**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 31 residents. The sample included 12 residents with three reviewed for abuse. Based on observation, record review, and interview the facility failed to report an incident of neglect for Resident (R) 14 to the State Agency as required. This placed the resident at risk for ongoing neglect. Findings included: - R14 ' s Electronic Health Record (EHR) revealed diagnoses of paraplegia (paralysis characterized by motor or sensory loss in the lower limbs and trunk) spinal stenosis (degenerative condition of the spine that could cause weakness and loss of use of extremities,) and muscle weakness. The Quarterly Minimum Data Set (MDS), dated [DATE], documented the resident had intact cognition, with a Brief Interview for Mental Status (BIMS) score of 13. The resident required extensive staff assistance with activities of daily living (ADL) and was dependent on staff for chair-to-bed transfers and sit-to-lying positioning. R14 used a wheelchair for mobility. The resident received opioids (a class of medications to relieve pain), antianxiety (a class of medications that calm and relax people) medication, antidepressants (a class of medications used to treat mood disorders), hypoglycemic medications ( medication used to lower blood sugar) and anticoagulant (class of medication used to prevent and treat blood clots) medications. R14's Care Plan, dated 02/23/24, directed staff to assist R14 with all ADL and self-care. The care plan documented the resident used a wheelchair for mobility and required extensive assistance from two staff and a total body lift for transfers. The plan documented R14 enjoyed sitting outside daily when the weather was acceptable. The care plan directed staff to monitor, document, and report any signs or symptoms of immobility, contractures (abnormal fixation of a joint or muscle) formation or worsening, skin breakdown, and fall-related injuries. The care plan directed staff to cue, reorientate, and supervise R14 as needed. The Nurses Notes, dated 04/14/24 at 05:15 PM, recorded R14 was found outside, unresponsive, in his wheelchair with no shirt on. Staff wheeled him back in and obtained vital signs. The note recorded R14 had drool down his frontside and his head was turned down to the left. R14 groaned when spoken to and he was able to minimally squeeze staff's hand with his left hand, but not with his right. Staff placed cold wet towels on the resident's neck, under his arms, and on his forehead and then wheeled the resident to the nurse ' s station; staff called Emergency Medical Services (EMS). R14 started to cool down and he became more responsive. He was then able to sip on some water and take his evening medications before EMS arrived. When EMS arrived, R14 was loaded onto their cot via a full-body lift. The notes documented staff notified Administrative Nurse D, Administrative Staff A, and the resident's representative of the transfer. A review of R14 ' s EHR lacked evidence an investigation including witness statements and analysis of causative factors was done regarding the event. Upon request, the facility was unable to provide an investigation related to the event. On 05/14/24 at 03:00 PM observation revealed R14 sat in a wheelchair outside on the front patio. R14 wheeled from one door to the other trying to open each side of the double doors and was unable to do so. The surveyor summoned Administrative Staff B and asked if R14 was ok outside and if he could get back inside on his own. Administrative Staff B went to the door and assisted R14 inside. R14 stated he could not get in. Administrative Staff B asked R14 if he had his walkie-talkie. Administrative Staff B helped him locate his walkie-talkie which was rolled up in the front tail of R14's t-shirt. He appeared unaware he had it or how to use it. On 05/15/24 at 12:39 PM, Administrative Staff A stated on 04/14/24, CNA M let R14 outside as she went off duty and the oncoming aides and agency nurse did not check on him or possibly, did not even know he was outside. Administrative Staff A stated the facility was still gathering information regarding the event. The facility ' s Abuse, Neglect, and Exploitation policy, undated, recorded the Nursing Home Administrator would report abuse to the state agency per State and Federal requirements. The facility failed to report an incident of neglect for R14 to the State Agency as required. This placed the resident at risk for ongoing neglect.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 31 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to thoroughly investigate an incident of neglect for Resident (R)14. This placed R14 at risk for unidentified and ongoing neglect. Findings included: - R14 ' s Electronic Health Record (EHR) revealed diagnoses of paraplegia (paralysis characterized by motor or sensory loss in the lower limbs and trunk) spinal stenosis (degenerative condition of the spine that could cause weakness and loss of use of extremities,) and muscle weakness. The Quarterly Minimum Data Set (MDS), dated [DATE], documented the resident had intact cognition, with a Brief Interview for Mental Status (BIMS) score of 13. The resident required extensive staff assistance with activities of daily living (ADL) and was dependent on staff for chair-to-bed transfers and sit-to-lying positioning. R14 used a wheelchair for mobility. The resident received opioids (a class of medications to relieve pain), antianxiety (a class of medications that calm and relax people) medication, antidepressants (a class of medications used to treat mood disorders), hypoglycemic medications ( medication used to lower blood sugar) and anticoagulant (class of medication used to prevent and treat blood clots) medications. R14's Care Plan, dated 02/23/24, directed staff to assist R14 with all ADL and self-care. The care plan documented the resident used a wheelchair for mobility and required extensive assistance from two staff and a total body lift for transfers. The plan documented R14 enjoyed sitting outside daily when the weather was acceptable. The care plan directed staff to monitor, document, and report any signs or symptoms of immobility, contractures (abnormal fixation of a joint or muscle) formation or worsening, skin breakdown, and fall-related injuries. The care plan directed staff to cue, reorientate, and supervise R14 as needed. The Nurses Notes, dated 04/14/24 at 05:15 PM, recorded R14 was found outside, unresponsive, in his wheelchair with no shirt on. Staff wheeled him back in and obtained vital signs. The note recorded R14 had drool down his frontside and his head was turned down to the left. R14 groaned when spoken to and he was able to minimally squeeze staff's hand with his left