**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 51 residents. The sample included 15 residents with five reviewed for unnecessary medications. Based on observations, interview and record review the facility failed to obtain a consent form for a psychotropic 9alters mood or thoughts) medication for Resident (R) 3. This placed the residents at risk for adverse side effects of the medications and uninformed decisions.Findings included: - R3's Physician Orders dated 07/18/25 revealed the following diagnosis: major depressive disorder (major mood disorder, which causes persistent feelings of sadness). R3's Annual Minimum Data Set(MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS indicated R3 received antidepressant medication (class of medications used to treat mood disorders).R3's Quarterly MDS dated [DATE] recorded a BIMS score of 14, which indicated intact cognition. The MDS documented R3 had no behaviors. The MDS noted R3 received an antidepressant medication. R3's Care Assessment Area dated 0/7/18/25 Psychotic Medication Use adverse effects (falls, sedation, and impaired balance) due to his daily use of psychotropic medication. R3's Care Plan documented the resident used antidepressant medication for depression and directed staff to monitor changes in behaviors, mood, cognition, suicidal thoughts, and social isolation. R3's Electronic Medical Record (EMR) revealed a Physician's Order for bupropion HCl (an antidepressant), give 150 mg (milligrams) by mouth one time a day, related to major depressive disorder. Observation on 08/06/25 at 08:10 AM, R3 sat in his wheelchair heading to the main dining room on the first floor. R3 had a device on the back of his wheelchair that alarmed if the resident tried to stand up without assistance. Observation on 08/0625 at 10:27 AM, R3 was in the commons area waiting for his shower. On 08/07/25 at 08:30 AM, Administrative Nurse D stated she only had consent forms for two other residents and confirmed there was no informed consent for R3's psychotropic medication. On 08/07/25 at 09:49 AM, Consultant Staff GG reported that the administrative nurse must have misunderstood regarding the informed consents for psychotropic medications. She said all psychotropic medication should have consent, and she had sent the form to the administrative nurse last month to complete. The facility did not provide a policy on informed consent.

The facility reported a census of 51 residents; the sample included 15 residents. Based on observation, interviews, and record review, the facility failed to ensure an environment free from physical restraints (any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body) when staff failed to assess and ensure safety regarding Resident (R) 28's use of a seatbelt on his motorized wheelchair. This deficient practice placed R28 at risk for complications related to restraints and impaired safety.Findings included:- Review of the Electronic Health Record (EHR) documented R28 had diagnoses which included chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), and atrial fibrillation (rapid, irregular heartbeat).R28's 03/18/25 Annual Minimum Data Set (MDS) documented a Brief Interview of Mental Status (BIMS) of 15, which indicated intact cognition. The MDS documented R28 required moderate assistance for bathing, transfers, dressing, personal hygiene, bed mobility, and toileting. The MDS documented R28 was independent with wheelchair mobility and eating. The MDS documented R28 had impairment of both upper and lower extremities. The MDS documented R28 did not have a physical restraint.R28's 03/22/25 Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) documented R28 required assistance from staff related to his limited range of motion and impaired balance. Staff were to encourage R28 to participate in his daily care as he is able.R28's 06/11/25 Quarterly MDS documented a BIMS score of 14, which indicated intact cognition. The MDS documented R28 required moderate assistance for transfers. The MDS documented R28 was independent with wheelchair mobility. The MDS documented R28 had impairment of both upper and lower extremities. The MDS documented R28 did not have a physical restraint.R28's EHR lacked evidence the facility assessed R28's ability to release his seatbelt.R28's Care Plan dated 08/06/25, documented R28 used a maroon electric wheelchair for locomotion, date initiated 08/2024.R28's Physician Orders dated 08/06/25 did not address R28's seatbelt on the motorized wheelchair.R28's Progress Notes reviewed from 08/06/24 through 08/05/25 lacked mention of the seatbelt.During an observation on 08/04/25 at 01:21 PM, R28 had an engaged seatbelt on his electric wheelchair placed over his upper thighs. R28 reported that he could not undo the seatbelt independently as he could not reach it. R28 attempted to reach down with his right arm and could not reach the seatbelt. R28 reported that the staff would apply and release the seatbelt.During an observation on 08/05/25 from 01:20 PM through 03:45 PM, R28's seatbelt remained intact with no release until 03:45 PM. R28 was in bingo, then he independently went outside to sit in his wheelchair. R28 reported he had the electric wheelchair for about a year, and it has always had a seatbelt on it. R28 reported that he was told he had to wear the seatbelt. R28 said he did not have a choice to wear the seatbelt and reported that the staff was strict about the seatbelt.During an observation and interview on 08/05/25 at 03:42 PM, Certified Medication Aide (CMA) S reported R28 had to wear a seatbelt in the type of electric wheelchair he had, as it made R28 a high risk for injury. CMA S reported that not all residents required a seatbelt. CMA S verified that R28 was not able to undo his seatbelt independently. CMA S said it would be documented on the care plan if a resident required a seatbelt and went on to say it was ok to leave the seatbelt on longer than two hours. At 03:45 PM, CMA S entered R28's room and assisted R28 to the bathroom. CMA S released the seatbelt and assisted R28 to a standing position without a gait belt. R28 struggled to stand up independently, and CMA S pulled under R28's forearm to assist him up. During an interview on 08/05/25 at 03:50 PM, Licensed Nurse (LN) G reported that it was policy for the residents to wear a seatbelt in an electric wheelchair. LN G reported she was unaware who evaluated the seatbelt to see if a resident could release the seatbelt independently. LN G reported the seatbelt was a restraint if not released every two hours.During an interview on 08/05/25 at 04:32 PM, Administrative Nurse D and Administrative Nurse E reported that if a resident preferred to have the seatbelt on, the resident should be able to unbuckle the seatbelt, and it would be documented on the care plan. Administrative Nurse E reported that there were no residents currently who wore a seatbelt. Administrative Nurse D reported that the facility did not have a seatbelt safety assessment that would be completed.During an interview on 08/05/25 at 05:20 PM, Administrative Staff A reported that no resident had a seatbelt safety assessment completed, and no residents had a seatbelt care plan.The facility's policy Nursing Standards, Guidelines, Protocols, Procedures, and Position Statements, dated 10/10/24, the latest edition of Lippincott Nursing Procedure shall be used. Obtain a practitioner's order for a restraint.

The facility reported a census of 51 residents; the sample included 15 residents. Five residents were reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to ensure an appropriate indication, or a documented physician rationale which included the multiple unsuccessful attempts for nonpharmacological symptom management and risk versus benefits for the continued use of an antipsychotic (class of medications used to treat mental disorder characterized by a gross impairment in reality testing) for Resident (R) 1. This deficient practice placed R1 at risk for adverse effects associated with the use of psychotropic (alters mood or thoughts) medications.Findings included:- R1 's Electronic Health Record (EHR) revealed diagnoses of depression (a mood disorder that causes a persistent feeling of sadness and loss of interest) and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear).R1's 10/22/24 Annual Minimum Data Set (MDS) documented the resident had a Brief Interview for Mental Status (BIMS) score of nine, which indicated moderately impaired cognition. R1 required supervision for bathing and was independent for all other activities of daily living (ADL). The MDS documented R1 had no behaviors. The MDS recorded R1 received antipsychotic and antidepressant (class of medications used to treat mood disorders) medication on a routine basis. The MDS documented no gradual dose reduction.R1's 10/25/25 Psychotropic Drug Use Care Area Assessment (CAA) recorded R1 was at risk for adverse effects (falls, sedation, impaired balance, side effects outlined in the black box warning) due to his daily use of a psychotropic medication. Staff would monitor for signs and symptoms. The facility would review for possible gradual dose reduction if indicated. Staff would notify the physicians of any adverse reactions noted.R1's 06/30/25 Quarterly MDS documented a BIMS score of four, which indicated severely impaired cognition. The MDS documented R1 had no behaviors. R1 required maximal assistance for bathing. R1 required moderate assistance for toileting and lower body dressing. The MDS recorded R1 received antipsychotic and antidepressant on a routine basis with no gradual dose reduction.R1's Care Plan dated 11/07/23 documented R1 used psychotropic medications, including aripiprazole (atypical antipsychotic medication), for major depressive disorder. The plan noted an intervention dated 11/07/23, which directed staff to administer medications as ordered; monitor and document for side effects and effectiveness. The plan further directed staff to consult with the pharmacy and physician to consider dosage reduction when clinically appropriate; discuss with the physician and family regarding the ongoing need for use of medication. The plan directed staff to review behaviors, interventions, and alternate therapies attempted and their effectiveness per policy. The plan directed staff to provide education to the resident, family, and caregivers about risks, benefits, and the side effects and/or toxic symptoms of aripiprazole. Staff were instructed to monitor, document, and report any adverse reactions of psychotropic medications including unsteady gait, tardive dyskinesia (an abnormal condition characterized by involuntary repetitive movements of the muscles of the face, limbs, and trunk), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps nausea, vomiting, and behavior symptoms not usual to the person.R1's Physician's Orders documented an order for mirtazapine oral tablet (an antidepressant), give 30 milligrams (mg) by mouth one time a day for depression and sleep date ordered 11/08/22.R1's Physician's Orders documented an order for aripiprazole oral tablet, give 1 mg tablet by mouth daily for depression, date ordered 06/11/25.R1's Medication Regimen Review reviewed from 08/31/24 through 07/30/25, lacked evidence that Pharmacy Consultant GG identified the aripiprazole diagnosis of depression or the lack of documentation for what symptoms the antipsychotic medication was being administered for.During an observation on 08/06/25 at 08:00 AM, R1 was in his room eating his breakfast, with no concerns noted.During an interview on 08/07/25 at 08:30 AM, Administrative Nurse D reported she did not know if depression was an acceptable diagnosis for R1's aripiprazole. Additionally, she reported that the managed symptoms of R1's behaviors should be in order. During an interview on 08/07/25 at 09:49 AM, Pharmacy Consultant Staff GG reported that depression was not an acceptable diagnosis for R1's antipsychotic medication, and the order was missing some components of managed symptoms of R1's behaviors.The facility did not provide a policy on psychotropic medications.

