off with an X. A handwritten comment on both forms Resident discharged from facility before signature was received. The forms were only signed by the Social Service Designee (SSD) K on 03/08/24. On 09/11/24 review of Physical Therapy Discharge Summary revealed R146 was discharged on physical therapy on 03/07/24, as R146 met maximal potential. On 09/11/24 review of Occupational Therapy Discharge Summary revealed R146 was discharged from occupational therapy on 03/07/24, as R146 met maximal potential. On 03/06/24 at 01:24 PM, a Progress Note revealed the facility received discharge orders from R146's physician, to be discharged on current treatment plan. On 03/07/24 at 08:49 AM, a Progress Note revealed R146 to be discharged home on current treatment plan on 03/08/24. On 03/08/24 at 09:01 AM, a Progress Note revealed R146 discharged from the facility. On 09/11/24 at 03:38 PM, Administrative Staff I reported R146 requested the discharge and R146's husband came to the facility on [DATE] and R146 wanted to go home. Administrative Staff I had made no comment when questioned about discharge orders requested on 03/04/24 and received on 03/06/24. On 09/11/24 at 04:40 PM, Social Service Designee (SSD) K revealed R146 had a planned discharged . SSD K confirmed she received the SNFABN and NOMNC forms on 03/08/24 from Administrative Staff I to have R146 sign. SSD K confirmed she wrote the comment on the form that resident discharged from the facility before R146's signature obtained. Additionally, SSD K reported that Administrative Staff I normally would complete the required forms. On 09/12/24 at 10:49 AM, Administrative Staff A confirmed the above concern was an issue. On 09/12/24 at 02:45 PM, Physical Therapy Staff Y revealed R146 was a planned discharge to home and she gave Administrative Staff I the NOMNC a few days prior to her discharge. The facility's policy Medicare Advance Beneficiary and Medicare Non-Coverage Notices dated September 2022, documented residents are informed in advance when changes will occur to their bills. The resident is informed that they may choose to continue receiving skilled services that may not be paid by Medicare and assume financial responsibility. A NOMNC is issued to the resident at least two calendar days before benefits end. The facility failed to ensure the correct and complete Beneficiary Protection Notification forms were issued to R146, as required.

The facility reported a census of 40 residents with 12 residents selected for review. Based on observation, interview, and record review, the facility failed to accurately complete the [NAME] Data Set for two residents, Resident (R)7 and R8 related to falls. Additionally, R7 for dentition (the arrangement or condition of the teeth). This placed the resident at risk for uncommunicated care needs. Findings included: - Resident (R)7's medical diagnoses included diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin), end stage renal disease (ESRD-a terminal disease of the kidneys) and anxiety. The [DATE] Admission Minimum Data Set (MDS), documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. R7 had a total mood severity score of 00, indicating no depression and there were no behaviors. R7 required total assistance with activities of daily living (ADLs), with toileting hygiene, bathing, dressing, personal care, and transfers. R7 required set up for eating. R7 was occasionally incontinent of bladder. R7 required oxygen and dialysis (procedure where impurities or wastes were removed from the blood). No concerns with dentition. The [DATE] Functional Abilities Care Area Assessment (CAA), documented R7 admitted to the facility for skilled services. R7 required assistance with ADLs and transfers related to impaired mobility and was at risk for falls and skin breakdown related to incontinence. The [DATE] Quarterly MDS, documented a BIMS score of 15, indicating intact cognition. R7 required total assistance with ADLs, and he had no falls. No concerns with dentition. The [DATE] Care Plan documented staff were instructed to monitor for any signs or symptoms of bleeding. Additionally, staff were instructed to observe and report any signs and symptoms of anemia (inadequate number of healthy red blood cells to carry adequate oxygen to body tissues): pallor (unhealthy pale appearance), fatigue, dizziness, headache, palpitations (irregular or rapid heartbeat that can feel like fluttering, pounding, or skipping a beat), weakness or feeling cold, dated [DATE]. The [DATE] Physician Orders lacked any orders for falls or oral care. Review of the Progress Notes from [DATE] to [DATE] documented the following: On [DATE] a Progress Note at 01:36 PM, R7 had a fall when the transportation van ramp had a mechanical malfunction. R7's wheelchair tipped back and R7 hit the back of his head and he sustained a laceration (wound to the skin) on back of head and an abrasion on his left elbow. R7 was transported to hospital. On [DATE] a Progress Note at 05:44 PM, R7 transported back to facility from hospital, laceration was glued, and hospital instructed to keep area dry. On [DATE] at 07:21 AM, R7 reported the wheelchair transportation van ramp collapsed and he had a fall. R7 stated he hit the back of his head and had to go to the hospital. On [DATE] at 07:52 AM, R7 reported he would need to see a dentist. However, he had not said anything to the staff about the need. Observation revealed R7 had several discolored and missing/broken natural teeth. On [DATE] at 03:20 PM, Administrative Nurse C reported the MDS's are completed off site by Consultant Nurse J. Administrative Nurse C reported the Consultant Nurse J calls the facility every day at the morning meeting and a tele-conference completed with the Interdisciplinary team. On [DATE] at 09:57 AM, Administrative Nurse B revealed she expected the MDS information to be completed correctly. On [DATE] at 03:02 PM, Consultant Nurse J was called on phone number provided and did not answer the call. Review of facility's Resident Assessment Instrument Completion of the RAI dated [DATE] documented: The MDS completion is comprised of many individuals known as the Interdisciplinary Team and that there are many sections that are completed. An accurate assessment requires collecting information from multiple sources, some of which are mandated by regulations. The facility failed to accurately complete the MDS for (R)7 related to falls and dentition. This placed the resident at risk for uncommunicated care needs. 46960 - Review of the Electronic Health Record (EHR) for Resident (R)8 included the diagnoses of osteoporosis (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk), history of falling, repeated falls, generalized muscle weakness, lack of coordination and dementia (a progressive mental disorder characterized by failing memory, confusion). The Significant Change Minimum Data Set (MDS) dated [DATE], documented R8 was unable to complete the Brief Interview for Mental Status (BIMS) assessment and staff assessed R8 to have severely impaired cognition. The assessment documented R8 required substantial or maximal assistance from staff for cares. R8 was dependent on staff to perform oral hygiene. R8 required supervision and setup for eating. R8 was frequently incontinent of bladder and always incontinent of bowel. The assessment documented R8 had no falls since the previous assessment. The Cognitive Loss / Dementia Care Area Assessment (CAA) dated [DATE], documented R8 as deceased although resident was observed in the facility on [DATE], [DATE], [DATE] and [DATE]. The Visual Function CAA dated [DATE], documented R8 as deceased although resident was observed in the facility on [DATE], [DATE], [DATE] and [DATE]. The Communication CAA dated [DATE], documented R8 as deceased although resident was observed in the facility on [DATE], [DATE], [DATE] and [DATE]. The Urinary Incontinence and Indwelling Catheter (a hollow flexible tube that collects urine and leads to a drainage bag) CAA dated [DATE], documented R8 as deceased although resident was observed in the facility on [DATE], [DATE], [DATE] and [DATE]. The Psychosocial Well-Being CAA dated [DATE], documented R8 as deceased although resident was observed in the facility on [DATE], [DATE], [DATE] and [DATE]. The Behavioral Symptoms CAA dated [DATE], documented R8 as deceased although resident was observed in the facility on [DATE], [DATE], [DATE] and [DATE]. The Falls CAA dated [DATE], documented R8 as deceased although resident was observed in the facility on [DATE], [DATE], [DATE] and [DATE]. The Pressure Ulcer/Injury CAA dated [DATE], documented R8 as deceased although resident was observed in the facility on [DATE], [DATE], [DATE] and [DATE]. The Psychotropic Drug Use CAA dated [DATE], documented R8 as deceased although resident was observed in the facility on [DATE], [DATE], [DATE] and [DATE]. The Pain CAA dated [DATE], documented R8 as deceased although resident was observed in the facility on [DATE], [DATE], [DATE] and [DATE]. The Quarterly MDS dated [DATE], documented R8 was unable to complete the BIMS assessment and staff assessed R8 to have severely impaired cognition. The assessment documented R8 was dependent on staff for toileting, bathing and all forms of hygiene and required substantial or maximal assistance for all other cares except eating which was required supervision/setup. R8 was frequently incontinent of bowel and always incontinent of bladder. The assessment documented that R8 had fallen since the previous assessment. Review of the facility Fall Investigation revealed on [DATE], R8 fell and obtained a minor injury. The facility's root cause analysis determined R8's limited safety awareness caused the fall. The fall report documented that the immediate intervention was that staff would perform more close monitoring with one-on-one supervision as much as possible. The fall investigation report documented the permanent care plan intervention was to ask R8's family to bring a television to her room so staff would place the television on a music channel, then wait to see if she was willing to lay and watch television and/or sleep. The Progress Notes for R8 lacked documentation related to this fall. The resident's Care Plan included an intervention dated [DATE], which documented family would bring R8 in a television and staff were to put it on a music channel which would allow her to watch, relax, and sleep. Review of the Progress Note dated [DATE] at 03:22 AM, staff documented a witnessed fall when R8 attempted to stand unassisted from a wheelchair without additional injuries; however, the facility lacked a fall investigation related to this fall. The resident's Care Plan included an intervention dated [DATE], which indicated staff had a meeting with family regarding additional interventions to prevent R8 from falling again with suggestions made that staff would implement with the goal to keep R8 calm; however, no additional information was provided. Observation on [DATE] at 12:50 PM, revealed R8 in a powered lift chair recliner in the common area near the nurses' station with her eyes closed. Observation on [DATE] at 07:40 AM, revealed R8 in a powered lift chair recliner in the common area near the nurses' station with her eyes closed. Observation on [DATE] at 10:00 AM, revealed R8 in a powered lift chair recliner in the common area near the nurses' station with her eyes closed. Observation on [DATE] at 12:00 PM, revealed R8 in a powered lift chair recliner in the common area near the nurses' station with her eyes closed. Two unknown CNA staff assisted R8 to an upright seated position using the powered mechanism of the lift chair, then performed a two-person pivot-transfer from recliner to R8's wheelchair and assisted R8 to the dining area for the noon meal. On [DATE] at 03:20 PM, Administrative Nurse C reported the MDS's are completed off site by Consultant Nurse J. Administrative Nurse C reported the Consultant Nurse J calls the facility every day at the morning meeting and a tele-conference completed with the Interdisciplinary team. On [DATE] at 09:57 AM, Administrative Nurse B revealed she expected the MDS information to be completed correctly. On [DATE] at 03:02 PM, Consultant Nurse J was called on phone number provided and did not answer the call. Review of facility's Resident Assessment Instrument Completion of the RAI dated [DATE] documented: The MDS completion is comprised of many individuals known as the Interdisciplinary Team and that there are many sections that are completed. An accurate assessment requires collecting information from multiple sources, some of which are mandated by regulations. The facility failed to accurately complete the MDS for R8 related to falls. This placed the resident at risk for uncommunicated care needs.