The facility reported a census of 51 residents. The sample included 12 residents with five residents reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to act upon the pharmacist's monthly medication review (MRR) or document the rationale for Resident (R) 1. The deficient practice had the potential to lead to the residents receiving unnecessary medications.Findings included:- R1's Electronic Health Record (EHR) revealed diagnoses of depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and pain.R1's 10/22/24 Annual Minimum Data Set (MDS) documented the resident had a Brief Interview for Mental Status (BIMS) score of nine, which indicated moderately impaired cognition. R1 required supervision for bathing and was independent for all other activities of daily living (ADL). The MDS documented R1 had no behaviors. The MDS recorded R1 received antipsychotic and antidepressant (class of medications used to treat mood disorders) medication on a routine basis.R1's 10/25/25 Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) R1 triggered related to the resident's potential need for assistance with ADLs. The CAA noted R1 had diagnoses of anxiety disorder and pain. He may be screened by therapy for a potential increase in ADL status, strength, balance, and mobility. He was at risk for incontinence, falls, and skin impairments. The CAA noted the care plan would address the resident's need for assistance with ADLs.R1's 06/30/25 Quarterly MDS documented a BIMS score of four, which indicated severely impaired cognition. The MDS documented R1 had no behaviors. R1 required maximal assistance for bathing. R1 required moderate assistance for toileting and lower body dressing. The MDS recorded R1 received antipsychotic and antidepressant medications on a routine basis.R1's Care Plan documented on 08/29/23, staff instructed to administer Celebrex (medication commonly used to relieve pain and reduce inflammation)100 milligrams (mg) per order. The plan directed staff to monitor, record, and report to the nurse any resident complaints of pain or requests for pain treatment.R1's Physician's Orders documented an order for Celebrex oral capsule, one capsule, by mouth, one time a day for pain, date ordered 03/16/23.R1's Medication Regimen Review (MRR) on 09/10/24, documented a review was completed with no duplicate therapy or irregularities noted. The MRR noted R1 received Celebrex, and his creatinine (levels in the blood or urine can be measured to assess kidney function) was 1.78 milligram/deciliter (mg/dL) (Normal is 0.65-1.36 mg/dL) in May 2024 and the hemoglobin (Hgb-measure of blood that carried oxygen to the cells from the lungs and carbon dioxide away from the cells to the lungs) was 9.6 gram/dL. (Normal Hgb was 13.4-18.0 g/dL). R1's current creatinine was a little better but still elevated at 1.51. The consultant pharmacist recommended considering discontinuing the Celebrex 100 mg due to renal (kidney) or gastrointestinal involvement.R1's Physician Response to the 09/10/24 MRR, noted on 09/12/24, documented the physician's response of No to the recommendation but lacked a rationale. R1's Laboratory Results dated 05/13/25 noted R1's creatinine was 2.5 mg/Dl.During an observation on 08/06/25 at 08:00 AM, R1 was in his room eating his breakfast.During an interview on 08/07/25 at 08:30 AM, Administrative Nurse D reported she did not know if the physician was required to document a rationale for a pharmacy recommendation when not wanting to follow it.During an interview on 08/07/25 at 09:49 AM, Pharmacy Consultant Staff GG reported that the physician was not required to provide a rationale when not wanting to follow a recommendation, but only required one with gradual dose reductions for psychotropic medications.The facility's Drug Regimen Review dated October 10, 2024, documented to ensure residents at the Kansas Soldiers' Home maintain their highest practicable level of functioning and prevent or minimize adverse consequences related to medication therapy to the extent possible. Appropriate response from physician(s) concerning previous drug regimen review recommendations or drug irregularities.

The facility had a census of 51 residents. The sample included 12 residents. Based on observations, interviews, and record review, the facility failed to provide services to meet professional standards of care related to medication administration. This placed the residents at risk for medication-related complications and ineffective medication regimes. Findings included:- During an observation on 08/05/25 at 08:45 AM, Certified Medication Aide (CMA) R was at the medication cart on the third floor. Observation revealed CMA R reviewed the computer screen with several residents' names highlighted in pink, indicating overdue medications. CMA R prepared medications without using the electronic Medication Administration Record (MAR) to verify the medication orders. CMA R stated she had prepared Resident (R)8's medications. Upon inquiry about the 14 residents that were highlighted pink and the preparation of the medications without looking at the MAR, CMA R shrugged her shoulders and walked away. During an observation and interview on 08/05/25 at 08:50 AM, Licensed Nurse (LN) H accessed the MAR in the Electronic Health Record (EHR) and noted 14 residents highlighted in pink; LN H reported the residents orders were all 07:30 AM scheduled medications and since it was just a little past 08:30 AM, the medications were not that late. LN H reported that the residents were independent, and it was hard to always administer medications on time. LN H reported the staff did not have time to chase after the residents. LN H reported that the medications were scheduled for a specific time, and if the MAR was pink, it meant the medications were late. LN H verified the facility did not have a liberalized mediation pass (allows long-term care residents to choose when they receive their medications, within a designated window, based on their individual schedules and preferences, rather than adhering strictly to a fixed schedule). During an observation on 08/06/25 at 09:52 AM, CMA T administered the 07:30 AM scheduled medications to R2. R2 received 18 late oral medications and one late inhaled medication. R2 declined the nasal spray.During an interview on 08/05/25 at 09:44 AM, Administrative Nurse D verified that the medications were scheduled for 07:30 AM and confirmed the facility did not have a liberalized medication pass time. Administrative Nurse D said she expected all medications to be administered on time; she expected staff to locate the residents to make sure all medications were passed on time. During an interview on 08/06/25 at 09:52 AM, CMA T stated he was trained by another certified medication aide and was told medications were only considered late after 10:00 AM. The facility policy Medication Administration dated 10/19/18 states that all administration of medications, the nurse shall keep in mind the following. Right drug, right dose, right time, right route, right indication, and right documentation.

The facility reported a census of 51 residents. The sample included 15 residents. Based on observation, interview and record review the facility failed to ensure a medication error rate of less that five percent. 35 medication administration opportunities were observed, and 22 errors identified resulting in a medication error rate of 52.94 percent. This placed the residents at risk for medication related complications and ineffective medication regimes.Finding included:- Resident (R) 2's July Medication Administration Record/Treatment Administration Record (MAR/TAR) documented 18 oral medications scheduled at 07:30 AM, two nasal spray medications were scheduled at 07:30 AM, as well as one inhaled medication. On 08/06/25 at 09:52 AM, observation revealed Certified Medication Aide T administered the 07:30 AM scheduled medications to R2, outside of the one hour before or after protocol. R2 received 18 late oral medications and one late inhaled medication. R2 declined the nasal spray. On 08/06/25 at 09:52 AM, CMA T stated he was trained by another certified medication aide and was told medications were only considered late after 10:00 AM. On 08/05/25 at 09:44 AM, Administrative Nurse D verified that the medications were scheduled for 07:30 AM and confirmed the facility did not have a liberalized medication pass time. Administrative Nurse D said she expected all medications to be administered on time; she expected staff to locate the residents to make sure all medications were passed on time. The facility policy Medication Administration dated 10/19/18, all administration of medications, the nurse shall keep in mind the following. Right drug, right dose, right time, right route, right indication, and right documentation.

The facility reported a census of 51 residents. The facility identified five Certified Nurse Aides (CNA) employed for over 12 months during the review period. Based on interviews and record review, the facility failed to complete an annual performance review at least once every 12 months for the five CNAs reviewed, to ensure adequate and appropriate care and services were provided to the residents of the facility. This placed the residents at risk for decreased quality of care. Findings included:- Review of employee files on 08/06/25 at 01:07 PM revealed a lack of performance evaluations signed by management for the five CNAs that had been employed over one year, that included CMA L date of hire 01/29/10, CMA R date of hire 05/08/23, CMA II date of hire 07/12/23, CMA JJ date of hire 05/28/15, and CMA KK date of hire 09/24/06.During an interview on 08/07/25 at 10:10 AM, Administrative Staff A reported he expected 100 percent compliance to have the annual performances evaluations completed annually.The facility did not provide a policy on annual performance evaluations.

The facility reported a census of 51 residents, and one main kitchen. Based on observation, record review and interview the facility failed to prepare and serve food under sanitary conditions to prevent the potential for food borne bacteria. This placed the residents at risk for food borne illnesses.Findings included: - During a second tour of the kitchen on 08/5/25 at 10:30 AM, observation revealed three-barrel type trash cans that did not have a lid covering the trash cans. Dietary Staff DD did ask the staff to locate the lids to the trash cans, and all but one was found. On 08/0525 at 10:35 AM, observation revealed Dietary Staff DD washed her hands, then put on gloves, and pureed the food for five residents, which included country fried steak and asparagus. Dietary Staff DD followed the recipe. During the observation, Dietary Staff DD removed her soiled glove at the counter, put them in the trash barrel that did not have a lid, then reapplied new gloves without washing her hands. During the serving of the food on 08/06/25 at 11:00 AM, Dietary Staff CC removed her gloves, washed her hands, and donned new gloves. She then grabbed a plate with her gloved hands and then touched the hamburger buns package. Wearing the same gloves, she grabbed the breaded chicken with her gloved hand, turned, and then opened the tomato containers. Dietary Staff CC then removed her gloves, washed her hands, donned new gloves, and then proceeded to touch the tomatoes, plates, picked up a loaf of bread, and then went into the refrigerator for the prepared coleslaw. On 08/06/25 at 11:50 AM, Certified Dietary Manager BB stated the facility expected staff to provide food in a safe and healthy environment. CDM BB stated she provided training on food handling every year and met with her supervisors every Monday to discuss areas that staff needed to work on. The facility's policy Hand Washing, revised on 10/10/21, indicated staff will wash hands frequently as needed throughout the day, following proper hand washing procedure. After handling soiled equipment, during food preparation, as often as necessary to remove soil and contamination and to prevent cross-contamination when changing tasks.

The facility reported a census of 51 residents. Based on observations, interviews and record review, the facility failed to maintain and/or dispose of kitchen garbage and refuse properly. This placed facility residents at risk for insect or rodent infestation.Findings included: - During a second tour of the kitchen on 08/5/25 at 10:30 AM observation revealed three-barrel type trash cans which did not have a lid. Dietary Staff DD did ask the staff to locate the lids to the trash cans and all but one was found.On 08/06/25 at 03:15 PM observation of the outside garbage bins with Certified Dietary Manager (CDM) BB revealed eight trash bins against the fence and two of the bins had lids up. The wind at the time of the observation was calm breeze and there were no strong winds noted.On 08/06/25 at 03:15 PM CDM BB said the bins were usually closed but maybe the wind lifted the lids. CDM BB said he had no idea why the lids were open at that time.The facility's policy Waste Disposal revised on 10/10/24 all garbage will be disposed of daily and in needed throughout the day. Trash will be deposited into a sealed container outside the premises.