The facility reported a census of 41 residents and identified 11 cognitive impaired females. The sample included three residents reviewed for abuse. Based on interviews, observations, and record review, the facility failed to provide a safe environment when staff did not provide adequate supervision to prevent resident-to-resident sexual abuse. On 12/10/23 staff found cognitively intact, independent Resident (R )1 kissing R2, a resident with severe cognitive impairment who lacked the ability to consent. Staff reported R1 had his hand inside of R2's shirt, and R2 had her hand inside of R1's pants. The staff separated the residents. This deficient practiced placed R2 in immediate jeopardy. Finding included: - Resident (R)1's Physician Orders dated 10/01/22 revealed a diagnosis of unspecified dementia unspecified severity with other behavioral disturbance (progressive mental disorder characterized by failing memory and confusion). The Annual Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview Mental Status (BIMS) score of 14, indicating intact cognition. The assessment did not indicate any behaviors and R1 was independent with Activities of Daily Living (ADLs). The Quarterly MDS dated [DATE] indicated a BIMS score of 09, which indicated moderately impaired cognition. The assessment did not indicate any behaviors and R1 was independent with ADLs. The Care Plan dated 06/19/23, revealed R1 had a history of alteration in mood, or exhibition of behaviors symptoms of depression, anxiety, and impulse disorder that presented as sexual behaviors. Staff were to have frequent monitoring of R1's whereabouts by all staff members, added to the care plan on 11/02/19. In addition, on 12/10/23, the care plan included inappropriate behaviors with another resident. The care plan lacked interventions to prevent future sexual incidents with other residents. The Nurses Notes dated 12/10/24 at 05:00 PM, documented Certified Medication Aide (CMA) R notified the nurse that R1 and R2 were in the activity room on the couch, alone. R1 had his hand under R2's shirt and R2 had her hand inside of R1's pants, while they kissed. The staff immediately separated the residents, and the nurse notified the director of nursing and the family. On 01/02/24 at 11:25 AM, R1 sat at a dining room table. R2 sat at a different table. Interview with R1 on 01/02/24 at 12:55 PM, revealed he denied he placed his hand in the shirt of R2 or any resident. R1 stated, The staff is just making this stuff up. (His BIMS score indicated he had moderate impaired cognition.) Additionally, R2's Physician Orders dated 03/13/23 indicated a diagnosis of unspecified dementia (progressive mental disorder characterized by failing memory and confusion). The Significant Change Minimum Data Set, dated dated dated [DATE] revealed a BIMS score of 00, indicating the resident's inability to complete the assessment. It did not identify any behaviors by the resident, and she required extensive assistance with dressing, toileting, and personal hygiene. The Care Plan dated 03/14/23, included R2 had a history for alteration in mood or exhibition of behavioral symptoms of wandering, self-isolation, tearfulness, and refusal of cares. Addition on 06/19/23, the care plan included the resident wandered and was at risk for elopement (an incident in which a cognitively impaired resident with poor or impaired decision-making ability/safety awareness leaves the facility without the knowledge of staff) related to confusion, poor cognition related to dementia, and poor safety awareness. On 12/11/23, an addition to the care plan included the resident had inappropriate sexual behaviors. The care plan lacked further interventions to protect this confused resident from R1 to prevent possible further sexual abuse to her. TheNurses Notes on 12/09/23 lacked information regarding the sexual abuse between R1 and R2, and the nurse's notes lacked notification to the family related to the resident-to-resident sexual abuse. Observation on 01/02/24 at 11:20 AM, revealed R2 sat in the dining room at a table. R1 was also in the dining room, however the two were separated. Observations on 01/02/24 at 11:40 AM, both residents R1 and R2 were in the dining room. R2 had been sitting at a different table than R1, R2 stood up and started moving chairs into tables. An unidentified staff member assisted R2 to another table for the lunch meal. Both residents were separated from each other. On 01/02/24 at 02:15 PM Certified Medication Aide R revealed on the day the incident occurred, she walked by the activity room doorway and saw R1 and R2 kissing. She stood in the doorway of the activities room and called for Licensed Nurse (LN) G for assistance to separate the two residents. CMA R reported staff separated the two residents within seconds. Interview with LN G on 01/02/24 at 02:20 PM, reported staff should do frequent checks in attempt to keep R1 and R2 away from each other. If staff were to observe the two residents sitting together, staff should separate them. Interview with Administrative Nurse D on 01/02/24 at 02:45 PM, revealed she expected the staff to ensure R2 was safe, and then notify the Administrator and herself. Administrative Nurse D stated the staff should always contact the physician and family related to (resident) incidents and said the staff should document resident behaviors. Administrative Nurse D confirmed the facility failed to provide staff additional education related to abuse, neglect, or exploitation after R1 and R2's sexual conduct. The facility's policy for Abuse, Neglect and Exploitation Prevention Policy and Procedure (ANE), dated 01/26/18, included the seven components: The facility will identify resident whose personal histories render them at risk for abusing other resident through the prescreening process. The nursing staff is responsible for reporting the appearance of injuries including bruising, lacerations, and any other abnormalities to the charge nurse. The charge nurse will notify the Director of Nursing for further reporting, assessment and investigation. The facility failed to provide a safe environment when staff did not provide adequate supervision to prevent resident-to-resident sexual abuse on 12/10/23, when staff found cognitively intact, independent R1 kissing R2, a resident with severe cognitive impairment who lacked the ability to consent. Staff reported R1 had his hand inside of R2's shirt, and R2 had her hand inside of R1's pants This deficient practiced placed R2 in immediate jeopardy. The facility provided an acceptable plan of removal on 01/03/24 at 02:58 PM, which included following: 1. On 01/03/24 at 05:00 PM, started all staff education regarding resident-to-resident abuse: Abuse, Neglect and Exploitation and reporting of inappropriate sexual behaviors. All staff will receive the above education prior to reporting to their designated work area. 2. During staff education, staff member will be asked if they are aware of any residents who they feel have the potential to sexually abuse others. 3. A review of each resident's medical record will be conducted including behavior notes, IDT notes, care plan entries and diagnosis. 4. Following the steps above, further actions will be taken to increase monitoring or instituting appropriate care plan intervention to mitigate the potential for sexual abuse of at-risk-residents. 5. Monitoring nursing or designee will read all progress and behavior notes to identify sexually inappropriate behavior for all residents with potential for inappropriate sexual behaviors. During routine rounds, Executive Director and/ or Director of Nursing will interact with residents, staff providing opportunity to report incidents of sexual abuse. The surveyor verified the facility implemented the corrective action to remove the immediacy, while onsite on 01/04/24 at 10:20 AM. The deficient practice remained at a scope and severity of D after removal of the jeopardy.

The facility reported a census of 44 residents, with five sampled for falls. Based on observation, interview, and record review the facility failed to thoroughly complete fall investigations for each resident to include identification of causal factors related to the fall and/or a new fall prevention intervention to prevent future falls after each fall experienced by Resident (R)2, R4, and R5. Due to these failures, R2 fell multiple times, endured a subacute subdural hematoma (type of brain bleed that results from a tear in a blood vessel in the brain, usually from trauma), fell again later the same day, and staff found the resident unresponsive. Findings included: - Resident (R) 2's pertinent diagnoses from the 11/09/21 Physician's Order in the Electronic Medical Record (EMR) documented the following: left femur fracture (break of the longest bone in the leg), dementia (progressive mental disorder characterized by failing memory, confusion) with behaviors, and mood disorder (category of mental health problems, feelings of sadness, helplessness, guilt, wanting to die were more intense and persistent than what may normally be felt from time to time). The 11/11/21 Admission Minimum Data Set (MDS) was in progress and not complete at the time of the survey. The 11/09/21 Care Plan documented staff were to ensure the call light and all personal items remained within the resident's reach. Staff were also to provide assistance as needed and provide appropriate footwear when transferring and ambulating. In addition, safety mats were to be placed on the floor next to the bed. The 11/09/21 Care Plan did not contain updates after falls experienced by R2 on 11/06/21 at 12:05 PM, 11/06/21 at 01:25 PM, 11/08/21 at 07:00 AM, 11/08/21 at 08:00 PM, 11/10/21 at 11:05 AM, and 11/14/21 at 07:40 AM. The 11/06/21 Progress Note documented R2 was found at 12:05 PM sitting on the floor with his back against the bottom of the wheelchair's footrest. The Licensed Nurse (LN) completed an assessment with no injuries noted. R2 stated he did not hit his head and staff assisted him back to bed. R2 was later found on the floor by the closet at 01:25 PM, on his right side. The LN completed an assessment and found a bruise to R2's right forehead and cheek with a scrape to his right hand. R2 stated he hit his head and complained of pain in his head and back. R2 transferred to the hospital and staff notified his family and Administrative Nurse B. The facility did not have a Fall Investigation completed for the two falls on 11/06/21. The facility further failed to place an intervention on the resident's care plan to prevent further falls for R2. The 11/06/21 Falls Risk Assessment documented a score of 11, indicating R2 at a moderate fall risk with no current falls. The 11/08/21 Progress Note documented R2 was found on the floor with his legs in front of him at 07:00 AM. R2 told staff he was leaving the facility. The staff noted no injuries and the resident denied pain but became agitated with staff. The staff transferred R2 to the wheelchair and brought him to the nurses' station and then transferred R2 into a recliner. Approximately 10-15 minutes later, R2 attempted to stand on his own and slid to the floor. The LN completed the assessment with no injuries noted, but neurological checks (evaluation of a person's physical and mental responses) were started per facility protocol. The facility did not complete/provide a Fall Investigation for R5's fall that occurred on 11/08/21 at 07:00AM. The facility's Fall Investigation for the fall on 11/08/21 at 08:00 PM documented R2 was found on the floor, lying beside his recliner. Staff obtained vital signs, and LN K assessed the resident with no injuries noted. Staff notified Administrative Staff A and Administrative Nurse B, but there was no documentation the staff notified the physician of the fall. The fall investigation lacked casual factors and lacked post fall interventions to prevent future falls. The facility Fall Investigation for the fall on 11/10/21 at 11:05 AM documented R2 was at the nurses' station sitting in his wheelchair, attempted to transfer himself to recliner, and fell to the floor landing on his left side. R2 denied pain and injury. The staff obtained vital signs and LN D assessed the resident with no injury noted. R2's neuro checks were normal, and three staff members assisted R2 into the recliner with a gait belt. The 11/10/21 Fall Investigation lacked casual factors related to the fall and lacked post fall interventions to prevent future falls. The facility did not provide evidence/documentation of the neuro check logs related to the 11/10/21 fall. The 11/11/21 Progress Note documented staff found R2 on the floor at 10:10 AM rolling around and yelling for help. R2 stated he was trying to get out of bed and fell , hitting his head. R2 had a large [carpet burn looking] area to the front of his scalp and upper right shoulder. R2 also had a scraped right pinky finger and right knee. The facility did not complete/provide a Fall Investigation for the 11/11/21 fall experienced by R2. The Skin Observation assessment dated [DATE] documented the resident had an abrasion (scrape to the skin caused by skin rubbing against a rough surface) to the top of his head due to a fall The 11/14/21 Progress Note documented staff responded to a call light in the resident's room and found R2 slid out of his wheelchair onto the floor. The LN completed an assessment with no injuries noted. The staff notified the physician of R2 complaining of pain and the physician ordered pain medication. The note documented R2 had a second fall the morning of 11/14/21 and became non-weight bearing (not putting any weight onto affected limb) to his right side. The Interdisciplinary Team (IDT) Review dated 11/14/21 at 07:40 AM documented R2 was found on the floor in a kneeling position with a root cause being confusion and unsteady gait. The IDT recommended staff keep R2's wheelchair close to the bed. The facility did not complete/provide a Fall Investigation for the falls experienced by R2 on 11/14/21. The 11/14/21 CT Head Results from the hospital documented R2 had a right sided subdural hematoma measuring 6 millimeters (mm) in thickness. The Skin Observation assessment dated [DATE] documented resident had a scalp abrasion, right knee abrasion, and a left knee abrasion from a recent fall. The 11/14/21 and 11/15/21 Falls Risk Assessment documented the resident at a high fall risk, because he had multiple falls since admission. The facility's Fall Investigation completed on 11/15/21 at 02:24 AM revealed staff discovered R2 lying on the floor on his right side holding his head and moaning. Staff obtained vital signs and noted a bruise to the top of his scalp, but R2 could not explain what happened. The staff called Emergency Medical Services (EMS), who placed R2 onto stretcher and took him to the hospital. The hospital called the facility to give an update on R2 and told the LN the resident had a subacute subdural hematoma. R2's family stated they wanted R2 placed on comfort care (care that helps or soothes a person at end of life). R2 returned to the facility with increased rounding for monitoring. The 11/15/21 Fall Investigation lacked physician notification, lacked casual factors related to the fall, and lacked post fall interventions to prevent future falls for R2. The 11/15/21 Progress Note documented the resident was found on the floor of his room at 06:31 AM, on his back with his head under the bed. R2 was naked and unresponsive to painful stimuli. R2's eyes [pupils] were sluggish, but vital signs were normal. R2 could not talk to staff or move his limbs. The LN assisted R2 back into bed and notified R2's family. R2's family requested the facility send R2 to the hospital for further evaluation, to which the LN agreed. R2 transferred to the hospital at 07:15 AM and returned to the facility approximately 10:30 AM, after a computed tomography scan (CT, imaging of the head and brain) and blood work. The facility placed R2 on one to one observation. The facility's Fall Investigation completed on 11/15/21 at 07:12 AM documented the LN responded to R2's room on 11/15/21 at 06:31 AM, because R2 was found on the floor. R2 was naked and unresponsive, would not acknowledge staff or react to painful stimuli, his pupils were sluggish, and R2 could not move his arms or legs. R2's family requested EMS notification and the facility transferred the resident to the hospital for further evaluation and treatment. R2 returned to the facility and required a staff member to be with him at all times. The fall investigation documented no injuries to R2. The facility's 11/15/21 Fall Investigation lacked physician notification and lacked causal factors of the falls for R2. On 11/18/21, staff updated the resident's Care Plan to include the following: 11/11/21: mattress replaced to a scoop mattress (a special type of mattress with raised sides that serves as a fall prevention measure by stopping residents from sliding out of bed). On 11/18/21, staff updated the Care Plan to include the following: 11/15/21: one on one at all times. Observation of R2 on 11/17/21 at 02:15 PM revealed R2 played Bingo with staff. R2 sat in a wheelchair, covered with a blanket. He did not appear to be in distress or pain. He was calm and did not attempt to get out of the wheelchair. Observation of R2 on 11/17/21 at 04:17 PM revealed staff propelled R2 throughout the facility. R2 requested to see people and wanted to go outside. R2 spoke with no purposeful sentences. Interview with Administrative Staff A on 11/17/21 at 11:17 AM revealed the fall interventions for R2 have remained the same, since his first fall in the facility. She stated Administrative Nurse B would complete a progress note related to the most recent fall explaining the root cause (causal factors). Interview on 11/17/21 at 03:00 PM with Certified Nurse Aide (CNA) F revealed R2 was impulsive and tried to do things on his own, which led to his falls. Interview on 11/17/21 at 03:28 PM with CNA E revealed R2 was a new resident to the facility and had many falls since admission. CNA E said R2 was impulsive and the staff watched him as often as they could. Interview on 11/18/21 at 03:53 PM with LN D revealed on 11/06/21, three residents fell in the facility at the same time, but in different locations. LN D notified Administrative Nurse B that she needed help because of the falls. When R2 fell LN D was told not to update the care plan with interventions by Administrative Nurse B. LN D said with one of R2's falls, LN I found flesh with hair in it on R2's dresser and LN I said Physician G would be notified. When LN D called Physician G about R2's continued falls, Physician G stated she was never notified of R2 hitting his head during a fall. The facility sent R2 to the hospital on 11/14/21 and noted he had a brain bleed. After returning from the hospital, R2 fell again overnight and was sent to the hospital again. Interview on 11/17/21 at 04:07 PM with Administrative Nurse B and Administrative Nurse C revealed R2 had poor safety awareness and impulsivity leading to his falls. R2 was placed on one to one observation with staff after his fall on 11/15/21. The surveyor had an unsuccessful attempt to interview the Physician G on 11/22/21 at 03:05 PM. The Fall Guidelines - Assessing Falls and Their Causes revised in 10/2010, staff were to notify the Attending Physician immediately by phone when a fall resulted in a significant injury or change in condition. An incident report must be completed for falls in Risk Management for each fall and should be completed by the LN and submitted to the Director of Nursing. Nursing staff in collaboration with IDT will begin to identify possible or likely causes of the incident and would continue to collect and evaluate information until the cause of the falling could either be determined or not determined. The facility failed to thoroughly complete fall investigations for each fall experienced by R2, to include identifying causal factors of the falls and new fall prevention interventions to prevent future falls with injury for R2, one which resulted in a head injury and brain bleed. - R4's pertinent diagnoses from the 10/11/21 Physician's Order in the Electronic Medical Record (EMR) documented a fracture of the left femur and dementia (progressive mental disorder characterized by failing memory, confusion) without behaviors. The 10/18/21 Significant Change Minimum Data Set (MDS) revealed a brief interview for mental status (BIMS) of four, indicating severely impaired cognition. R4 required extensive assist for all activities of daily living (ADL) that occurred during the review period. R4 had one fall with injury since the previous assessment. The 10/18/21 Fall Care Area Assessment (CAA) documented R4 was at risk for falls due to past falls, diagnosis of dementia, decreased safety awareness, and balance issues during transfers. The CAA noted the Interdisciplinary Team (IDT) would complete safety interventions as needed with care plan updates to minimize risks. The Care Plan initiated on 08/05/21 and updated on 09/28/21 documented staff were to review information on past falls and attempt to determine the cause of falls, to ensure all personal items and call light remained with reach of the resident, and to ensure resident had appropriate footwear on during transfers. The 10/04/21 Skin Observation Assessment documented R4 had a quarter sized skin tear on the left elbow, as well as bruising on the lower right leg. The Fall Investigation completed by the facility dated 10/04/21 at 04:29 PM, documented Licensed Nurse (LN) N entered R4's room and found her sitting on the floor, leaning against her dresser. R4 stated she got up to close the curtains and fell backward, landing on her right side. LN N completed an assessment, vital signs, and neuro checks. LN N noted a skin tear approximately two-inches by two-inches to R4's left elbow, R4 complained of pain when staff attempted to move her left leg and she stated her hip hurt. The facility transferred R4 to the hospital for evaluation and treatment. The investigation documented R4 was alert and oriented to herself, place, time and the situation. A witness statement documented R4 told LN N she landed on the left side of her body and hit her head on the floor. The Care Plan updated on 10/05/21, documented staff were to place bright colored tape on the call light as a reminder for R4 to use the call light. The IDT Review signed by Administrative Staff A on 10/21/21, regarding the fall on 10/04/21, documented that the root cause of the fall as resident laughingly stated 'I slid right out of that wheelchair.' The immediate intervention suggested to put a gripper mat in the wheelchair so the cushion would not roll out. The 10/17/21 Skin Observation Assessment documented R4 had a skin tear to the left elbow and left thigh. The 10/17/21 and 10/19/21 Fall Risk Tool documented R4 scored 21, indicating high fall risk due to multiple falls in the last six months of completing the assessment. The 10/18/21 Progress Note documented R4 fell out of bed overnight and became unresponsive while waiting to go to go to the hospital. R4 transferred to the hospital for an Xray. The facility did not complete/provide a Fall Investigation for the fall experienced by R4 on 10/18/21. The Final X-Ray Report completed on 10/19/21 documented R4 did not have any acute bony abnormalities (new changes in the bone structure) in the right hip. The Care Plan updated on 10/20/21, documented staff were to ensure R4's bed was in the lowest position and to place a fall mat next to the bed. The 10/23/21 Progress Note documented R4 fell and vital signs and neuro checks were completed, with no further information documented in the note. The facility did not complete/provide a Fall Investigation or documentation of neuro checks completed for the fall experienced by R4 on 10/23/21. Interview on 11/17/21 at 11:17 AM with Administrative Staff A revealed the staff did not complete post fall interventions or a root cause to the investigation for the fall that occurred on 10/04/21. Interview on 11/23/21 at 08:10 AM with LN D revealed R4 arrived at the facility with a hip fracture and was to be non-weight bearing. LN D said she did not work on 10/04/21 but she did fall once while LN D was working. LN D said she found R4 in her room naked, confused, and R4 complained of left hip and right shoulder pain. R4 told LN D she was trying to get out of bed, but did not know why. LN D stated she wanted to send R4 to the hospital to ensure there was no damage to her previous hip fracture, but the Administrative Nurse at the time told LN D that sending R4 to the hospital would make the facility look bad and the facility needed to get family permission. LN D called the family for approval and called EMS for transport. LN D did not remember R4 having any skin tears from her fall but stated R4 had syncopal ([CONDITION(S)]) episodes on occasion. LN D stated she was not told to complete any Fall Investigations just to complete a progress note for each fall. The facility policy titled Fall Guidelines - Assessing Falls and Their Causes, revised in 10/2010, directed staff to notify the Attending Physician immediately by phone when a fall resulted in a significant injury or change in condition. An incident report must be completed for falls in Risk Management for each fall and should be completed by the LN and submitted to the Director of Nursing. The LN staff in collaboration with IDT would begin to identify possible or likely causes of the incident and would continue to collect and evaluate information until the cause of the fall could either be determined, or not determined. The facility failed to thoroughly complete fall investigations for each fall experienced by R4, to include lack of identifying causal factors of each fall and failure to implement new fall prevention interventions to prevent future falls with injury, for R4. - R5's pertinent diagnoses from 09/17/21 Physician's Order in the Electronic Medical Record (EMR) documented cerebral infarction (result of disrupted blood flow to the brain due to problems with the blood vessels that supply it) and dementia (progressive mental disorder characterized by failing memory, confusion) with behaviors. The 10/14/21 Significant Change MDS revealed a BIMS was not completed as R5 was rarely or never understood. The staff assessment of mental status documented R5 had a memory problem. R5 did have verbal behaviors directed towards others one to three days in the seven-day look back period. R5 required one-person extensive assistance for all ADL. R5 had two or more falls without injury and two or more falls with minor injury since the previous assessment. The 10/14/21 Care Area Assessment (CAA) documented R5 was at risk for falls related to history of falling, cognitive loss with dementia, decreased safety awareness, balance issues during transfers, and limited mobility. Staff were to anticipate and meet needs daily as well as provide verbal cues for safety during cares. The 10/08/21 Care Plan documented R5 to have anti rollbacks and toppers placed on the wheelchair, as well as a Dycem (non-slip mat) on the cushion of the wheelchair. Staff were to ensure a mattress was placed next to each side of the bed on the floor, ensure all personal items including the call light were within reach, and that R5 wore proper footwear. In addition, staff were to review information on past falls and attempt to determine the cause of the falls. 