The facility reported a census of 51 residents. The sample included 15 residents. Based on interviews, observation and record review, the facility failed to establish and maintain a consistent infection prevention and control program. Additionally the facility failed to utilize Enhanced Barrier Precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms which employ targeted gown and glove use during high contact care) when providing direct care to residents with catheters (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid), wounds, and/or surgical artificial openings entering the body to prevent the spread of infection. The facility further failed to provide catheter care using aseptic technique and failed to implement measures to prevent the growth of Legionella (a serious type of lung infection caused by inhaling water droplets or mist contaminated with Legionella bacteria) and other opportunistic water borne pathogens in the facility's water systems to prevent the spread of infections. These deficient practices had the potential to spread infections to the residents in the facility.Findings included:- Review of the facility Matrix, dated 08/05/25 revealed 11 residents with indwelling catheters and three residents with wounds. Upon request, the facility was unable to provide documentation or evidence of a water management program to mitigate Legionella and other water born pathogens.During an observation on 08/04/25 at 11:00 AM, initial tour of the facility revealed no evidence of EBP set up nor signage to indicate residents that required EBP personal protective equipment (PPE).During an observation on 08/04/25 at 01:58 PM, Certified Nurse Aide (CNA) O emptied Resident (R)32's indwelling catheter drainage bag. She donned gloves but did not wear a gown. CMA O then accessed the outlet access port, drained the urine and reinserted the outlet access into the holder port with cleansing it first. CNA O reported she did not know what EBP were. Observation revealed there was no signage regarding EBP or readily accessible PPE in or around the resident's room. CNA O confirmed the resident's door lacked signage to indicate the need for staff to wear PPE and the lack of assessable PPE in the room other than gloves.During an observation on 08/05/25 at 11:20 AM, R33 laid in the bed with an indwelling urinary catheter collection bag placed inside of a dignity bag. Further observation revealed there was no signage to inform those entering the room of required PPE, or gowns available in the room or surrounding area to be used when providing direct care and/or contact.On 08/06/25 at 01:24 PM, Administrative Nurse F confirmed the above findings. She stated she was not aware of the 04/01/2024 Center of Medicare and Medicaid Service (CMS) requirement for EBP to prevent infections for residents that had catheters, wounds and/or artificial openings in their body as noted above. Administrative Nurse F said catheter care should be provided each shift using aseptic technique to prevent cross contamination and the spread of infection. Administrative Nurse F reported she had not completed the July or August Infection Control Log. She stated she normally completed the documentation at the end of each month and did not track or trend infections more frequently to identify trends and patterns. She said she expected staff to clean the spout with an alcohol wipe before replacing the outlet when providing catheter care.On 08/07/25 at 10:46 AM, Administrative Nurse D, confirmed the above findings and stated she was not aware of the 04/01/2024 directive for the use of enhanced barrier precautions for residents with catheters, wounds, and/or artificial openings into their bodies. She stated catheter care should be provided each shift and should include cleaning the outlet tube with an alcohol wipe after emptying the drainage bag of urine and before replacing the tube in the sleeve to prevent cross contamination and the spread of infection. Administrative Nurse D said the infections in the facility should be tracked at the time the infection is identified to ensure timely interventions are implemented, not at the end of the month.The undated facility policy Infection Control, Program documentation included the function of the infection Control Program includes but is not limited to a system of surveillance designed to identify possible communicable disease or infection, tracking and trending infections before they can spread to another person in the facility and monitor the use of antibiotics. Staff providing direct care to residents should follow hand hygiene procedures.The facility did not have a policy related to prevention of Legionella.

The facility reported a census of 51 residents; the sample included 15 residents. Based on interview and record review, the facility failed to establish and infection prevention and control program which included an antibiotic stewardship program with antibiotic use protocols and a system to monitor antibiotic use. This placed the residents at risk for infectious diseases.Findings included: - The facility Matrix, dated 08/05/25, noted seven residents who received antibiotics. Review of the infection control surveillance log dated 07/01/25 through 08/06/25 revealed the facility lacked documentation of tracking and trending of Resident (R) 33, with a diagnosis of recurrent urinary tract infection (UTI), who received gentamycin (antibiotic) bladder irrigations for prevention of urinary tract infection. The log lacked documentation of tracking and trending of R4, with diagnosis of UTI, for receiving amoxicillin (antibiotic), ordered 7/31/25, for seven days.On 08/06/25 at 01:24 PM, Administrative Nurse F confirmed the above findings. She stated R33 and R4 received antibiotics, which she failed to include on the Infection Control Log, dated 07/01/25 through 08/06/25. Administrative Nurse F reported she had not completed the July Infection Control Log to include antibiotic use in the facility. She stated she normally completed the documentation at the end of each month and did not track/trend antibiotic use daily. She reported the facility used McGeer's Criteria to determine the appropriateness of prescribed antibiotics. Upon Inquiry, she reported that the physician prescribed antibiotics, and the facility did not conduct formal reviews or audits to determine the appropriateness or effectiveness of the use of each antibiotic in the facility. On 08/07/25 at 10:46 AM, Administrative Nurse D stated the infections and antibiotics in the facility should be tracked when prescribed and reviewed for appropriate use.The undated facility policy Infection Control lacked address of the identified areas of concern.

The facility reported a census of 51 residents with 14 selected for review. Based on interview, observation, and record review, the facility failed to protect the privacy and dignity of Resident (R)21 and R11. This occurred with R21 when certified nurse aide (CNA) L entered R21's room without knocking, and R11 through the failure of the staff to place R11's call light within reach and R11's use of an air horn to alert staff to his need for assistance. Findings included: - On 08/28/23 at 02:29 PM, during interview with R21, CNA L opened the door and entered the resident's room without knocking or announcing himself and began rearranging items. R21 asked CNA L what he was doing, but no response was given by staff. When CNA L became aware of the presence of a surveyor in the room, he promptly left. R21 stated that CNA L would frequently enter his room unannounced and move items in his room despite protests from R21. R21 confirmed this would upset him. On 08/28/23 at 02:32 PM, CNA L confirmed that he entered R21's room without knocking or announcing himself. Further confirmed that he was supposed to knock and announce himself, then inform the resident of what he needed to do and approximately how long it would take. On 08/28/23 at 02:34 PM, Licensed Nurse (LN) G stated that every staff member should knock, announce themselves, inform the resident of what they needed to do and approximately how long it would take. On 08/28/23 at 03:00 PM, Administrative Nurse B stated that every staff member should knock on the resident's door, announce themselves, inform the resident of what they needed to do, and approximately how long it would take. Furthermore,on 08/30/23 at 11:55 AM during an interview with R11, observation revealed a canned air-horn intended for nautical use sat on R11's over-the-bed table. R11 stated that he is frequently placed in bed without being given his call light. Due to mobility issues while in bed, he cannot reach the wall box to call for assistance. R11 stated that this has caused him distress as he has become incontinent at times because he could not alert staff to his needs. R11 further explained that it negatively affected his pride and dignity when he had to use his own money to buy the air-horn to alert staff as he cannot discretely notify staff of his need for assistance. On 09/06/23 at 11:02 AM Certified Medication Aide (CMA) H stated that call lights should be placed where residents can easily reach them. On 09/06/23 at 11:12 AM, Licensed Nurse (LN) K stated that call lights should be placed close to residents where they can easily reach them. On 09/06/23 at 11:29 AM, Administrative Nurse B stated that call lights should be placed where residents can easily alert staff to their needs. The facility's Resident's Rights policy dated 04/10/19, documented that every resident in the facility has a right to a dignified existence and rights include but are not limited to privacy and confidentiality. The facility failed to protect the privacy and dignity of R21 when staff entered resident rooms without knocking, and of R11 by not placing the call light where he could easily access it.