1. The 09/01/21 facility Fall Investigation documented R5 had an unwitnessed fall in his room causing a 0.5cm x 0.5cm abrasion to the right hip, on 09/01/21. The Interdisciplinary Team (IDT) summary did not identify a causal factor or intervention associated with the 09/01/21 fall until 10/10/21, 39 days after the fall. 2. The 09/07/21 facility Fall Investigation documented R5 had an unwitnessed fall in the library/parlor room, on 09/07/21. The Interdisciplinary Team (IDT) summary did not identify a causal factor or intervention associated with the 09/07/21 fall until 10/21/21, 44 days after the fall. 3. The facility Fall Investigation completed on 09/19/21 at 05:56 PM by LN L documented see nurse notes in all areas of the investigation. LN L documented low staffing, one nurse and one CNA with 48 residents. Unsafe staffing ratio. The investigation noted the staff heard R5 yelling in the COVID unit and found the resident on the floor in another resident room. The investigation did not indicate whether R5 was injured or not with this fall. The investigation lacked casual factors related to the fall and lacked post fall interventions to prevent future falls. 4. The facility Fall Investigation completed on 09/22/21 at 04:45 PM by LN M documented R5 had an unwitnessed fall in the dining room and was found lying on his right side. The investigation lacked casual factors related to the fall and lacked post fall interventions to prevent future falls. The 09/22/21 Falls Risk Assessment documented Falls Risk Assessment documented the resident at a moderate fall risk, because he had multiple falls since admission. 5. The 10/13/21 Progress Note documented R5 was found on the floor scooting off the fall mat next to the bed. R5 denied any pain or discomfort and no injuries were noted. The facility did not complete/provide a Fall Investigation for the 10/13/21 fall experienced by R5; therefore, no causal factors or interventions implemented to prevent future falls. 6. The 10/14/21 facility Fall Investigation documented R5 had an unwitnessed fall on 10/14/21. Staff found the resident on the floor at the end of his bed, next to his wheelchair with his pants and brief around his ankles. Neuro checks were started, and a skin assessment was completed. R5 was found to have an abrasion to the back of his head that was clotted with bright red blood. R5 was cleaned and taken to the nurses' station. The investigation lacked casual factors related to the fall and lacked post fall interventions to prevent future falls. 7. The 11/02/21 Progress Note documented R5 had an unwitnessed fall in his room with the wheelchair across the room from R5. R5 stated he was trying to get out of bed. The facility did not complete/provide a Fall Investigation for the 11/02/21 fall experienced by R5; therefore, no causal factors or interventions implemented to prevent future falls. The 11/02/21 Fall Risk Assessment documented the resident at a high fall risk, because he had multiple falls since admission. Interview on 11/18/21 at 03:53 PM with LN D revealed on 11/06/21, three residents fell in the facility at the same time, but in different locations. The staff found R5, the fourth resident to fall, in the activities room by another staff member. LN D notified Administrative Nurse B she needed help because of the falls and Administrative Nurse B told LN D the staff were reason the residents were falling. Interview on 11/23/21 at 08:24 AM with LN D revealed R5 always fell . The facility care planned a mat on the floor, so that if R5 fell , it would not count as a fall from his bed. LN D stated Administrative Nurse H told her this. LN D stated she did not remember R5 being injured with any of his falls and that R5 did not go to the hospital. The Fall Guidelines - Assessing Falls and Their Causes revised in 10/2010, staff were to notify the Attending Physician immediately by phone when a fall resulted in a significant injury or change in condition. An incident report must be completed for falls in Risk Management for each fall and should be completed by the LN and submitted to the Director of Nursing. Nursing staff in collaboration with IDT will begin to identify possible or likely causes of the incident and would continue to collect and evaluate information until the cause of the falling could either be determined or not determined. The facility failed to thoroughly complete fall investigations for each of the 7 falls experienced by R5 in two months (09/01/21-11/02/21), to include identifying causal factors of the falls and implementing new fall prevention interventions to prevent future falls with injury for R5.

The facility census totaled 48 residents, with three residents (R) in contact precautions (safeguards designed to reduce the risk of transmission of microorganisms by direct or indirect contact) due to cough or fever symptoms. Based on observation, interview, and record review, the facility failed to screen staff and visitors for COVID-19 signs and symptoms before entry into the facility and access to residents. The facility failed to ensure that staff correctly applied and removed the recommended personal protective equipment (PPE) upon entry and exiting residents' rooms who were in contact precautions. The facility's failure to ensure all who entered the facility were screened for COVID-19 symptoms and temperatures were taken along with the failure to correctly apply all PPE and remove PPE upon entry/exiting residents' rooms with contact precautions, placed all residents in the facility in immediate jeopardy. Findings included: - A review of the Visitor Sign In/Out Log from 03/16/20 to 04/20/20 revealed the facility identified a total of 28 visitors who were allowed entry to the facility. The facility had identified visitors permitted entry into the facility as not highlighted or colored in green highlighter. The screening was not required for emergency medical personnel and therefore excluded from the count. The form itself lacked any screening questions regarding the symptoms of COVID-19. A review of the forms entitled Help Us Prevent COVID-19 Infection, for the time between 03/16/20 to 04/20/20, revealed these forms contained questions related to the guest's symptoms associated with COVID-19. However, the facility only provided 12 of the expected 28 completed guest forms from the Visitor Sign In/Out Log. Two forms had an unreadable signature, and nothing else completed. There was one form that matched the Visitor Sign In/Out Log, but lacked documentation of temperature on either form. Entry to the facility on [DATE] at 07:28 AM revealed signage posted on the locked front door which read the facility restricted entry due to the current COVID-19 pandemic. Housekeeping Staff (HS) F, wore a mask, opened the front door and asked the surveyor to take their temperature with the thermometer sitting on the table, sign their name in a logbook, and to step in a black basin with fluid in it. HS F failed to ask the surveyor if she experienced any COVID-19 signs or symptoms, did not ensure the surveyor properly took her own temperature, or look to see the temperature result of the surveyor before allowing entry into the facility. During an interview with HS F on 04/20/20 at 12:23 PM, revealed she failed to have the surveyor complete the additional form, which had the COVID-19 symptom questions. Interview with Administrative Nurse H on 04/20/20 at 10:24 AM revealed during usual business hours, hospitality staff answered the door and performed guest screening. Administrative Nurse H said all staff received training over the entry screening procedure, and the incident indicated reeducation over the process needed to occur. During electronic communication with Administrator B on 04/23/20 at 02:36 PM revealed management made the decision on whether or not a guest was allowed entry into the building Review of a Centers for Medicare and Medicaid Services (CMS) guidance, dated 04/02/20, entitled COVID-19 Long-Term Care Facility Guidance, revealed long term care facilities were to implement symptom screening on every individual entering a long-term care facility, including inquiry over COVID-19 symptoms and temperatures checked. The facility failed to ensure thorough screening of guests for COVID-19 symptoms before entering the facility, which allowed full access to residents and their environment. This failure put all residents in immediate jeopardy. - Review of R1's eINTERACT SBAR Summary for Providers Situation, dated 04/07/20, revealed the physician had been contacted due to the resident having a cough and abnormal lung sounds. The physician advised staff to start antibiotic medication and obtain samples to send to check for strep throat and influenza (the flu). The staff implemented the Novel Coronavirus Prevention and Response policy per the documentation. During an observation on 04/20/20 at 08:54 AM certified nurse aide (CNA) C prepared to enter R1's room identified with contact precautions. The signage on the door indicated a gown, gloves, facemask, and goggles were required to enter the room. CNA C donned (put on) shoe coverings and gloves before entering the room, but did not don the gown, facemask, or goggles, as required. During an interview with CNA C on 04/20/20 at 08:57 AM revealed she utilized one gown hanging up in the foyer of the room, even though those were the same gowns that were used from the previous day. CNA C said she forgot the goggles due to having her prescription glasses on. She reported the resident was on contact precautions due to having a cough and fever. Review of R2's eINTERACT SBAR Summary for Providers Situation note, dated 04/04/20, revealed R2 complained of a sore throat, cough, and hoarseness. The resident's throat was red upon visualization. The physician ordered staff to obtain samples to check for the flu and strep throat. Review of a Nursing Note, dated 04/04/20, revealed the resident was on isolation at that time and he complained of his throat being sore. Observation on 04/20/20 at 11:57 AM revealed Housekeeping Staff (HS) I exited R2's room designated as being on contact precautions. HS I wore a cloth gown, shoe coverings, gloves, face mask, face shield, and goggles. She exited the room in the full PPE, walked approximately eight feet down the hall, then returned to the housekeeping cart located outside of the resident's room. She then removed the face shield and placed it in the bottom drawer of the plastic three-bin storage container situated outside the resident's room that was utilized to hold the clean PPE. She then put the goggles in the same drawer. The items were not cleaned or disinfected before placement in the drawers. She then started to remove the cloth gown, fold it up, and began to place it in the middle drawer of the three bin container used to hold the clean PPE, when Administrative Nurse H and another staff member (acting as an interpreter) arrived, and stopped HS I from placing the gown in the drawer. Interview with Administrative Nurse H on 04/20/20 at 10:00 AM revealed all staff received training on the correct way to put on and take off the PPE. She stated that if they see staff inappropriately utilizing PPE, they were retrained on the spot, and if there were consistent problems, then they would complete twice-weekly CNA meetings. During a follow-up interview at 12:05 PM revealed she provided on the spot education to HS I and she would have HS I sign a form later. Review of the facility provided policy, implemented 03/13/20, entitled Novel Coronavirus Prevention and Response, revealed staff were to be educated on the proper use of PPE, making PPE, including facemasks, eye protection, gowns, and gloves, available immediately outside of the resident's room, and positioning a trash can near the exit inside any residents room for the disposal of PPE. The policy stated that residents with an undiagnosed respiratory infection, standard, contact, and droplet precautions were to be implemented. The facility failed to ensure staff knowledge of the proper procedures in wearing and removing PPE to prevent the cross-contamination and spread of an infectious virus, Covid 19. On 04/20/20 at 04:48 PM, the surveyor provided Administrative Staff B with the IJ template and notified that the facility failure to ensure all guests were screened for COVID-19 symptoms and temperature along with the inability to ensure staff prevented the potential spread of infectious organisms constituted immediate jeopardy at F880, with the potential to affect all residents in the facility. The facility presented an acceptable plan for removal of the immediate jeopardy on 04/20/20 at 08:39 PM, which included one-on-one education for staff regarding PPE and procedures for screening guests prior to access within the resident living space. The survey team validated the immediate jeopardy removal on 04/21/20 at 09:47 AM following the facility's implementation of the plan for removal of the immediate jeopardy. The deficient practice remained at a scope and severity of an F.