The facility reported a census of 51 residents which included 14 selected for review. Based on interview and record review, the facility failed to fully complete comprehensive Minimum Data Set (MDS) assessment O-special treatments and programs and failed to complete Section V, Care Area Assessment Summary (CAA) for Resident (R)11 to include an analysis and rationale for care planned decisions. This placed the resident at risk for not accurately reflecting the resident's status and needs to develop an individualized comprehensive plan of care. Findings include: - R11's pertinent diagnoses from the Electronic Health Record (EHR) documented chronic obstructive pulmonary disease (COPD - a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), shortness of breath and OSA (obstructive sleep apnea - a condition in which the person cannot maintain an open airway while asleep). The 01/10/23 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The resident required extensive assistance of two staff for all cares except eating, which required setup and supervision. The resident received oxygen. The section O-special treatment and programs lacked documentation that the resident required a continuous positive airway pressure (CPAP) support. The 01/10/23 Care Area Assessment (CAA) lacked documentation related to the use of the resident's CPAP equipment. The 06/01/23 to 08/31/23 EHR Treatment Administration Record (TAR) lacked documentation for the CPAP equipment. On 08/29/23 at 08:50 AM, R11 observed resting in bed watching TV with the CPAP machine sitting on the bedside table with hose/mask intact and placed on top of the machine. On 08/30/23 at 11:55 AM, observation of R11's room revealed the CPAP machine sitting on the bedside table with hose/mask intact and placed on top of the machine. On 08/31/23 at 08:41 AM, observation of R11's room revealed the CPAP machine on the bedside table with hose/mask intact on top of the machine. On 09/06/23 at 11:29 AM, Administrative Nurse B confirmed that CPAP use was not on R11's most recent comprehensive MDS assessment. Administrative Staff A stated at 09/06/23 at 03:00 PM that the facility utilized RAI (resident assessment instrument) manual for guidance related to accuracy of MDS assessments. The facility failed to complete an accurate comprehensive admission assessment on the MDS for R11, related to the resident's CPAP use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** - Resident (R)42's diagnoses from the Electronic Health Record (EHR) documented reduced mobility, polyosteoarthritis (degenerative changes to many joints characterized by swelling and pain) and fracture of the left femur (thigh bone). R42's Significant Change Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) of six, which indicated severely impaired cognition. The resident required extensive assistance of one to two staff for all ADL's (activities of daily living). R42 had two or more falls since the prior assessment. R42's quarterly MDS, dated [DATE], documented a BIMS of 13, indicating intact cognition, and the resident required extensive assistance of one staff member for all ADL cares. The resident had two or more falls since the prior assessment. The Falls Care Area Assessment (CAA) dated 03/16/23, revealed that the resident was at increased risk for falls and injury due to impaired balance and staff were to ensure the ensured resident wore appropriate footwear. Staff encouraged R42 to utilize the call light for assistance. The care plan, dated 09/04/23, revealed the following: 1. The facility recognized the resident was an increased risk of falls on 03/02/22 related to deconditioning and balance problems and had the following interventions in place: continue to offer assistance even when declined by resident, be sure resident's call light is in reach and encourage resident to use it as needed and staff to go outside with resident when he goes outside to smoke. 2. The resident had a fall on 02/06/23. The care plan lacked appropriate interventions to possibly prevent further falls. The care plan lacked for a person-centered care plan revision. 3. The resident had a fall on 02/17/23. The care plan lacked appropriate interventions to possibly prevent further falls. The care plan lacked for a person-centered care plan revision. 4. The resident had a fall on 02/25/23. The care plan lacked appropriate interventions to possibly prevent further falls. The care plan lacked for a person-centered care plan revision. 5. The resident had a fall on 03/26/23. The care plan lacked appropriate interventions to possibly prevent further falls. The care plan lacked for a person-centered care plan revision. 6. The resident had a fall on 04/26/23. The care plan lacked appropriate interventions to possibly prevent further falls. The care plan lacked for a person-centered care plan revision. 7. The resident had a fall on 04/30/23. The care plan lacked appropriate interventions to possibly prevent further falls. The care plan lacked for a person-centered care plan revision. 8. The resident had a fall on 05/01/23. The care plan lacked appropriate interventions to possibly prevent further falls. The care plan lacked for a person-centered care plan revision. The EHR assessments revealed fall risk screenings, dated 12/20/22, 02/06/23, 03/03/23, 03/30/23, 04/26/23 and 04/30/23 that indicated that resident was a high risk of falls. The Fall reports reviewed from 01/01/23 to 09/05/23 revealed the following: 1. On 02/06/23, R42 had a fall without injury. The immediate intervention was documented that resident was assisted up. The fall report lacked an investigation that outlined root cause analysis. The fall report documented the addition to the care plan was to encourage resident to wait for staff when going off the unit. However, the care plan lacked a corresponding entry to prevent future falls. 2. On 02/17/23, R42 had a fall without injury. The immediate intervention to prevent additional falls was documented for staff to keep eyes on R42 when he came back from smoking until he returned to bed. The fall report lacked an investigation that outlined root cause analysis. The fall report documented the addition to the care plan was to keep an eye on resident when he came back from smoking to ensure needs were met. However, the care plan lacked a corresponding entry to prevent future falls. 3. On 02/25/23, R42 had a fall without injury. The immediate intervention to prevent additional falls was documented that vital signs were obtained, and resident was assisted to the wheelchair. The fall report lacked an investigation that outlined root cause analysis. The fall report documented the addition to the care plan was to increase visual checks on resident to 30 minutes. However, the care plan lacked a corresponding entry to prevent future falls. 4. On 03/26/23, R42 had a fall without injury. The immediate intervention to prevent additional falls was documented that the resident was assessed for injuries and assisted to the wheelchair. The fall report lacked an investigation that outlined root cause analysis. The fall report documented the addition to the care plan was to add pain medication or increase current regimen. However, the care plan lacked a corresponding entry to prevent future falls. 5. On 04/26/23, R42 had a fall with minor injury. The immediate intervention to prevent additional falls was documented that the staff were to leave door open and privacy curtain pulled back. The fall report lacked an investigation that outlined root cause analysis. The fall report documented the addition to the care plan was for staff to keep door open and privacy curtain pulled back while awake. However, the care plan lacked a corresponding entry to prevent future falls. 6. On 04/30/23, R42 had a fall without injury. The immediate intervention to prevent additional falls was documented that the staff assessed the resident for injury. The fall report lacked an investigation that outlined root cause analysis. The fall report documented the addition to the care plan was to keep resident in sight and to ensure safety measures are taken. However, the care plan lacked a corresponding injury to prevent future falls. 7. On 05/01/23, R42 had a fall without injury. The immediate intervention to prevent additional falls was for staff to utilize a toileting schedule and to re-educate resident for use of call light. The fall report documented the addition to the care plan was to initiate one-on-one supervision with resident. However, the care plan did not reflect this entry until 06/14/23, which was 45 days later. On 09/05/23 at 04:01 PM, Administrative Nurse C reported when a resident fell, the nurse on duty was responsible for filling out a fall report and developing an immediate intervention to be implemented until the interdisciplinary team (IDT) could meet and determine the root cause of the fall. The IDT would develop a permanent intervention to be added to the care plan. Additionally stated that no documentation exists that outlines investigative process that the IDT used to determine root cause or development of care plan interventions. Administrative Nurse C confirmed the lack of care plan interventions for falls on 02/06/23, 02/17/23, 02/25/23, 03/26/23, 04/26/23, 04/30/23 and 05/01/23 and stated that the nurse on duty at the time of the fall could make addendums to care plan interventions, but ultimately it was the responsibility of Administrative Nurse C. On 09/06/23 at 11:29 AM, Administrative Nurse B reported that the immediate interventions on the fall report should be appropriate to mitigate the risk for falls and the nurse that is on duty should amend the care plan with a new intervention. If the nurse that was on duty at the time of the fall failed to add a care plan intervention or if the intervention was inappropriate, then Administrative Nurse C would correct it on the next business day. The facility's Accident, Incident and Unusual Occurrence Reporting Procedure policy, dated 02/15/21 documented to revise care plan with updated interventions as it relates to the accident and/or incident. The facility failed to review and revise the care plan for this resident that had multiple falls. The facility reported a census of 51 residents with a sample of 14 residents. Based on observation, interview, and record review, the facility failed to review and revise the care plan for Resident (R1) and R42, related to fall interventions. Findings included: - Review Resident (R)1's Physician order Sheet, dated 08/02/23, documentation included diagnoses of lack of coordination, need for assistance with personal care, Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure) with late onset, behavioral disturbances, and hypertension (high blood pressure). The Significant Change in Status Minimum Data Set, (MDS) dated [DATE], documentation revealed the resident with a Brief Interview for Mental Status, score of two, indicating severe cognitive impairment. He required extensive assistance from staff with bed mobility, transfer, locomotion, dressing, toilet use. The resident did not ambulate during the assessment. His balance during transition was not steady. He was only able to stabilize with staff assistance. He had functional limitation in range of motion (ROM) of bilateral (both) lower extremities and used a wheelchair as an assistive device. The resident was frequently incontinent of bladder and always continent of bowel. He exhibited shortness of breath (SOB) or trouble breathing with lying flat and exertion (e.g., walking, bathing, transferring). He experienced two or more no injury falls. The resident received anti-anxiety medication for seven days of the look back period and antidepressant medication for one day of the look back period. The resident did not receive therapy nor restorative nursing program (RNP). He did use a bed and chair alarm daily. The Quarterly MDS dated 08/09/23, documented the changes which included a decreased BIMS score of 99, indicating a decline in mental status. He was occasionally incontinent of bowel. The resident did not experience SOB. He had two no injury falls and one fall with injury which was not major injury. The Care Area Assessment for Cognition/Dementia, Falls, and Psychoactive Drug Use, (CAA), respectfully, dated 11/28/22, documentation included the resident scored two on his BIMS. The resident stated that he just can't remember. He is at risk for further decline in cognition related to not feeling well. The resident does well with cueing, redirection, and reminders to complete tasks. Staff should keep his routine consistent and assist with Activities of daily living (ADL's). The resident is at risk for falls due to agitation, impulsiveness, incontinence, impaired balance, and medications. Staff to ensure he has appropriate footwear on while transferring. Staff to encourage him to utilize the call light for assistance and monitor for safety routinely. He was at risk for adverse effects (falls, sedation, impaired balance, side effects outlined in the black box warning) due to his use of a psychotropic medication. The Care Plan dated 08/22/23, directed staff that the resident was at risk for falls secondary to limited mobility. The care plan included that staff should provide medical adaptive equipment that included a Reacher (a handheld mechanical tool used to increase the range of a person's reach and grasp when grabbing objects) to assist the resident with grabbing items. Staff were to verify the resident's belt as appropriate. Verify belt is fastened properly not allowing pants to fall. Staff were to check each time the resident dressed and after every toileting. The resident had limited physical mobility and would maintain the ability to ambulate with walker with one staff assistance and guided staff that the resident could ambulate without assistive devices with impaired balance with one staff. He needed a four wheeled walker but would often refuse to use it. The care plan lacked guidance for the body alarm. The Morse fall scale, dated 12/27/22, 03/14/23, 03/21/23, 04/18/23 and 05/18/23 indicated R1 was at a high risk for falls. R1's electronic health record revealed the resident had multiple falls. From 03/04/23 to 06/27/23, the resident fell on 11 occasions. Review of the electronic records, on 04/04/23 at 11:20 PM, the resident's body alarm sounded like he was repositioning. After the alarm continued to sound, staff checked on R1, and the resident fell from his bed to the floor, with his upper body on the bed. On 10/24/22 at 08:15 PM, the resident fell while standing without assistance. The immediate intervention was to always place a pad alarm in bed and in the chair, even in the presence of staff. On 05/30/23 at 07:42 PM, an unidentified CNA assisted him to bed. He was found lying on his back by the north side of his bed. The root cause was the body alarm was in the resident's wheelchair, and not in his bed. On 06/11/23 at 12:30 AM, an unidentified certified Nurse aide (CNA) discovered the resident on the floor next to the bed. The root cause was the bed alarm appeared to be nonfunctional. Staff put the resident back to bed, however no documentation to reveal staff replaced the bed alarm with a functional body alarm. On 06/11/23 at 12:50 AM, shortly after first fall, staff discovered the resident on the floor, next to his bed. The root cause was a nonfunctional bed alarm. On 06/27/23 at 07:58 PM, the resident fell from his bed to the floor. The resident was incontinent and did not have his body alarm in place. Observation on 08/29/23 at 10:40 AM, R1 sat in recliner, no signs of discomfort. On 08/31/23 at 03:01 PM, R1 sat in a recliner by the nurse's station in visual field of staff. R1 made no attempts to get out of the recliner. On 09/05/23 at 01:31 PM, CNA F reported the resident would attempt to get out of his bed in the morning. If he gets up, the pressure alarm will activate. On 09/05/23 at 02:22 PM, Licensed Nurse (LN) G reported the resident underestimates what he can do, and he gets restless most of the time and tries to get up and out of bed on his own. On 09/06/23 at 11:29 AM, Administrative Nurse B reported that the immediate interventions on the fall report should be appropriate to mitigate the risk for falls and the nurse that is on duty should amend the care plan with a new intervention. The resident had intervention for the body alarm, and staff had to be reeducated because the alarm wasn't in place and another fall, staff did not answer the call light timely. Another fall occurred when staff didn't put the call light in place. The facility's Accident, Incident and Unusual Occurrence Reporting Procedure policy, dated 02/15/21 documented to revise care plan with updated interventions as it relates to the accident and/or incident. The facility failed review and revise this resident's care plan related to his multiple falls.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** - Resident (R)42's diagnoses from the Electronic Health Record (EHR) documented reduced mobility, polyosteoarthritis (degenerative changes to many joints characterized by swelling and pain) and fracture of the left femur (thigh bone). R42's Significant Change Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) of six, which indicated severely impaired cognition. The resident required extensive assistance of one to two staff for all ADL's (activities of daily living). R42 had two or more falls since the prior assessment. R42's quarterly MDS, dated [DATE], documented a BIMS of 13, indicating intact cognition, and the resident required extensive assistance of one staff member for all ADL cares. The resident had two or more falls since the prior assessment. The Falls Care Area Assessment (CAA) dated 03/16/23, revealed that the resident was at increased risk for falls and injury due to impaired balance and staff were to ensure the ensured resident wore appropriate footwear. Staff encouraged R42 to utilize the call light for assistance. The care plan, dated 09/04/23, revealed the following: 1. The facility recognized the resident was an increased risk of falls on 03/02/22 related to deconditioning and balance problems and had the following interventions in place: continue to offer assistance even when declined by resident, be sure resident's call light is in reach and encourage resident to use it as needed and staff to go outside with resident when he goes outside to smoke. 2. The resident had a fall on 02/06/23. The care plan lacked appropriate interventions to possibly prevent further falls. 3. The resident had a fall on 02/17/23. The care plan lacked appropriate interventions to possibly prevent further falls. 4. The resident had a fall on 02/25/23. The care plan lacked appropriate interventions to possibly prevent further falls. 5. The resident had a fall on 03/26/23. The care plan lacked appropriate interventions to possibly prevent further falls. 6. The resident had a fall on 04/26/23. The care plan lacked appropriate interventions to possibly prevent further falls. 7. The resident had a fall on 04/30/23. The care plan lacked appropriate interventions to possibly prevent further falls. 8. The resident had a fall on 05/01/23. The care plan lacked appropriate interventions to possibly prevent further falls. 9. On 06/14/23 instructed staff to be one-on-one at all times to prevent falls. The Physician's orders documented on 06/14/23 for staff to be one-on-one at all times for fall prevention. The EHR assessments revealed fall risk screenings, dated 12/20/22, 02/06/23, 03/03/23, 03/30/23, 04/26/23 and 04/30/23 that indicated that resident was a high risk of falls. The Fall reports reviewed from 01/01/23 to 09/05/23 revealed the following: 1. On 02/06/23, R42 had a fall without injury. The immediate intervention was documented that resident was assisted up. The fall report lacked an investigation that outlined root cause analysis. The fall report documented the addition to the care plan was to encourage resident to wait for staff when going off the unit. However, the care plan lacked a corresponding entry to prevent future falls. 2. On 02/17/23, R42 had a fall without injury. The immediate intervention to prevent additional falls was documented for staff to keep eyes on R42 when he came back from smoking until he returned to bed. The fall report lacked an investigation that outlined root cause analysis. The fall report documented the addition to the care plan was to keep an eye on resident when he came back from smoking to ensure needs were met. However, the care plan lacked a corresponding entry to prevent future falls. 3. On 02/25/23, R42 had a fall without injury. The immediate intervention to prevent additional falls was documented that vital signs were obtained and resident was assisted to the wheelchair. The fall report lacked an investigation that outlined root cause analysis. The fall report documented the addition to the care plan was to increase visual checks on resident to 30 minutes. However, the care plan lacked a corresponding entry to prevent future falls. 4. On 03/26/23, R42 had a fall without injury. The immediate intervention to prevent additional falls was documented that the resident was assessed for injuries and assisted to the wheelchair. The fall report lacked an investigation that outlined root cause analysis. The fall report documented the addition to the care plan was to add pain medication or increase current regimen. However, the care plan lacked a corresponding entry to prevent future falls. 5. On 04/26/23, R42 had a fall with minor injury. The immediate intervention to prevent additional falls was documented that the staff were to leave door open and privacy curtain pulled back. The fall report lacked an investigation that outlined root cause analysis. The fall report documented the addition to the care plan was for staff to keep door open and privacy curtain pulled back while awake. However, the care plan lacked a corresponding entry to prevent future falls. 6. On 04/30/23, R42 had a fall without injury. The immediate intervention to prevent additional falls was documented that the staff assessed the resident for injury. The fall report lacked an investigation that outlined root cause analysis. The fall report documented the addition to the care plan was to keep resident in sight and to ensure safety measures are taken. However, the care plan lacked a corresponding injury to prevent future falls. 7. On 05/01/23, R42 had a fall without injury. The immediate intervention to prevent additional falls was for staff to utilize a toileting schedule and to re-educate resident for use of call light. The fall report documented the addition to the care plan was to initiate one-on-one supervision with resident. However, the care plan did not reflect this entry until 06/14/23, which was 45 days later. On 09/05/23 at 04:01 PM, Administrative Nurse C reported when a resident fell, the nurse on duty was responsible for filling out a fall report and developing an immediate intervention to be implemented until the interdisciplinary team (IDT) could meet and determine the root cause of the fall. The IDT would develop a permanent intervention to be added to the care plan. Additionally stated that no documentation exists that outlines investigative process that the IDT used to determine root cause or development of care plan interventions. Administrative Nurse C confirmed the lack of care plan interventions for falls on 02/06/23, 02/17/23, 02/25/23, 03/26/23, 04/26/23, 04/30/23 and 05/01/23 and stated that the nurse on duty at the time of the fall could make addendums to care plan interventions, but ultimately it was the responsibility of Administrative Nurse C. On 09/06/23 at 11:29 AM, Administrative Nurse B reported that the immediate interventions on the fall report should be appropriate to mitigate the risk for falls and the nurse that is on duty should amend the care plan with a new intervention. If the nurse that was on duty at the time of the fall failed to add a care plan intervention or if the intervention was inappropriate, then Administrative Nurse C would correct it on the next business day. The facility's Accident, Incident and Unusual Occurrence Reporting Procedure policy, dated 02/15/21 lacked guidance related to the investigation process. The facility failed to provide a safe environment when staff failed to appropriately and thoroughly investigate falls to determine root-cause to prevent further falls and initiate appropriate interventions to prevent further falls. This placed R42 at an increased risk for injury from falls. The facility reported a census of 51 residents with a sample of 14 residents, which included two residents reviewed for accidents. Based on observation, interview, and record review, the facility failed to thoroughly investigate falls to determine contributing factors and causes of falls to implement appropriate immediate interventions to prevent further falls for resident (R)1 and R 42 with multiple falls. Findings included: - Review Resident (R)1's Physician order Sheet, dated 08/02/23, documentation included diagnoses of lack of coordination, need for assistance with personal care, Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure) with late onset, behavioral disturbances, and hypertension (high blood pressure). The Significant Change in Status Minimum Data Set, (MDS) dated [DATE], documentation revealed the resident with a Brief Interview for Mental Status, score of two, indicating severe cognitive impairment. He required extensive assistance from staff with bed mobility, transfer, locomotion, dressing, toilet use. The resident did not ambulate during the assessment. His balance during transition was not steady. He was only able to stabilize with staff assistance. He had functional limitation in range of motion (ROM) of bilateral (both) lower extremities and used a wheelchair as an assistive device. The resident was frequently incontinent of bladder and always continent of bowel. He exhibited shortness of breath (SOB) or trouble breathing with lying flat and exertion (e.g., walking, bathing, transferring). He experienced two or more no injury falls. The resident received anti-anxiety medication for seven days of the look back period and antidepressant medication for one day of the look back period. The resident did not receive therapy nor restorative nursing program (RNP). He did use a bed and chair alarm daily. The Quarterly MDS dated 08/09/23, documented the changes which included a decreased BIMS score of 99, indicating a decline in mental status. He was occasionally incontinent of bowel. The resident did not experience SOB. He had two no injury falls and one fall with injury which was not major injury. The Care Area Assessment for Cognition/Dementia, Falls, and Psychoactive Drug Use, (CAA), respectfully, dated 11/28/22, documentation included the resident scored two on his BIMS. The resident stated that he just can't remember. He is at risk for further decline in cognition related to not feeling well. The resident does well with cueing, redirection, and reminders to complete tasks. Staff should keep his routine consistent and assist with Activities of daily living (ADL's). The resident is at risk for falls due to agitation, impulsiveness, incontinence, impaired balance, and medications. Staff to ensure he has appropriate footwear on while transferring. Staff to encourage him to utilize the call light for assistance and monitor for safety routinely. He was at risk for adverse effects (falls, sedation, impaired balance, side effects outlined in the black box warning) due to his use of a psychotropic medication. The Care Plan dated 08/22/23, directed staff that the resident was at risk for falls secondary to limited mobility. The care plan included that staff should provide medical adaptive equipment that included a Reacher (a handheld mechanical tool used to increase the range of a person's reach and grasp when grabbing objects) to assist the resident with grabbing items. Staff were to verify the resident's belt as appropriate. Verify belt is fastened properly not allowing pants to fall. Staff were to check each time the resident dressed and after every toileting. The resident had limited physical mobility and would maintain the ability to ambulate with walker with one staff assistance and guided staff that the resident could ambulate without assistive devices with impaired balance with one staff. He needed a four wheeled walker but would often refuse to use it. The care plan lacked guidance for the body alarm. The Morse fall scale, dated 12/27/22, 03/14/23, 03/21/23, 04/18/23 and 05/18/23 indicated R1 was at a high risk for falls. R1's electronic health record revealed the resident had multiple falls. From 03/04/23 to 06/27/23, the resident fell on 11 occasions. Review of the electronic records, on 04/04/23 at 11:20 PM, the resident's body alarm sounded like he was repositioning. After the alarm continued to sound, staff checked on R1, and the resident fell from his bed to the floor, with his upper body on the bed. On 10/24/22 at 08:15 PM, the resident fell while standing without assistance. The immediate intervention was to always place a pad alarm in bed and in the chair, even in the presence of staff. On 05/30/23 at 07:42 PM, an unidentified CNA assisted him to bed. He was found lying on his back by the north side of his bed. The root cause was the body alarm was in the resident's wheelchair, and not in his bed. On 06/11/23 at 12:30 AM, an unidentified certified Nurse aide (CNA) discovered the resident on the floor next to the bed. The root cause was the bed alarm appeared to be nonfunctional. Staff put the resident back to bed, however no documentation to reveal staff replaced the bed alarm with a functional body alarm. On 06/11/23 at 12:50 AM, shortly after first fall, staff discovered the resident on the floor, next to his bed. The root cause was a nonfunctional bed alarm. On 06/27/23 at 07:58 PM, the resident fell from his bed to the floor. The resident was incontinent and did not have his body alarm in place. Observation on 08/29/23 at 10:40 AM, R1 sat in recliner, no signs of discomfort. On 08/31/23 at 03:01 PM, R1 sat in a recliner by the nurse's station in visual field of staff. R1 made no attempts to get out of the recliner. On 09/05/23 at 01:31 PM, CNA F reported the resident would attempt to get out of his bed in the morning. If he gets up, the pressure alarm will activate. On 09/05/23 at 02:22 PM, Licensed Nurse (LN) G reported the resident underestimates what he can do, and he gets restless most of the time and tries to get up and out of bed on his own. On 09/06/23 at 11:29 AM, Administrative Nurse B reported that the immediate interventions on the fall report should be appropriate to mitigate the risk for falls and the nurse that is on duty should amend the care plan with a new intervention. The resident had intervention for the body alarm, and staff had to be reeducated because the alarm wasn't in place and another fall, staff did not answer the call light timely. Another fall occurred when staff didn't put the call light in place. The facility's policy for Accident, Incident and Unusual Occurrence Reporting Procedure policy, dated 02/15/21, lacked guidance related to body alarms. The facility failed to ensure this resident had appropriate interventions related to his falls.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 51 residents with 14 residents sampled which included one resident reviewed for urinary catheters. Based on observation, interview, and record review, the facility failed to provide necessary treatment and services regarding catheter care for one Resident (R)49, This deficient practiced placed R49 at risk for catheter related complications. Findings included: - Review of Resident (R)49's Physician Orders, (POS) dated 08/02/23, documentation included diagnosis of stage five chronic kidney disease and obstructive and reflux uropathy ( a disorder of the urinary tract that occurs due to obstructed urinary flow causing the back-up of urine into the kidneys). The admission Minimum Data Set (MDS), dated [DATE], documented the resident entered the facility on 07/27/23,with a Brief Interview for Mental Status score of 12, indicating moderate cognitive impairment. He required staff limited assistance for toilet use. The resident had an indwelling urinary catheter (insertion of a catheter into the bladder to drain the urine into a collection bag). The Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA), dated 08/08/23, documented the resident at risk for complications related to his chronic urinary catheter use. Staff should provide him with assistance for management and monitor for signs and symptoms of complications. The Care Plan dated 08/16/23, revealed the resident had a potential for impairment related to his chronic indwelling catheter use. The staff should change the large catheter bag to a leg bag each morning between 5:00 AM to 6:00 AM and change back to the large catheter bag at bedtime. Staff were to observe for signs and symptoms of urinary tract infection (UTI) which included pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, urinary frequency, foul smelling urine, fever, chills, altered mental status, and/or change in behavior, initiated on 07/28/23. The POS, dated 09/01/23, documented a new medication order for an antibiotic of amoxicillin (antibiotic) tablet, 500 milligrams (MG), three times a day, for 10 days, by mouth, for UTI. On 08/29/23 at 10:01 AM, the resident sat at his bedside with his walker in front of him with his dignity bag attached to his walker. On 09/05/23 at 04:21 PM, during observation of catheter care and peri care provided by Certified Nurse Aide (CNA) E , noted CNA E laid the resident's catheter bag directly on the floor when she assisted the resident to the toilet. CNA E changed the residents brief and pants, and CNA E continued to place the catheter bag directly on the floor. On 09/05/23 at 04:34 PM, on inquiry, CNA E stated staff should not lay the catheter collection bag directly on the floor. She confirmed doing so would place the resident at risk for infection. On 09/05/23 at 05:00 PM, Licensed Administrative Nurse C stated the urine collection bag of the resident's indwelling catheter should not come in direct contact with the floor. The staff should suspend the urine collection bag below the bladder and off the floor to prevent cross contamination and/or urinary tract infection to prevent cross contamination and prevent UTIs. On 09/06/23 at 03:15 PM, Administrative Nurse B confirmed the facility policy for catheter care and related practices was referenced from the Lippincott Nursing Procedures as acceptable standard of practice. She stated the catheter urine collection bag should be maintained below the resident's bladder but not placed directly on the floor to prevent cross contamination and resulting UTI. The facility policy for Internal Management Policy or Procedure, dated 06/24/20, references the Lippincott Nursing Procedures seventh edition, Indwelling Urinary Catheter Care and Removal, page 387. Documentation included Don't place the drainage bag on the floor, to reduce the risk of contamination. The facility failed to provide necessary treatment and services regarding catheter care for the resident to prevent catheter related complications.