The facility reported a census of 50 residents, with three residents sampled for cardiopulmonary resuscitation (CPR- emergency medical procedure for restoring normal heartbeat and breathing to victims of heart failure, drowning, etc.). Based on interview and record review the facility failed to ensure licensed nursing staff A continued CPR prior to contacting and turning over care to emergency medical services for resident #1 when he/she lacked the presence of vital signs (no pulse or respirations) and had a full code status (signed documentation which indicated the status of a resident with respect to his/her desire for resuscitative efforts, unless the resident specifically requested not to be resuscitated) in his/her medical record and the resident died . This placed resident #1 in immediate jeopardy. Findings included: - Review of resident #1's signed physician orders dated [DATE] revealed the following Diagnoses: [REDACTED]. Review of the significant change in status minimal data set ((MDS) dated [DATE] revealed the resident had a brief interview for mental status (BIMS) score of 3, which indicated severe cognitive impairment. Review of the quarterly MDS dated [DATE] revealed no changes in the resident's status. Review of the resident's care plan dated [DATE] revealed: The resident chose to have a full code status (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). Staff would review the resident's code status and advanced directive quarterly and as needed. Staff would respect the resident's full code status and perform cardiopulmonary resuscitation in the event the resident's heart stopped. Review of the nurse's note dated [DATE] at 5:14 PM revealed the resident arrived at the facility from the hospital at 2:37 PM via facility transportation. Review of the nurse's note dated [DATE] at 2:15 AM revealed direct care staff M and licensed nurse A went into resident #1's room to turn and check on him/her. The writer planned to administer a tube feeding (the introduction of a nutrient solution through a surgically inserted tube into the stomach through the abdominal wall) to the resident. When staff entered the resident's room he/she was not breathing. Staff checked the resident for a pulse and it could not be found. The writer began to administer CPR to the resident and continued for about three minutes. The resident continued to lack vital signs. The writer notified the physician, the resident's family and the mortuary. Review of resident #1's physician orders dated [DATE] lacked an order to discontinue CPR on the resident and/or release the resident's body to the mortuary. The resident's medical record dated [DATE] lacked evidence the licensed nurse contacted emergency medical services (EMS) when he/she found the resident without vital signs. Review of the signed, notarized witness statement dated [DATE] revealed direct care staff M went with licensed nurse A to do the resident's tube feeding. Upon entering the resident's room, both staff noticed the resident unresponsive and not breathing. Staff M stated direct care staff N came in the resident's room and licensed staff A instructed him/her to get the facility emergency cart, so he/she could start CPR. Licensed nurse A then started CPR and after a while he/she stopped and told the direct care staff to clean the resident up while he/she went to call someone to see if they could tell him/her what to do next. Staff A told the direct care staff he/she had not done CPR before and did not know what to do. Review of the signed, notarized witness statement dated [DATE] revealed on [DATE] direct care staff N walked out of a room and saw a nurse running into resident #1's room. He/she retrieved the equipment to do CPR and returned to the resident's room. Staff N stated the licensed nurse began CPR on the resident and continued for a while (,[DATE] min or more). Staff N further stated the licensed nurse stopped CPR because the resident was not breathing and there was no heartbeat. The nurse went to notify the resident's physician while direct care staff stayed to clean the resident and prepare for the funeral home to pick him/her up. Review of the signed, notarized witness statement dated [DATE] by licensed nursing staff A revealed he/she went into the resident's room to check on him/her, turn him/her and do his/her 2:00 AM tube feeding. When staff A entered the resident's room, the resident was not breathing and had no pulse. Staff A stated he/she ran to get CPR equipment, lowered the bed to a flat position, and started CPR. After about 3 rounds of CPR the resident did not have a pulse or respirations. Staff A stated his/her first instinct was to notify the physician and get the ambulance to the facility, so he/she left the resident to make a call. The resident's physician asked how the residents skin felt and staff A stated warm/cool. The physician stated the resident most likely passed away about an hour ago and instructed the nurse to stop CPR and call the funeral home. An interview on [DATE] at 2:55 PM with licensed nurse G revealed resident's code statuses were on their profile page, Medication Administration Record [REDACTED]. Staff G stated once a nurse started CPR, they should continue until EMS arrived at the facility to take over performing CPR. An interview on [DATE] at 3:30 PM with administrative nursing staff B revealed the resident had a full code status. Staff B expected the nurse to start CPR and continue until EMS relieved him/her. Staff B stated licensed staff A should have had a direct care staff call emergency services, but he/she stopped CPR and called the resident's physician. Staff B stated licensed staff A was a new nurse but had CPR certification. Review of the facility policy for cardiopulmonary Resuscitation (CPR) dated [DATE] revealed a licensed nurse would begin CPR if the adult victim became unresponsive (not breathing normally (ignoring occasional gasps) and without pulse). Rescuers would continue CPR until EMS arrived and took over life-saving efforts. The facility failed to ensure licensed nursing staff A continued CPR prior to contacting and turning over care to emergency medical services for resident #1 when he/she lacked the presence of vital signs (no pulse or respirations) and had a full code status in his/her medical record and the resident died . This deficient practice placed resident #1 in immediate jeopardy. The facility abated the immediate jeopardy on [DATE] at 9:37 PM when the facility educated all staff in all departments on the correct requirements for performing CPR. The facility conducted a full house audit for code status and audit of CPR VLS status. The facility provided one to one education to the licensed staff member and the director of nursing trained all department heads on the requirement for performing their roles during an emergency event. Staff were asked to demonstrate/acknowledge understanding of the requirements verbally. The facility compiled a list of all employees and ensured all staff members were trained. The Administrator/DON/Designee would be available either within the facility or by phone to answer questions or complete additional training on providing CPR as needed until all staff members were fully trained, staff not present for training would not be allowed to return to work until they received the education. The facility had a policy in place to address cardiopulmonary resuscitation of residents. The policy was based on regulatory requirements, facility policy and their desire to protect the residents. Training included explanation of the policy and what each staff members role would be during such an event, verbalization of knowledge for each staff members, location of code book and crash cart. During orientation all future employees would receive CPR training. Employees would further be educated annually on the Emergency Procedure and Cardiopulmonary Resuscitation procedure and policy. The Administrator/designee would conduct random CPR audits daily each shift for the next seven days, then weekly for four weeks, then monthly for three months to validate staff's knowledge of the facility's Emergency Procedure and Cardiopulmonary Resuscitation Policy and any identified trends or concerns would be addressed immediately. The facility would forward results of audits to the Quality Assurance Performance Improvement (QAPI) Committee for review. A Quality Assurance meeting would be held to review area of concern and an action plan created to ensure staff followed the emergency procedure. All information forwarded to the QAPI Committee would be reviewed for any trends with corrective plans revised or resolved as deemed appropriate by the committee. This deficient practice remained at a scope and severity of a G.

The facility identified a census of 50 residents with three residents sampled for falls. Based on observation, record review and interview the facility failed to provide supervision and safety devices to each resident to prevent avoidable accidents. The facility failed to apply a safety belt to cognitively impaired resident #3 according to the manufactures recommendation when using the whirlpool bath chair, which resulted in the resident falling out of the chair and fracturing his/her right distal femur (thigh bone). Findings included: - Review of resident #3's signed physician orders [REDACTED]. Review of the 7/26/18 quarterly minimum data set (MDS) assessment revealed the resident had a brief interview for mental status score of 3, which indicated severely impaired cognition. The resident required extensive assist of 2 staff for transfers and required a wheelchair for mobility. The resident required total dependence of 2 or more staff for bathing. The resident had one injury (except major) fall since admission or the prior assessment. The resident required oxygen therapy. Review of the resident's care plan closed 10/22/18 revealed: 5/1/17 - The resident had a risk for falls related to cognitive impairment, decreased mobility, slick surfaces, impaired balance, transferring self and seeking out items. 5/1/17 - Staff would monitor the resident for changes in condition that warranted increased supervision/assistance and notify charge nurse. 5/1/17 - Physical and Occupational therapy would screen the resident quarterly and as needed. 5/1/17 - Staff would provide frequently used items within easy reach 5/11/17 - The resident required 1 person assist for bathing. 5/11/17 - The resident transferred with 1 person assist and a gait belt. 5/11/17 - Staff would encourage the resident to notify them when he/she needed assistance. 9/26/17 - The resident would wear non-skid socks or other appropriate footwear, which allowed grip when the resident transferred. 2/5/18 - Staff would apply Dycem (non-slip mat used in to create a non-slip surface) to the resident's wheelchair. 10/9/18 - The resident would be helped by two people when they rotated the resident/chair out of the whirlpool tub. Review of the Nurse's note dated 10/8/18 revealed staff notified the resident's physician via fax the resident fell in the whirlpool room. The resident suffered a small abrasion on the left shoulder and the right knee appeared to be more swollen then the left. The resident complained of sharp pain to the right knee and yelled when staff touched the area. Emergency management picked up the resident and transported him/her to the hospital. Review of the nurse's note dated 10/8/18 revealed the resident admitted to the hospital with [REDACTED]. Review of the signed, notarized witness statement dated 10/8/18 written by direct care staff O revealed the resident fell out of the whirlpool from a seated position in the shower chair. The resident leaned forward to get him/herself out of the chair and by the time staff O reached for the resident he/she was already at the edge of the chair and fell head first into the whirlpool. Staff O immediately called for help to get the resident up on the floor to examine his/her injuries. Staff assisted the resident from the floor to the wheelchair, checked the resident's vital signs and checked for bruising. The resident's right knee began to swell and bruise. Interview with direct care staff O on 1/2/19 at 4:05 PM revealed resident #3 fell in the whirlpool room on 10/8/18 as he/she assisted the resident out of the whirlpool. Staff O stated the resident had episodes where he/she thought he/she could not breathe so the resident tried to get him/herself out of the whirlpool by him/herself. Staff O had the resident in the whirlpool chair and the resident leaned forward. Staff O tried to push the resident back and he/she fell forward out of the whirlpool chair. Staff O stated he/she did not have training on the use of the belt located on the chair in the whirlpool, only on how to use the whirlpool when he/she started at the facility. Administration trained staff O on use of the belt on the chair in the whirlpool after the resident fell , but he/she stated there was no belt on the chair in the whirlpool at the time the resident fell . Observation of the facility whirlpool on 1/2/18 revealed a safety belt in place on the whirlpool chair. An interview on 1/3/19 at 11:50 AM with direct care staff P revealed when staff placed a resident in the whirlpool chair, after removing clothing staff would put the safety belt on the resident before placing the resident in the tub. Staff P stated the whirlpool chair had a safety belt on it the entire time he/she worked at the facility (more than a year) and he/she had training on how to use the seatbelt. If a resident refused the belt the intervention would be on their care plan. An interview with administrative nursing staff B on 1/3/18 at 2:00 PM revealed staff would follow the resident's care plan to transfer the resident. Staff B stated the resident was transitioning from the whirlpool chair to the wheelchair. Staff B stated direct care staff O took the belt from the whirlpool off to put on a gait belt to transfer the resident to the wheelchair. Staff B stated there should have been two staff members in the whirlpool room to transfer resident #3. Review of the facility bathing policy on 1/2/19 lacked instructions for staff to use a seat belt to secure residents while in whirlpool. Reviewed of the Whirlpool Operation Manual with maintenance staff U on 1/2/19 at 6:00 PM revealed the manual identified the required use of a safety belt while in the whirlpool chair. Staff U stated the whirlpool has had a safety belt on it for more than a year and a half he/she worked for the facility. The facility failed to apply a safety belt to cognitively impaired resident #3, according to the manufactures recommendation when using the whirlpool bath chair, which resulted in the resident falling out of the chair and fracturing his/her distal femur.