The facility reported a census of 51 residents with 14 residents sampled, including three residents reviewed for respiratory care. Based on observations, record reviews, and interviews, the facility failed to properly store the nebulizer (a device for administering inhaled medications) and to correctly store distilled water used for oxygen humidification for to Resident (R)2, R11 and R21 in accordance with the standards of care. In addition, the facility failed to disassemble and clean the CPAP (continuous positive airway pressure - a machine used to provide continuous airway pressure in people diagnosed with obstructive sleep apnea [a condition in which a person cannot maintain an open airway while sleeping]) for R11. Findings included: - R2's pertinent diagnoses from the Electronic Health Record (EHR) documented chronic obstructive pulmonary disease (COPD - a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). The 08/06/23 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of eight, indicating moderately impaired cognition. The resident required extensive assistance of 2 staff for all cares except eating. The resident received oxygen. The 05/12/23 Quarterly MDS documented a BIMS of eight, indicating moderately impaired cognition. The resident received oxygen. The 08/06/23 Care Area Assessment (CAA) lacked documentation related to a nebulizer or oxygen use. The Care Plan dated 08/31/23, documented that the resident had altered respiratory status related to COPD and other disorders of the lungs, and instructed staff to administer medications as ordered, but lacked information specific to care of nebulizer equipment. The resident's Physician Orders included ipratropium-albuterol inhalation solution to be given once per day, and every four hours, as needed for difficulty breathing related to COPD, dated 03/16/23. The 06/01/23 to 08/31/23 EHR Treatment Administration Record (TAR) lacked documentation for cleaning/maintenance of the resident's nebulizer equipment. On 08/30/23 at 11:04 AM, R2 was in bed with oxygen on. The nebulizer tubing and medication chamber was on top of the nebulizer machine. Moisture and a clear liquid remained in the medication chamber of the nebulizer. On 08/31/23 at 08:30 AM, R2 observed resting in bed wearing oxygen via nasal cannula. The nebulizer machine sat of top of the bedside table. There was no tubing/medication chamber. On 08/30/23 at 03:19 PM, Administrative Nurse I and Administrative Nurse J stated that after a resident receives a nebulizer treatment, the nebulizer equipment should be disassembled and rinsed with water then set on a paper towel to dry. Further stated that it is unacceptable practice for nebulizer's to be left intact between treatments. On 09/05/23 at 05:38 PM, Administrative Nurse C revealed that after a nebulizer treatment, the nebulizer equipment should be disassembled and soaked in a vinegar solution for 15 minutes then left disassembled to air dry on a paper towel between uses. On 09/06/23 at 10:34 AM, Certified Medication Aide (CMA) H revealed that after a resident received a nebulizer treatment, staff should disassemble the nebulizer and clean with soap and water, then left to air dry on a paper towel. On 09/06/23 at 11:12 AM, Licensed Nurse (LN) K revealed that after a resident received a nebulizer treatment, the nebulizer equipment should be disassembled and rinsed with water and left to air dry on a paper towel. On 09/06/23 at 03:00 PM, Administrative Nurse B revealed that in the absence of a policy or procedure guide specific to any nursing process, that the standard of care should be followed. The facility's policy for Nursing Standards, Guidelines, Protocols, Procedures and Position Statements, dated 06/24/20 documented that Lippincott Nursing Procedures would be used by nursing personnel as the standard of care for practices and processes. The facility failed to provide a policy or procedure guide specific to nebulizer medication administration. The facility failed to provide respiratory care consistent with professional standards of care for R2, regarding the cleaning and storage of the nebulizer. - R11's pertinent diagnoses from the Electronic Health Record (EHR) documented chronic obstructive pulmonary disease (COPD - a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), shortness of breath and obstructive sleep apnea [a condition in which the person cannot maintain an open airway while asleep]). The 01/10/23 Annual Minimum Data Set (MDS) documented Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The resident received oxygen. The MDS lacked documentation that resident received a continuous positive airway pressure (CPAP). The 08/27/23 Quarterly MDS documented a BIMS of 15, which indicated intact cognition. The resident received oxygen. The 01/10/23 Care Area Assessment (CAA) lacked documentation related to oxygen use, nebulizer medication administration, or CPAP use. R11's EHR Physician Orders included ipratropium-albuterol inhalation solution to be given three times per day for shortness of air and continuous oxygen but lacked orders for CPAP. The Care Plan dated 08/30/23 documented on 01/24/22 that the resident has altered respiratory status. Administer medication/puffers as ordered. Staff instructed for the CPAP machine to use titrated pressure with full -face mask when sleeping. The physician's order included ipratropium-Albuterol solution, 3 milligrams per 3 milliliters, use 1 application, and inhale orally three times a day, for shortness of breath, dated 07/12/23. Review of the Treatment Administration Record from 07/12/23 to 08/31/23, lacked documentation of the care for the nebulizer equipment or the CPAP equipment. he 06/01/23 to 08/31/23 EHR Treatment Administration Record (TAR) lacked documentation for the care of nebulizer equipment or CPAP equipment. On 08/29/23 at 08:50 AM, R11 was in bed, the resident's nebulizer mask laid directly on the bed linens, and the nebulizer's medication chamber contained a clear liquid. On 08/30/23 at 11:55 AM, observation of R11's room revealed a nebulizer mask hung from the edge of the bed by an elastic strap. There was clear liquid inside the nebulizer medication chamber. On 08/30/23 at 03:04 PM, R11 observed sitting upright in bed receiving breathing treatment with nebulizer mask. R11 pressed the call light and unknown Certified Nurse Aide (CNA) responded to the call light and removed the nebulizer mask at the request of R11, then placed the nebulizer mask on top of the nebulizer machine on the resident's bedside table. The nebulizer was intact with an unknown clear liquid that remained in the nebulizer chamber. The CNA then left the room. On 08/30/23 at 03:19 PM, Administrative Nurse I and Administrative Nurse J stated that after a resident received a nebulizer treatment, the nebulizer equipment should be disassembled and rinsed with water, then set on a paper towel to dry. It was unacceptable practice for nebulizer's to be left intact between treatments. On 08/31/23 at 08:41 AM, observation of R11's room revealed the nebulizer intact on the bedside table with unknown clear liquid in the nebulizer chamber. On 09/05/23 at 05:38 PM, Administrative Nurse C revealed that after a nebulizer treatment, the nebulizer equipment should be disassembled and soaked in a vinegar solution for 15 minutes then left disassembled to air dry on a paper towel between uses. On 09/06/23 at 10:34 AM, Certified Medication Aide (CMA) H revealed that after a resident received a nebulizer treatment, staff should disassemble the nebulizer and clean with soap and water, then left to air dry on a paper towel. On 09/06/23 at 11:12 AM, Licensed Nurse (LN) K revealed that after a resident received a nebulizer treatment, the nebulizer equipment should be disassembled and rinsed with water and left to air dry on a paper towel. On 09/06/23 at 03:00 PM, Administrative Nurse B revealed that in the absence of a policy or procedure guide specific to any nursing process, that the standard of care should be followed. The facility's policy for Nursing Standards, Guidelines, Protocols, Procedures and Position Statements, dated 06/24/20 documented that Lippincott Nursing Procedures would be used by nursing personnel as the standard of care for practices and processes. The facility failed to provide a policy or procedure guide specific to nebulizer medication administration. The facility failed to provide respiratory care consistent with professional standards of care for R11, regarding the cleaning and storage of the nebulizer. - R21's pertinent diagnoses from the Electronic Health Record (EHR) documented chronic obstructive pulmonary disease (COPD - a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). The 05/30/23 admission Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The resident required limited assistance of one staff for all cares except eating, which required setup and supervision. The 08/21/23 Quarterly MDS documented a BIMS of 15, indicating intact cognition. The 03/08/23 Care Area Assessment (CAA) lacked documentation related to the nebulizer medication use. R21's Physician Orders included: Ipratropium-albuterol inhalation solution, to be given four times, per day for shortness of air, ordered 05/23/23. Budesonide inhalation solution, to be given two times per day, for shortness of air, ordered 05/23/23. On 08/28/23 at 02:17 PM, observed R21's nebulizer mask outside the room, with the nebulizer mask stored directly on the handrail in the hallway. On 08/30/23 at 10:35 AM, R21's nebulizer mask stored intact on top of the bedside table near the door, with an unknown clear liquid inside the nebulizer chamber. On 09/05/23 at 01:06 PM, R21's nebulizer mask stored intact on top of the bedside table near the door, with an unknown clear liquid inside the nebulizer chamber. On 08/30/23 at 03:19 PM, Administrative Nurse I and Administrative Nurse J stated that after a resident received a nebulizer treatment, the nebulizer equipment should be disassembled and rinsed with water, then set on a paper towel to dry. Further stated that it is unacceptable practice for nebulizer's to be left intact between treatments. On 09/05/23 at 05:38 PM, Administrative Nurse C revealed that after a nebulizer treatment, the nebulizer equipment should be disassembled and soaked in a vinegar solution for 15 minutes then left disassembled to air dry on a paper towel between uses. On 09/06/23 at 10:34 AM, Certified Medication Aide (CMA) H revealed that after a resident received a nebulizer treatment, staff should disassemble the nebulizer and clean with soap and water, then left to air dry on a paper towel. On 09/06/23 at 11:12 AM, Licensed Nurse (LN) K revealed that after a resident received a nebulizer treatment, the nebulizer equipment should be disassembled and rinsed with water and left to air dry on a paper towel. On 09/06/23 at 03:00 PM, Administrative Nurse B revealed that in the absence of a policy or procedure guide specific to any nursing process, that the standard of care should be followed. The facility's policy for Nursing Standards, Guidelines, Protocols, Procedures and Position Statements, dated 06/24/20 documented that Lippincott Nursing Procedures would be used by nursing personnel as the standard of care for practices and processes. The facility failed to provide a policy or procedure guide specific to nebulizer medication administration. The facility failed to provide respiratory care consistent with professional standards of care for R21, regarding the cleaning and storage of the nebulizer.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 51 residents, with 14 residents sampled. Based on observation, interview and record review, the facility failed to provide Resident (R2) a bed of appropriate size for the safety and convenience of the resident. Findings included: - Resident (R)2's diagnosis included chronic obstructive pulmonary disease (COPD is a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). The Annual Minimum Data Set (MDS) dated [DATE], documented the resident had a Brief Interview for Mental Status score of eight, indicating moderately impaired cognition. The resident required extensive assistance for ADL's, other than eating. The resident was 73 inches tall. On 08/30/23 at 11:04 AM, the resident was in his bed, his legs in a bullfrog position. He was able to lower the bed to a flat position, and his body noted to hang off the top and bottom of the mattress with approximately three inches of combined clearance between his head and the headboard and his feet to the footboard. On 08/31/23 at 11:04 AM, the resident reported he must lay with his legs in a bullfrog position to be comfortable. He reported he wanted/needed a longer bed and had told staff that he needed a longer bed. The resident reported his height was 6 foot 3 inches (75 inches). On 08/30/23 at 03:35 PM, maintenance staff M reported the bed measurement from the headboard to the food board was 80 inches, and the mattress was 76 inches in length. The footboards could be removed from the bed from compromising the structural integrity of the bed. On 08/31/23 at 11:40 AM, Administrative Staff A reported he was not aware that the resident was uncomfortable in the bed. He reported the mattress was pinned to the bed frame, so there was no reason why the footboard could not be removed. On 09/05/23 at 12:57 PM, the resident reported he did not want the footboards removed because this would make his feet hand off the end of the bed. The facility did not provide a policy related to bed length. The facility failed to provide Resident (R2) a bed of appropriate size for the safety and convenience of the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** - R2's pertinent diagnoses from the Electronic Health Record (EHR) documented chronic obstructive pulmonary disease (COPD - a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). The 08/06/23 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of eight, indicating moderately impaired cognition. The resident required extensive assistance of 2 staff for all cares except eating. The resident received oxygen. The 05/12/23 Quarterly MDS documented a BIMS of eight, indicating moderately impaired cognition. The resident received oxygen. The 08/06/23 Care Area Assessment (CAA) lacked documentation related to a nebulizer or oxygen use. The Care Plan dated 08/31/23, documented that the resident had altered respiratory status related to COPD and other disorders of the lungs, and instructed staff to administer medications as ordered, but lacked information specific to care of nebulizer equipment. The resident's Physician Orders included ipratropium-albuterol inhalation solution to be given once per day, and every four hours, as needed for difficulty breathing related to COPD, dated 03/16/23. The 06/01/23 to 08/31/23 electronic health record (EHR) Treatment Administration Record (TAR) lacked documentation for cleaning/maintenance of the resident's nebulizer equipment. On 08/30/23 at 11:04 AM, R2 was in bed with oxygen on. The nebulizer tubing and medication chamber was on top of the nebulizer machine. Moisture and a clear liquid remained in the medication chamber of the nebulizer. On 08/31/23 at 08:30 AM, R2 observed resting in bed wearing oxygen via nasal cannula. The nebulizer machine sat of top of the bedside table. There was no tubing/medication chamber. On 08/30/23 at 03:19 PM, Administrative Nurse I and Administrative Nurse J stated that after a resident receives a nebulizer treatment, the nebulizer equipment should be disassembled and rinsed with water then set on a paper towel to dry. Further stated that it is unacceptable practice for nebulizer's to be left intact between treatments. On 09/05/23 at 05:38 PM, Administrative Nurse C revealed that after a nebulizer treatment, the nebulizer equipment should be disassembled and soaked in a vinegar solution for 15 minutes then left disassembled to air dry on a paper towel between uses. On 09/06/23 at 10:34 AM, Certified Medication Aide (CMA) H revealed that after a resident received a nebulizer treatment, staff should disassemble the nebulizer and clean with soap and water, then left to air dry on a paper towel. On 09/06/23 at 11:12 AM, Licensed Nurse (LN) K revealed that after a resident received a nebulizer treatment, the nebulizer equipment should be disassembled and rinsed with water and left to air dry on a paper towel. On 09/06/23 at 03:00 PM, Administrative Nurse B revealed that in the absence of a policy or procedure guide specific to any nursing process, that the standard of care should be followed. The facility's policy for Nursing Standards, Guidelines, Protocols, Procedures and Position Statements, dated 06/24/20 documented that Lippincott Nursing Procedures would be used by nursing personnel as the standard of care for practices and processes. The facility failed to provide respiratory care consistent with professional standards of care for R2, regarding the cleaning and storage of the nebulizer, to prevent possible cross contamination and infection. - R11's pertinent diagnoses from the Electronic Health Record (EHR) documented chronic obstructive pulmonary disease (COPD - a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), shortness of breath and obstructive sleep apnea [a condition in which the person cannot maintain an open airway while asleep]). The 01/10/23 Annual Minimum Data Set (MDS) documented Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The resident received oxygen. The MDS lacked documentation that resident received a continuous positive airway pressure (CPAP). The 08/27/23 Quarterly MDS documented a BIMS of 15, which indicated intact cognition. The resident received oxygen. The 01/10/23 Care Area Assessment (CAA) lacked documentation related to oxygen use, nebulizer medication administration, or CPAP use. R11's electronic health record (EHR) Physician Orders included ipratropium-albuterol inhalation solution to be given three times per day for shortness of air and continuous oxygen but lacked orders for CPAP. The Care Plan dated 08/30/23 documented on 01/24/22 that the resident has altered respiratory status. Administer medication/puffers as ordered. Staff instructed for the CPAP machine to use titrated pressure with full -face mask when sleeping. The physician's order included ipratropium-Albuterol solution, 3 milligrams per 3 milliliters, use 1 application, and inhale orally three times a day, for shortness of breath, dated 07/12/23. Review of the Treatment Administration Record from 07/12/23 to 08/31/23, lacked documentation of the care for the nebulizer equipment or the CPAP equipment. he 06/01/23 to 08/31/23 EHR Treatment Administration Record (TAR) lacked documentation for the care of nebulizer equipment or CPAP equipment. On 08/29/23 at 08:50 AM, R11 was in bed, the resident's nebulizer mask laid directly on the bed linens, and the nebulizer's medication chamber contained a clear liquid. On 08/30/23 at 11:55 AM, observation of R11's room revealed a nebulizer mask hung from the edge of the bed by an elastic strap. There was clear liquid inside the nebulizer medication chamber. On 08/30/23 at 03:04 PM, R11 observed sitting upright in bed receiving breathing treatment with nebulizer mask. R11 pressed the call light and unknown Certified Nurse Aide (CNA) responded to the call light and removed the nebulizer mask at the request of R11, then placed the nebulizer mask on top of the nebulizer machine on the resident's bedside table. The nebulizer was intact with an unknown clear liquid that remained in the nebulizer chamber. The CNA then left the room. On 08/30/23 at 03:19 PM, Administrative Nurse I and Administrative Nurse J stated that after a resident received a nebulizer treatment, the nebulizer equipment should be disassembled and rinsed with water, then set on a paper towel to dry. It was unacceptable practice for nebulizer's to be left intact between treatments. On 08/31/23 at 08:41 AM, observation of R11's room revealed the nebulizer intact on the bedside table with unknown clear liquid in the nebulizer chamber. On 09/05/23 at 05:38 PM, Administrative Nurse C revealed that after a nebulizer treatment, the nebulizer equipment should be disassembled and soaked in a vinegar solution for 15 minutes then left disassembled to air dry on a paper towel between uses. On 09/06/23 at 10:34 AM, Certified Medication Aide (CMA) H revealed that after a resident received a nebulizer treatment, staff should disassemble the nebulizer and clean with soap and water, then left to air dry on a paper towel. On 09/06/23 at 11:12 AM, Licensed Nurse (LN) K revealed that after a resident received a nebulizer treatment, the nebulizer equipment should be disassembled and rinsed with water and left to air dry on a paper towel. On 09/06/23 at 03:00 PM, Administrative Nurse B revealed that in the absence of a policy or procedure guide specific to any nursing process, that the standard of care should be followed. The facility's policy for Nursing Standards, Guidelines, Protocols, Procedures and Position Statements, dated 06/24/20 documented that Lippincott Nursing Procedures would be used by nursing personnel as the standard of care for practices and processes. The facility failed to provide respiratory care consistent with professional standards of care for R2, regarding the cleaning and storage of the nebulizer, to prevent possible cross contamination and infection. - R21's pertinent diagnoses from the Electronic Health Record (EHR) documented chronic obstructive pulmonary disease (COPD - a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). The 05/30/23 admission Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The resident required limited assistance of one staff for all cares except eating, which required setup and supervision. The 08/21/23 Quarterly MDS documented a BIMS of 15, indicating intact cognition. The 03/08/23 Care Area Assessment (CAA) lacked documentation related to the nebulizer medication use. R21's Physician Orders included: Ipratropium-albuterol inhalation solution, to be given four times, per day for shortness of air, ordered 05/23/23. Budesonide inhalation solution, to be given two times per day, for shortness of air, ordered 05/23/23. On 08/28/23 at 02:17 PM, observed R21's nebulizer mask outside the room, with the nebulizer mask stored directly on the handrail in the hallway. On 08/30/23 at 10:35 AM, R21's nebulizer mask stored intact on top of the bedside table near the door, with an unknown clear liquid inside the nebulizer chamber. On 09/05/23 at 01:06 PM, R21's nebulizer mask stored intact on top of the bedside table near the door, with an unknown clear liquid inside the nebulizer chamber. On 08/30/23 at 03:19 PM, Administrative Nurse I and Administrative Nurse J stated that after a resident received a nebulizer treatment, the nebulizer equipment should be disassembled and rinsed with water, then set on a paper towel to dry. Further stated that it is unacceptable practice for nebulizer's to be left intact between treatments. On 09/05/23 at 05:38 PM, Administrative Nurse C revealed that after a nebulizer treatment, the nebulizer equipment should be disassembled and soaked in a vinegar solution for 15 minutes then left disassembled to air dry on a paper towel between uses. On 09/06/23 at 10:34 AM, Certified Medication Aide (CMA) H revealed that after a resident received a nebulizer treatment, staff should disassemble the nebulizer and clean with soap and water, then left to air dry on a paper towel. On 09/06/23 at 11:12 AM, Licensed Nurse (LN) K revealed that after a resident received a nebulizer treatment, the nebulizer equipment should be disassembled and rinsed with water and left to air dry on a paper towel. On 09/06/23 at 03:00 PM, Administrative Nurse B revealed that in the absence of a policy or procedure guide specific to any nursing process, that the standard of care should be followed. The facility's policy for Nursing Standards, Guidelines, Protocols, Procedures and Position Statements, dated 06/24/20 documented that Lippincott Nursing Procedures would be used by nursing personnel as the standard of care for practices and processes. The facility failed to provide respiratory care consistent with professional standards of care for R2, regarding the cleaning and storage of the nebulizer, to prevent possible cross contamination and infection. The facility reported a census of 51 residents with 14 residents sampled which included one resident reviewed for catheters, and three residents reviewed for respiratory care and services related to respiratory equipment. Based on observation, interview, and record review, the facility failed to provide necessary treatment and services regarding catheter care for R 49 and respiratory care and services for R 2, R 11, and R21 to prevent cross contamination and infection. Findings included: - Review of Resident (R)49's Physician Orders, (POS) dated 08/02/23, documentation included diagnosis of stage five chronic kidney disease and obstructive and reflux uropathy ( a disorder of the urinary tract that occurs due to obstructed urinary flow causing the back-up of urine into the kidneys). The admission Minimum Data Set (MDS), dated [DATE], documented the resident entered the facility on 07/27/23,with a Brief Interview for Mental Status score of 12, indicating moderate cognitive impairment. He required staff limited assistance for toilet use. The resident had an indwelling urinary catheter (insertion of a catheter into the bladder to drain the urine into a collection bag). The Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA), dated 08/08/23, documented the resident at risk for complications related to his chronic urinary catheter use. Staff should provide him with assistance for management and monitor for signs and symptoms of complications. The Care Plan dated 08/16/23, revealed the resident had a potential for impairment related to his chronic indwelling catheter use. The staff should change the large catheter bag to a leg bag each morning between 5:00 AM to 6:00 AM and change back to the large catheter bag at bedtime. Staff were to observe for signs and symptoms of urinary tract infection (UTI) which included pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, urinary frequency, foul smelling urine, fever, chills, altered mental status, and/or change in behavior, initiated on 07/28/23. The POS, dated 09/01/23, documented a new medication order for an antibiotic of amoxicillin (antibiotic) tablet, 500 milligrams (MG), three times a day, for 10 days, by mouth, for UTI. On 08/29/23 at 10:01 AM, the resident sat at his bedside with his walker in front of him with his dignity bag attached to his walker. On 09/05/23 at 04:21 PM, during observation of catheter care and peri care provided by Certified Nurse Aide (CNA) E , noted CNA E laid the resident's catheter bag directly on the floor when she assisted the resident to the toilet. CNA E changed the residents brief and pants, and CNA E continued to place the catheter bag directly on the floor. On 09/05/23 at 04:34 PM, on inquiry, CNA E stated staff should not lay the catheter collection bag directly on the floor. She confirmed doing so would place the resident at risk for infection. On 09/05/23 at 05:00 PM, Licensed Administrative Nurse C stated the urine collection bag of the resident's indwelling catheter should not come in direct contact with the floor. The staff should suspend the urine collection bag below the bladder and off the floor to prevent cross contamination and/or urinary tract infection to prevent cross contamination and prevent UTIs. On 09/06/23 at 03:15 PM, Administrative Nurse B confirmed the facility policy for catheter care and related practices was referenced from the Lippincott Nursing Procedures as acceptable standard of practice. She stated the catheter urine collection bag should be maintained below the resident's bladder but not placed directly on the floor to prevent cross contamination and resulting UTI. The facility policy for Internal Management Policy or Procedure, dated 06/24/20, references the Lippincott Nursing Procedures seventh edition, Indwelling Urinary Catheter Care and Removal, page 387. Documentation included Don't place the drainage bag on the floor, to reduce the risk of contamination. The facility failed to provide necessary treatment and services regarding catheter care for the resident to prevent cross contamination and infection.

The facility census totaled 31 residents with 12 included in the sample. Based on interview and record review the facility failed to complete and transmit a Discharge Minimum Data Set (MDS) assessments to the Centers for Medicare & Medicaid Services (CMS) in a timely manner for Resident (R)1. Findings included: - Record review on 12/14/21 at 07:30 AM revealed R1 discharged from the facility on 08/28/21. The resident record lacked evidence of a completed or transmitted Discharge Minimum Data Set (MDS) to the Centers for Medicare & Medicaid Services (CMS). On 12/14/21 at 07:36 AM Administrative Nurse B stated she was responsible for ensuring assessments were completed and confirmed there was not a discharge MDS completed and/or transmitted for R1. The facility's policy for MDS Process dated October 2019 revealed the facility would follow the 3.0 RAI [Resident Assessment Instrument] Manual for completion and submission of the MDS for each resident. The facility failed to complete and transmit a Discharge Minimum Data Set (MDS) assessment to the Centers for Medicare & Medicaid Services (CMS) in a timely manner for R1.

The facility reported a census of 31 residents with 12 sampled including five for unnecessary medications. Based on observation, interview, and record review the facility failed to ensure the pharmacist identified the lack of Abnormal Involuntary Movement Scale (AIMS) assessments completed per current standards of practice regarding potential side effects such as tardive dyskinesia (abnormal condition characterized by involuntary repetitive movements of the muscles of the face, limbs and trunk) in the administration of antipsychotic medications for Resident (R)19. Findings Include: - R19's pertinent diagnoses from the Physician's Orders in the Electronic Health Record (EHR) dated 11/12/21 documented major depressive disorder (major mood disorder), dementia (progressive mental disorder characterized by failing memory, confusion), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). The 07/16/21 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of four, indicating severely impaired cognition. R19 received an antipsychotic medication daily in the seven-day look back period. The 10/08/21 Quarterly MDS documented R19 received an antipsychotic medication daily in the seven-day look back period. The 10/02/21 Care Plan for R19 instructed staff to administer medications and monitor for side effects as ordered by the physician. The Physicians Orders documented an order dated 04/03/18 for Seroquel (antipsychotic medication) 25 milligrams (mg) daily. Review of the Abnormal Involuntary Movement Scale assessments in R19's EHR documented the completion on 02/22/20, and the next one completed was on 04/19/21 (almost 14 months later), and 10/05/21. Review of the monthly Pharmacy Medication Record Review (MRR) for November 2020 through November 2021 did not identify the lack of a completed AIMS assessment during the 14-month time gap between the 02/22/20 and 04/19/21 AIMS assessment. The pharmacist monthly MRR should have identified the lack of an AIMS assessment conducted when due in August of 2020, or that the facility staff did not complete an AIMS until eight months later on 04/19/21. On 12/14/21 at 04:32 PM observation revealed R19 laid in bed watching TV with no signs or symptoms of distress noted. On 12/14/21 at 04:34 PM Licensed Nurse (LN) C stated the floor nurse completed the AIMS assessment in the EHR and stated the program automatically generated a reminder to complete the AIMS assessments. On 12/14/21 at 02:59 PM Administrative Staff B confirmed the facility did not complete an AIMS assessment appropriately for R19. Administrative Staff B stated they expected the floor nurse to complete an AIMS assessment quarterly (every three months) on any resident who received an antipsychotic medication. On 12/15/21 at 02:00 PM Consultant Staff D confirmed the AIMS assessment should be completed for the antipsychotic medication (Seroquel) R19 received. Consultant Staff D stated she should have looked for them and informed the facility of the need for the AIMS assessments to be completed timely. She stated the AIMS assessments should be completed every six months, but a lot of facilities completed them with each MDS, so they were usually done every quarter. The facility's Drug Regimen Review policy reviewed 10/15/21 documented the drug regimen review would identify medications used without adequate monitoring. The facility failed to ensure the pharmacist identified the lack of assessments/monitoring of potential side effects in the use of antipsychotic medications for R19 when staff did not complete AIMS assessments in a timely manner.