The facility had a census of 50 residents with 3 residents reviewed for falls. Based on observation, interview, and record review, the facility failed to ensure 3 of 3 sampled residents received adequate supervision and assistive devices to prevent accidents. The facility failed to evaluate each fall for causative factors, implement appropriate fall prevention strategies, follow-up on fall interventions/recommendations, and failed to follow the care plan related to fall prevention. (#1, #2, and #3) Resident #1 had recurrent falls and required emergency treatment and sutures following falls on 4/30/14 and 5/30/14. Findings included: - Resident #1's 3/19/14 physician order [REDACTED]. The order sheet included an order for [REDACTED]. Resident #1's 5/20/14 annual MDS (minimum data set) assessment revealed the resident had a BIMS score of 4 which indicated severe cognitive impairment. The resident was dependent on 2 staff for bed mobility, transfers, and toilet use. The resident was always incontinent of bowel/bladder, walking did not occur, and he/she used a wheelchair for mobility. The resident had a history of [REDACTED]. Resident #1's 5/22/14 Fall CAA (care area assessment) summary indicated the resident required use of a full lift for transfers, was incontinent of bowel/bladder, received psychotropic medications, and a PT (physical therapy)/OT (occupational therapy) screen quarterly. Resident #1's 5/27/11 nursing care plan that was in place prior to 1/9/14 revealed the resident had a history of [REDACTED]. The care plan directed staff to reposition with 1-2 persons, keep the room free of clutter, and to call the resident's family if he/she became agitated or uncooperative. The care plan stated that at times the resident believed he/she could walk and directed staff to ensure the call light was in reach and to remind the resident how to use it. The care plan directed staff to keep his/her high/low bed in low position, keep in view of staff when not in his/her room, use mechanical lift for transfers, fall mat, and scoop mattress. Fall risk assessments for resident #1 revealed a score of 22 on 1/14/14, 24 on 2/21/14, and 26 on 5/22/14. Scores greater than 10 indicated the resident was at high risk for falls. Review of nurses notes and fall investigations revealed the resident sustained [REDACTED]. According to a 1/10/14 fall investigation, the resident fell at 6:00 a.m. when the resident fell from the bed on to the fall mat on his/her knees. Initiation of a bowel/bladder diary was recommended. Review of resident #1's bowel/bladder diary revealed the assessment was not initiated until 1/21/14, 11 days after the fall. Evaluation of the diary revealed no pattern and indicated a routine toileting schedule was appropriate. A 1/15/14 fall investigation revealed resident #1 fell from the bed without injury at 8:10 p.m. Facility staff placed a mattress on the floor bedside the bed to further reduce chances of injury until the resident completed his/her antibiotics and initiated 30 minute visual checks. The resident had a urinary tract infection discovered when the resident fell on [DATE] and currently received antibiotics. On 1/20/14 at 5:50 a.m. resident #1 fell from the bed to the mattress on the floor without injury. The care plan lacked implementation of a fall prevention strategy, other than to recheck the resident's urinalysis. An investigation dated 3/27/14 revealed resident #1 fell from the bed without injury at 5:45 a.m. The investigation recommendations included initiation of a 72 hour bowel/bladder assessment. Review of the resident's clinical record revealed staff started the bowel/bladder assessment on 4/12/14 that was incomplete, 17 days after the fall. According to the 4/9/14 fall investigation for resident #1 the resident fell from the bed without injury. An administrative review suggested continuation of 30 minute visual checks and to review these with staff. Review of the care plan lacked implementation of a new fall prevention strategy. An investigation on 4/19/14 documented resident #1 fell from his/her wheelchair in the hallway without injury. Interventions included a PT/OT evaluation. Review of the clinical record revealed no evidence of completion of the PT/OT evaluation as recommended after the fall. On 4/30/14, a fall investigation indicated resident #1 fell again from the wheelchair, landing on his/her face on the floor. There resident had bruising and swelling to the forehead and bruising to the right eye. The resident also had a 1 cm (centimeter) laceration to the bridge of the nose that required emergency treatment and sutures. Interventions placed included review bathing schedule, review bowel/bladder regimen, skin care for wound, and PT/OT assessment. A PT screen dated 5/9/14 indicated the resident had recurrent falls with the last fall on 4/30/14. PT recommendations included frequent checks and repositioning in the wheelchair at least every 30 minutes. Review of the care plan lacked implementation of the recommendations from PT. A fall investigation dated 5/17/14 stated the resident fell again from the wheelchair, falling forward on to a loveseat. Fall strategy interventions included follow up with the physician regarding lab results and to consider a new wheelchair to discourage the resident from leaning forward. A PT screen on 5/20/14 included a recommendation to reposition every hour while up in the wheelchair and to continue use of the alarms. Review of resident #1's care plan lacked interventions related to repositioning of the resident in the wheelchair, as recommended by PT. A fall on 5/30/14 at 8:15 a.m. described in a fall investigation that resident #1 had a fall from his/her bed to the floor. According to the investigation direct care staff C assisted resident #1 with incontinence care, went to the door of the resident's room to seek help, turned around and the resident was on the floor. Interventions included staff education and re-evaluation of interventions after the resident returned from the hospital. A 5/30/14 hospital history and physical stated the resident presented to the emergency room after resident #1 fell from his/her bed landing on the floor causing some significant trauma to his/her face. The resident had a laceration, a hematoma (a localized collection of blood, usually clotted, in an organ, space, or tissue), two black eyes, and was brought to the emergency room for further evaluation. On physical exam, the resident had a lot of bruising noted around the periorbital areas (tissue surrounding the orbits of the eyes) of both eyes and a large hematoma on his/her forehead that measured approximately 6 cm in diameter. The resident also had a laceration at his/her brow line between the eyes that required suturing. A CT (computerized tomography, CAT scan) done on 5/30/14 stated the resident had a large hematoma noted in the frontal region mainly to the left side, but appeared to be crossing to the right side of midline as well. Resident #1 returned to the facility with physician orders [REDACTED]. During an observation on 6/16/14 at 8:45 a.m. resident #1 rested in bed with his/her head elevated approximately 30 degrees. The bed had a scoop mattress, was in low position with a bed alarm in place and a fall mat by the bed. Direct care staff D sat with the resident. The resident had fading green/yellowish bruises to the face, forehead, and eyes with a Band-Aid across the bridge of his/her nose. At 9:26 a.m. direct care staff D and E repositioned the resident and checked for incontinence. After providing care, direct care staff D placed the bed in low position and replaced the fall mat by the bed. The bed alarm was on and he/she raised the head of the bed to 30 degrees. Direct care staff D remained at the resident's side and stated staff remained with the resident at all times providing one on one care. During an interview on 6/16/14 at 1:03 p.m. direct care staff C recalled resident #1's fall on 5/30/14. Staff C stated that on that day, the resident's alarm sounded and he/she went to the resident's room. Staff C stated when he/she entered the room the resident's legs were over the side of the bed. and was in need of incontinence care. Direct care staff C stated he/she raised the bed to provide incontinence care approximately 3-4 feet from the floor. Staff C stated he/she thought the resident wanted to get up and he/she went to the door of the resident's room to summon help leaving the bed in the raised position when he/she stepped away. When staff C turned around the resident had fallen to the floor and was lying face down directly on the floor. The floor mat was not by the bed as directed by the care plan. At that time licensed nurse E assessed the resident and directed staff to use the mechanical lift to transfer the resident to his/her bed. Direct care staff C also revealed the resident went to the hospital for treatment. An interview on 6/16/14 at 5:34 p.m. with licensed nurse F revealed resident #1 was restless at times and had the ability to move his/her trunk and extremities in the bed and could get out of the bed with the scoop mattress in place. Nurse F also stated the resident's bed was to remain in low position when he/she was in bed without staff in attendance. An interview on 6/16/14 at 6:19 p.m. with administrative nurse B verified staff failed to complete the bowel/bladder assessments in a timely manner in order to use the data to develop a toileting program to assist in fall prevention. Nurse B also confirmed a lack of follow-up after PT made recommendations related to the residents falls and wheelchair safety. He/she stated that each fall is reviewed and new fall strategies should be initiated to prevent future falls. Administrative nurse B confirmed resident #1's falls on 4/30/14 and 5/30/14 required emergency treatment and suturing of lacerations. Nurse B further stated that after the fall on 5/30/14 they provided immediate education to staff regarding fall prevention and confirmed the fall on 5/30/14 was avoidable. During an interview on 6/18/14 at 11:40 a.m., physician H confirmed resident #1 sustained falls that required medical treatment in the emergency room . Dr. H stated the resident had [DIAGNOSES REDACTED]. Dr H further stated the resident had a frontal hematoma as a result of the fall and also received Pradaxa a medication that thins the blood prior to the fall. The facility's 9/2009 Fall Prevention and Management Policy stated the team reviewed details related to falls and reviewed implemented interventions. The policy also stated the team should ensure the appropriateness of interventions and additional interventions may be identified and should be implemented immediately after the review process. The facility failed to place appropriate fall prevention strategies after each fall, failed to implement and complete the bowel/bladder assessment interventions in a timely manner, failed to follow up on PT recommendations to prevent falls, and failed to keep the resident's bed in low position as care planned. Resident #1 sustained falls on 4/30/14 and 5/30/14 that required emergency treatment and suturing of lacerations. - Resident #2's 2/7/14 admission orders [REDACTED]. The physician discontinued the Temazepam on 2/17/14 and ordered Halcion .25 mg at hour of sleep starting on 2/17/14. The resident also had an order for [REDACTED]. Resident #2's 2/14/14 admission MDS (minimum data set) assessment revealed the resident had a BIMS (brief interview for mental status) score of 14 which indicated intact cognition. The resident had the ability to transfer and walk in his/her room without assistance. He/she required extensive assistance of 1 person for walking in the corridor and toilet use. The resident had unsteady balance and had the ability to stabilize without assistance from staff. According to the assessment, the resident had not fallen since admission to the facility. He/she received diuretic and hypnotic (sleeping aid) medications for 7 days of the assessment period. Resident #2's 4/21/14 significant change MDS revealed the resident had a BIMS score of 14 which indicated intact cognition. The resident was dependent on 2 staff for bed mobility, transfers, dressing, toilet use, and walking did not occur. According to the assessment the resident had a fall with a fracture in the last month and no falls since readmission to the facility. The resident received hypnotic and diuretic therapy for the 7 days of the assessment period. The falls CAA (care area assessment) summary dated 4/24/14 identified the resident as at risk for falls due to his/her hypnotic and antidepressant use, history of falls and a recent fractured hip. The CAA also stated the resident received physical therapy and occupational therapy services. Resident #2's 2/7/14 nursing care plan indicated the resident was at risk for falls due to unsteady gait and use of sleep aids. The care plan directed staff to remind the resident to call for assistance with ambulation outside of his/her room. Updates to the care instructed staff to provide adequate lighting in the room, reduce clutter, and complete a medication review after the resident's fall on 2/20/14. An intervention for 30 minutes visual checks was implemented on 3/5/14 after a fall, appropriate footwear or non-skid socks on 3/22/14, and a revision on 3/24/14 indicated fall prevention strategies would be reviewed after the resident returned from the hospital. After returning from the hospital on [DATE], the care plan directed staff to use a full lift with 2 persons for transfers. Fall risk assessments for resident #2 revealed a score of 11 on 2/5/14, 17 on 4/4/14, and 20 on 4/24/14. Scores greater than 10 indicated the resident was at high risk for falls. Review of nurses notes and fall investigations revealed the resident sustained [REDACTED]. Resident #2's 2/7/14 admission orders [REDACTED]. The physician discontinued the Temazepam on 2/17/14 and ordered Halcion .25 mg at hour of sleep starting on 2/17/14. The resident also had an order for [REDACTED]. On 4/22/14 the physician ordered Temazepam 30 mg as needed for insomnia. Resident #2's 2/19/14 fall investigation form revealed the resident had a fall getting up from the toilet. Interventions placed after the fall included provide adequate lighting, reduce room clutter, and to review medication/hypnotic use. Review of the clinical record lacked evidence of a medication review related to the resident's medications, which included hypnotics and diuretics, which could contribute to the resident's fall risk. A fall investigation dated 3/5/14 revealed resident #2 sustained a fall at 8:00 a.m. while ambulating barefoot. Interventions placed after the fall on 3/5/14 included 30 minute visual checks by staff. Review of the MAR revealed resident #2 received Halcion .25 mg at hour of sleep on 3/4/14 and also received Ativan 1 mg (ordered "as needed" for sleep). New interventions failed to address the resident's lack of appropriate footwear. A fall investigation on 3/22/14 at 10:45 a.m. reported staff observed the resident on the floor by his/her recliner without injury. According to the investigation, the resident wore socks only that possibly contributed to sliding on the floor and falling. Interventions placed included continue 30 minute visual checks, reminders to call for help, and encourage the use of non skid socks and footwear. An investigation dated 3/24/14 stated resident #2 fell when he/she tried to reach for a blanket. The resident had shoes on when he/she fell . According to the report, the resident sustained [REDACTED]. During an observation on 6/16/14 at 4:26 p.m., direct care staff I and J transferred resident #2 from the bed to a wheelchair using a full lift after providing incontinence care. The resident had a high/low bed and scoop mattress on his/her bed. The resident remained in his/her room in the wheelchair with a call light within reach. During an interview on 6/16/14 at 1:03 p.m. direct care staff C stated that staff use a full lift for resident #2. He/she also used a high/low bed and personal alarm to prevent falls. Direct care staff C stated the resident used his/her call light to call for help. During an interview on 6/16/14 at 5:34 p.m., licensed nurse F stated the resident slid out of his chair when he fractured his hip. Nurse F confirmed the resident received Halcion every night and had orders for other as needed medications for sleep. Nurse F further added that resident #2 remained alert during the day, took naps in the afternoon, but was not sedated. An interview on 6/16/14 at 6:19 p.m. with administrative nurse B revealed that after resident #2's fall on 2/19/14, the administrative team recommended a medication review. The nurse and physician should review the resident's medications to determine if the medications may be contributing to the resident's falls. Nurse B was unaware if the staff or physician completed such a review for resident #2 after the fall as recommended. Nurse B also confirmed facility staff failed to address the resident's lack of appropriate footwear after his/her fall on 3/5/14. The facility's 9/2009 Fall Prevention and Management Policy stated the team reviewed details related to falls and reviewed implemented interventions. The policy also stated the team should ensure the appropriateness of interventions and additional interventions may be identified and should be implemented immediately after the review process. The facility failed to place appropriate fall prevention strategies after each fall and failed to complete a medication review for resident #2 who received medications that increased his/her fall risk. - Resident #3's 4/10/14 admission MDS (minimum data set) assessment revealed the resident had a BIMS (brief interview for mental status) score of 12, which indicated moderately impaired cognition. The resident required set up and supervision assistance for transfers, dressing and toilet use. The resident's 4/13/14 fall CAA (care area assessment) summary stated the resident #2 had impaired balance, antidepressant use, wandering, and cognitive impairments that increased his/her risk for falls. Resident #3's 4/3/24 nursing care plan for ADLs (activities of daily living) directed staff to assist the resident with a gait belt and 1 person for transfers. The care plan also instructed staff to keep his/her call light within reach. The fall care plan directed staff to place his/her wheelchair next to the bed for easy access, give verbal reminders not to ambulated or transfer without assistance, place items within, reach, and to instruct the resident on appropriate use of assistive devices. Fall risk assessments for resident #3 revealed a score of 16 on 3/25/14 and 16 on 4/3/14. Scores greater than 10 indicated the resident was at high risk for falls. Review of nurses notes and fall investigations revealed the resident sustained [REDACTED]. A fall investigation dated 4/8/14 stated resident #3 reported he/she fell without injury. Interventions included 30 minute checks and to encourage the resident to call for assistance. A 4/10/14 fall investigation report indicated resident #3 fell during a bath when the resident leaned forward falling off of the shower chair to the floor without injury. Interventions included a PT (physical therapy)/OT (occupational therapy) evaluation. Therapy screening dated 4/11/14 recommended a strength and balancing program with PT. The summary stated the resident displayed inconsistent progress with function due to cognitive deficits. A fall investigation form dated 4/27/14 stated resident #3 was found on the floor sitting close to the bed. The resident indicated he/she was trying to get to the bathroom and slid from the bed to the floor without injury. Interventions placed included PT/OT evaluation (previously done after 4/10/14 fall) and to assure the resident's scooter was in resident's reach. The facility failed to place an appropriate intervention for the resident when he/she fell trying to get to the toilet. A 5/6/14 fall investigation described a fall occurring at 9:45 p.m. when the resident yelled out and was found on the floor between the bed and wheelchair. The resident sustained [REDACTED]. Interventions placed included evaluation of the resident's bed to ensure the bed wheels locked. A fall investigation on 5/13/14 at 9:10 a.m. resident #3 was found on the beside his/her bed. The resident stated he/she was trying to get into the bed. Interventions placed included a PT/OT request for a screen and for nursing staff to complete the transfer assessment. Review of the nursing care plan lacked evidence addition of new fall prevention strategies to prevent future falls. A fall investigation form dated 5/19/14 at 7:40 am indicated resident #3 was found on the floor between his/her wheelchair and bed without injury. Interventions included a discussion with the resident and his/her family to consider a facility bed or positioning bar. A nurses note on 5/23/14 by administrative nurse B documented the resident refused the facility bed or positioning bar. The care plan lacked addition of an appropriate intervention to prevent falls after the resident refused. According to a fall investigation dated 5/24/14 at 12:40 a.m., the resident was found on the floor behind the door. The resident stated he/she tried to open the door and slipped out of the wheelchair. The resident fell again on 5/24/14 at 12:00 p.m. when staff found the resident on the floor beside the wall by the bed and the wheelchair. An intervention placed following the fall included replacing the resident's personal bed with a facility bed (previous request on 5/23/14). A nurses note on 5/27/14 indicated the resident again refused use of a facility bed. During an observation on 6/12/14 at 10:39 a.m. direct care staff D assisted resident #3 from the wheelchair to the bed with a gait belt in place. The resident's wheelchair was between the wall and bed with no room for staff to be in front of the resident for the transfer. Staff D leaned over from behind the wheelchair and attempted to transfer the resident in this manner. The resident stated, "Just push me over". Direct care staff D had difficulty controlling and supporting the resident during the transfer to the bed. After assisting the resident to bed, direct care staff D placed the resident's wheelchair in the bathroom. The resident's call light was approximately 2 feet from the head board of the bed and not within the resident's reach. During an interview on 6/12/14 at 10:50 a.m., resident #3 stated he/she always used his/her own bed and did not want to use a facility bed. An interview on 6/12/14 at 1:37 p.m. with direct care staff D confirmed he/she assisted resident #3 from behind and stated the resident was a fall risk, so for safety reasons he does not leave the wheelchair by his bed. Staff D was unaware of a care plan intervention to keep the wheelchair at the bedside. An interview on 6/16/14 at 4:12 p.m. with direct care staff K revealed resident #3 tried to transfer him/herself even though he/she should be assisted by 1-2 staff, and indicated that at times he/she required more help. Staff K further stated the resident had falls and prevention included using a wheelchair instead of the scooter, use of gait belt, bed in low position, and to keep his/her call light within reach. During an interview on 6/19/14 at 6:19 p.m., administrative nurse B acknowledged resident #3's care plan included repeated interventions. Nurse B also confirmed transferring a resident by leaning across the back of the wheelchair was an inappropriate transfer technique and expected staff to ensure the resident's call lights remained within their reach. The facility's 9/2009 Fall Prevention and Management Policy stated the team reviewed details related to falls and reviewed implemented interventions. The policy also stated the team should ensure the appropriateness of interventions and additional interventions may be identified and should be implemented immediately after the review process. The facility failed to place appropriate fall prevention strategies after each fall for resident #3. The facility also failed to ensure staff transfers resident #3 in a safe manner and ensured the resident's call light was within his/her reach, as care planned.