The facility reported a census of 31 residents with 12 sampled including five for unnecessary medications. Based on observation, interview, and record review the facility failed to ensure the Abnormal Involuntary Movement Scale (AIMS, a periodically used clinical scale to aid in monitoring the potential side effects of antipsychotic medications) assessments were completed per current standards of practice regarding antipsychotic (medication which affects brain activities with mental processes and behavior) medications administered for Resident (R)19. Findings Include: - R19's pertinent diagnoses from the Physician's Orders in the Electronic Health Record (EHR) dated 11/12/21 documented major depressive disorder (major mood disorder), dementia (progressive mental disorder characterized by failing memory, confusion), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). The 07/16/21 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of four, indicating severely impaired cognition. R19 received an antipsychotic medication daily in the seven-day look back period. The 10/08/21 Quarterly MDS documented R19 received an antipsychotic medication daily in the seven-day look back period. The 10/02/21 Care Plan for R19 instructed staff to administer medications and monitor for side effects as ordered by the physician. The Physicians Orders documented an order dated 04/03/18 for Seroquel (antipsychotic medication) 25 milligrams (mg) daily. Review of the Abnormal Involuntary Movement Scale assessments in R19's EHR documented the completion on 02/22/20, and the next one completed was on 04/19/21 (almost 14 months later), and 10/05/21. On 12/14/21 at 04:32 PM observation revealed R19 laid in bed watching TV with no signs or symptoms of distress noted. On 12/14/21 at 04:34 PM Licensed Nurse (LN) C stated the floor nurse completed the AIMS assessment in the EHR and stated the program automatically generated a reminder to complete the AIMS assessments. On 12/14/21 at 02:59 PM Administrative Staff B confirmed the facility did not complete an AIMS assessment appropriately for R19. Administrative Staff A stated they expected the floor nurse to complete an AIMS assessment quarterly (every three months) on any resident who received an antipsychotic medication. The facility's Drug Regimen Review policy reviewed 10/15/21 documented the drug regimen review would identify medications used without adequate monitoring. The facility failed to adequately monitor the use of antipsychotic medications for R19 when staff did not complete AIMS assessments in a timely manner.

The facility reported a census of 31 residents, with one main kitchen. Based on observation, interview, and record review the facility failed to store foods in a safe and sanitary manner when dietary staff failed to date and reseal opened food items and failed to discard expired food items. Findings included: - The initial kitchen tour on 12/13/21 at 10:45 AM revealed a large open bag of sausage crumbles and a bag of French fries were in the freezer and open to air with no date. Inspection of the refrigerator revealed cartons of thickened water, thickened orange juice, and a carton of Almond Milk which were all expired. Dietary Staff E removed and discarded these items. On 12/13/21 at 10:30 AM Dietary Staff E reported all dietary staff knew food items were to be dated when opened and put back into the refrigerator and freezer. DS E said she did not know if staff knew to look at the use by date (expiration date) on the liquid items, after they opened them. Review of the facility policy Food Storage dated 05/08/19 revealed left over food is stored in covered containers or wrapped carefully and securely. Each item is clearly labeled and dated before being refrigerated. Left over food to be used within 3 days or discarded. Frozen foods should be covered, labeled and dated. The facility failed to store foods in a safe and sanitary manner when dietary staff failed to date and reseal opened food items, and failed to discard liquid/fluid food items, by the use by date after opening.