The facility reported a census of 44 residents with 17 sampled. Based on observation, interview and record review, the facility failed to provide interventions to prevent weight loss for 4 of 4 residents reviewed for weight loss. (23, 42, 47, 58) Two of the four residents (58, 47) experienced significant to severe weight loss. Findings included: - An admission nursing evaluation showed the facility admitted resident 58 on 3/8/11 with a weight of 92 pounds. The incomplete nutrition risk assessment dated [DATE] lacked the resident ' s basic metabolic index (indicator of nutritional status), an assessment of the resident total calorie and total food needs, and did not determine the risk factor of the resident ' s nutritional status. A 4/6/11 30 - day MDS (minimum data set) showed the resident had no communication difficulties and moderate cognitive impairment. The resident required no assistance with eating and weighed 89 pound and had no significant weight loss The 4/21/11 care plan included a goal stated, " (the resident) will maintain weight. " Interventions included allowing the resident to choose meals, offer alternatives if the resident did not eat or did not like what the kitchen served, and weekly weights. Weight record showed the following weights: 3/15/11 - 91 pounds 3/22/11 - 89 pounds 4/12/11 - 84 pounds 4/19/11 - 82 pounds 4/27/11 - 83 pounds This showed a significant weight loss of 9.8% in one month and a 10.8% loss since the resident ' s admission. The record lacked any evidence of a licensed dietician assessing the resident, physician notification of the weight loss, or interventions to prevent weight loss. On 4/27/11 at 8:32 am, the resident received three slices of bacon and a piece of toast for breakfast. The resident did not eat at this time. Although several nursing and dietary staff walked by the resident, none of them encouraged the resident to eat. By 9 am, the resident had begun to eat and consumed all the bacon and ? of the toast. On 4/27/11 at 12:25 pm, the resident received baked chicken, mashed potatoes, Brussels sprouts, a hot roll, and orange sherbet. The resident had eaten a bite of chicken, a few bites of potatoes and began eating sherbet. Again, although several nursing and dietary staff walked by the resident, none of them encouraged the resident to eat or offered any other alternatives. The resident consumed a total of a few bites of chicken and potatoes and ? of the sherbet On 4/27/11 at 3:17 pm, dietary staff offered ice cream Sundaes to residents in the dining room. Resident 58 remained in his/her room. The dietary staff did not take the cart of ice cream sundae supplies down the halls to offer to residents in their rooms. A 4/28/11 interview with the registered dietician revealed she had no knowledge of the resident ' s weight loss. On 4/27/11 at 11:55 AM, administrative nursing staff B reported the facility had not tracked weights appropriately in the previous few months. She confirmed the facility had not implemented any interventions to prevent weight loss. Physician standing orders in the resident ' s record included the following order: " Weight loss: If a resident has lost 5% of usual weight in 30 days, 7.5 % in 90 days or 10% usual weight in 6 months, RN (registered nurse) may initiate facilities (sic( Fortified Meal Program and/or nutritional supplement per protocols. Physician will be notified of weights (current, 30 days ago, 90 days ago, and 6 months ago) and RD (registered dietician) will be notified. " An undated Immediate Temporary Interventions for Unplanned Significant Weight loss policy provided by the facility stated, " 1. The charge nurse will request temporary nutrition interventions as appropriate for significant/severe weight loss ....2. These temporary interventions may include: commercial supplement one to three times daily. House supplement one to three times a day, other interventions such as extra milk, pudding or extra portions as appropriate...5. The registered dietician and/or dietetic technician registered will review all significant/severe weight losses monthly or more often as needed. As part of this review, nutrition status will be assessed. At that time the temporary interventions may be changed as needed based on the reassessment process. " An undated Significant Weight loss policy identified a severe weight loss as greater than 5% weight loss in one month. The policy stated. " The goal of medical nutrition therapy is to identify underlying causes or factors contributing to the significant unplanned weight loss, and intervene as appropriate to resolve the problem and stabilize the weight .... a. Re-weigh the individual to assure accurate weight. b. Compare current weight to usual body weight. Assess whether or not the weight loss was desirable (avoidable or unavoidable) and document accordingly. c. Interview the direct caregivers for information on recent changes. d. Review the food intake records to estimate the average percent of food/fluid intake in the past two to four weeks. e. Assess for stress factors (flu, fever, pressure ulcers, [MEDICAL CONDITION], etc.) or cognitive changes (dementia, depression, etc) that may have contributed to the weight loss. f. Assess ability to eat independently, chewing/swallowing ability, tolerance/acceptance of diet, etc. g. Assess the individual ' s laboratory values. h. Assess for potential food-medication interactions i. Review the care plan for pertinent information. j. Document estimated nutritional needs (kilocalories, protein, fluid needs) versus estimated food/fluid intake (utilizing food intake charts). k. Assess the risk of under nutrition and protein-energy [MEDICAL CONDITION]. l. Interview the individual to identify possible causes and to determine appropriate interventions. m. Document the findings in the medical record. n. Request/implement interventions based on the individual case. Document additional nutritional values that these interventions will add to the diet. " In summary, resident #58 had a severe weight loss of 10.8% in 6 weeks. The facility failed to provide assessments and interventions as outlined in the standing orders and policy and procedures. - The facility's 1/11/10 standing orders instruct the licensed nurse if the resident experienced a weight loss of 5% in 30 days, 7.5% in 90 days, or 10% in 6 months, to initiate a Fortified Meal Program and/or nutritional supplement per protocols; and to notify the physician and registered dietician. The resident's 1/11/10 admission orders [REDACTED]. The facility provided an undated printed electronic weight record which revealed on 10/11/10, resident #47 weighed 121 pounds. The 1/7/11 annual MDS (minimal data set) assessment reported resident #47 with severely impaired cognition, a [DIAGNOSES REDACTED]. The 1/7/11 CAA (care area assessment) reported that the resident ate an average of 0% to 25% of meals, but lacked reasons for poor food intake. On 2/24/11 per standing orders, Administrative Nurse P initiated order for Med Pass (a high calorie, high protein supplement) 60 mL (milliliters) three times daily with meals. The undated printed electronic weight record revealed on 3/10/11, the resident weighed 104 pounds (a drop of 17 pounds, or 14.05% loss in 6 months). The 4/8/11 quarterly MDS assessment reported resident #47 with severely impaired cognition, a [DIAGNOSES REDACTED]. A 1/20/11 entry on the resident's care plan reported the daughter's awareness of the resident's weight loss. The care plan lacked revision regarding weight loss after 1/20/11. The resident's record lacked evidence that the facility initiated a Fortified Meal Program. During observations on 4/25/11 at 3:47 p.m., resident #47 smiled which revealed large gaps in between some lower teeth, and most lower teeth appeared brown, worn, and broken in places. An interview with the resident's daughter on 4/25/11 at 3:49 p.m. revealed she noted the resident's weight loss. To ensure the resident ate more food, she requested the facility cut the resident's food into bite size pieces. During an interview on 4/27/11 at 10:17 a.m., Administrative Nurse P reported difficulty with the resident's oral assessment due to the fact that the resident rejected cares often during the assessment period, and confirmed she should have reported "unable to examine" on the MDS. She also confirmed that the resident experienced a weight loss greater than 10% in 6 months. During an observation and interview on 4/27/11 at 10:25 a.m., Direct Care Staff O reported the resident complained of mouth pain and offered to help the resident brush her teeth. Direct Care Staff O set up the resident's toothbrush with paste, assisted the resident to the sink, and prompted the resident to brush his/her teeth. Observation of the resident's toothbrush revealed blood after the resident began brushing his/her teeth. The clinical record lacked evidence notification of the resident's weight loss to the physician or registered dietician. During an interview on 4/28/11 at 9:58 a.m., Administrative Nurse B confirmed the record lacked evidence of notification of weight loss to the physician or registered dietician, and the facility failed to follow the weight loss policy and standing orders to initiate Fortified Meal program for resident #47. The facility's undated Significant Weight Loss policy instructed staff to identify underlying causes or factors contributing to significant unplanned weight loss, and to intervene as appropriate to resolve the problem and stabilize the resident's weight. Approaches included to assess stress factors and cognitive changes such as dementia that may contribute to weight loss, and to implement interventions based on the individual case. In summary, the facility failed to ensure resident #47 did not experience significant, unavoidable weight loss. - On 6/16/10, the registered dietician's notes revealed resident #42 reported food allergies [REDACTED]. The resident's care plan included an entry on 1/13/11 to provide the resident ground meat. The 3/25/11 quarterly MDS (minimum data set) assessment reported resident #42 with intact cognition, independently able to feed self, [DIAGNOSES REDACTED]. The facility provided an undated printed electronic weight record which revealed the resident weighed: o 111 pounds on 12/20/10, o 106 pounds on 2/7/11 (a drop of 5 pounds or 4.5% in 50 days), o 103 pounds on 3/10/11 (a drop of 8 pounds or or 7.2% in three months, and o 100 pounds on 4/18/11 (a drop of 11 pounds, or 10% in four months). The resident's care plan lacked revision after 1/13/11 related to weight loss. The resident's clinical record lacked evidence notification of the resident's weight loss to the physician or registered dietician, or that a licensed nurse initiated the Fortified Meal Program and/or nutritional supplement per protocol. During an interview on 4/28/11 at 9:59 a.m., Administrative Nurse B confirmed the record lacked evidence of notification of weight loss to the physician or registered dietician, and the facility failed to follow the weight loss policy and standing orders to initiate Fortified Meal program and/or nutritional supplement for resident #42. In summary, the facility failed to ensure resident #42's weight maintained at stable levels. - An annual 3/11/11 MDS (minimum data set) identified resident 23 with moderate cognitive impairment, required no assistance with eating weighted 89 pounds and had no weight loss. A Nutritional Status Care Area Assessment identified the resident had an average food intake of 10-40% and took ensure twice daily for weight loss. A 3/24/11 care plan included interventions for staff to offer alternatives when the resident doesn't like what the kitchen served, report any significant weight loss to the physician, offer snacks between meals, and give fortified foods. Weight records showed the following weights: 10/12/10 - 96 pounds 1/12/11 -- 92 pounds 3/12/11 -- 90 pounds 4/13/11 - 91 pounds 4/26/11 - 89 pounds A 2/9/11 fax to the physician included an order for [REDACTED]. On 3/3/11, nursing sent a fax to the physician stated the dietician had recommended discontinuing [MEDICATION NAME] (an appetite stimulant) and starting [MEDICATION NAME] for appetite stimulation. The physician declined this recommendation. On 4/27/11 at 12:25 pm, the resident had received meatloaf, mashed potatoes, a hot roll, vegetable and orange sherbet. The resident ate bites of the meatloaf and potatoes. Although several nursing and dietary staff passed the resident in the dining room, none encouraged the resident to eat more. The resident consumed a total of ? the sherbet and ? the meatloaf and a few bites of the potatoes. The resident did receive 240 cc (cubic centimeters) of fortified milk of which he/she drank ?. On 4/27/11 at 2 pm, dietary staff G stated that residents receiving fortified foods received fortified eggs and hot cereal for breakfast and fortified milk three times a day. She stated that the facility did not monitor the intake of the fortified milk to ensure the resident consumed the extra calories. On 4/27/11 at 3:17 pm, dietary staff offered ice cream Sundaes to residents in the dining room. Resident 23 remained in his/her room. The dietary staff did not take the cart of ice cream sundae supplies down the halls to offer to residents in their rooms. On 4/27/11 at 3:30 pm, nursing staff H reported that dietary staff did not take the ice cream to the residents in their rooms on a regular basis. She stated, " It is not a usual occurrence. " On 4/28/11 at 8:20 am, the resident ate cold cereal with milk and had 2 strips of bacon. The resident consumed the cereal but not all the milk in bowl. On 4/28/11 at 8:29 am dietary staff S reported the resident did not receive the fortified eggs and hot cereal per the resident ' s request. She stated the resident did receive fortified milk on his/her cereal but staff did not ensure the resident consumed the milk. On 4/28/11 at 11 am, registered dietician C stated she had no knowledge the physician had declined her last recommendation. She stated she did not usually get any communication back regarding the physician ' s response to her recommendations. She reported that as the resident did not receive hot cereal or eggs at breakfast, the resident did not get a great benefit from the fortified meal program. In summary, the facility failed to monitor resident 23 ' s intake of a fortified diet to ensure the benefit of the intervention, failed to communicate with the dietician the physician ' s decline of an intervention for weight loss and failed to implement new interventions as the resident continued to lose weight.