hand, but not with his right. Staff placed cold wet towels on the resident's neck, under his arms, and on his forehead and then wheeled the resident to the nurse ' s station; staff called Emergency Medical Services (EMS). R14 started to cool down and he became more responsive. He was then able to sip on some water and take his evening medications before EMS arrived. When EMS arrived, R14 was loaded onto their cot via a full-body lift. The notes documented staff notified Administrative Nurse D, Administrative Staff A, and the resident's representative of the transfer. A review of R14 ' s EHR lacked evidence an investigation including witness statements and analysis of causative factors was done regarding the event. Upon request, the facility was unable to provide an investigation related to the event. On 05/14/24 at 03:00 PM observation revealed R14 sat in a wheelchair outside on the front patio. R14 wheeled from one door to the other trying to open each side of the double doors and was unable to do so. The surveyor summoned Administrative Staff B and asked if R14 was ok outside and if he could get back inside on his own. Administrative Staff B went to the door and assisted R14 inside. R14 stated he could not get in. Administrative Staff B asked R14 if he had his walkie-talkie. Administrative Staff B helped him locate his walkie-talkie which was rolled up in the front tail of R14's t-shirt. He appeared unaware he had it or how to use it. On 05/15/24 at 10:20 AM Administrative Nurse D stated that on 04/14/24, a CNA took R14 outside to the [NAME] patio around 02:00 PM. She said the CNA was going off shift and the evening shift was coming on. Administrative Nurse D said apparently, the evening shift staff was not informed the resident was outside. Administrative Nurse D verified R14 did not have any means to contact the facility to request assistance while he was outside. Administrative Nurse D said the facility did not conduct a written investigation and did not have a formal staff in-service related to the incident. She said the facility administrative staff just went around and talked to the staff after the incident. On 05/15/24 at 12:39 PM, Administrative Staff A stated on 04/14/24, CNA M let R14 outside as she went off duty and the oncoming aides and agency nurse did not check on him or possibly, did not even know he was outside. Administrative Staff A stated the facility was still gathering information regarding the event. The facility ' s Abuse, Neglect, and Exploitation policy, undated, recorded it is the policy of the facility that all allegations and reports of, mistreatment, and neglect, including injuries of unknown sources, exploitation, and misappropriation of property are thoroughly investigated. The investigation is the process used to determine what happened. The designated facility personnel would begin the investigation immediately. A root cause investigation and analysis would be completed, and the investigation gathered would be given to the Administrator. The individual conducting the investigation would review the incident report, the resident's clinical record, and other pertinent documentation. All witness statements obtained would be filed with the investigation report. The investigation would include who was involved, resident statements, resident's roommate statements, involved staff and witness statements of events, injuries present, and environmental considerations. All investigations related to abuse, neglect, exploitation, or mistreatment would be reviewed by the Quality Assurance Performance Improve Committee (QAPI) and interventions would be monitored for continued improvement. The facility failed to thoroughly investigate an incident of neglect for R14. This placed R14 at risk for unidentified and ongoing neglect

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 31 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to review and revise Resident (R) 26's Care Plan with interventions for the care of R26's stasis ulcers (open wound caused by problems with blood flow (circulation ) in your leg veins) on her shins. This deficient practice placed the resident at risk for decreased quality of care due to uncommunicated care needs. Findings included: - R26's Electronic Medical Record (EMR) documented R26 had diagnoses of weakness, neuropathy (weakness, numbness, and pain from nerve damage, usually in the hands and feet), and localized edema (swelling resulting from an excessive accumulation of fluid in the body tissues). R26's Quarterly Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview of Mental Status (BIMS) score of eight which indicated moderately impaired cognition. The MDS documented R26 required partial to moderate staff assistance with most activities of daily living (ADLs). The MDS documented R26 had one unhealed unstageable (depth of the wound is unknown due to the wound bed being covered by a thick layer of other tissue and pus) pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). R26's Care Plan, revised 05/01/24, documented R26 had localized edema in bilateral extremities and received Magic Cup (a frozen nutritional supplement)twice a day for wound healing. The care plan documented R26 required limited staff assistance with most ADLs. The care plan lacked a section regarding skin integrity with instructions to staff on how to care for R26's bilateral lower legs. The Physician Clinical Visit, dated 05/03/24, documented R26 had bilateral venous ulcerations to her legs. Physical therapy (PT) would see R26 weekly for wound care. On 05/14/24 at 07:41 AM, observation revealed R26 sat in a recliner in her room. Her lower legs were covered by her pants. On 05/15/24 at 10:17 AM, Licensed Nurse (LN) G stated R26 had venous stasis ulcers to her bilateral lower legs. LN G was unaware of what the ulcers looked like or what treatment was ordered for R26's ulcers since the resident went to the hospital for her wound care. On 05/16/24 at 09:37 AM, Administrative Nurse D verified R26's Care Plan lacked a section regarding skin integrity. Administrative Nurse D stated she was responsible for updating the care plan regarding skin integrity and stated that R26 should have one. The facility's Care Plan Revisions Policy, undated, documented changes in resident's condition always require changes to be made in the plan of care either by change in individual approaches or by the addition of new problems to the plan of care. The facility failed to update R26's Care Plan with information regarding the venous ulcers on her bilateral lower legs. These deficient practices placed the residents at risk for decreased quality of care due to uncommunicated care needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 31 residents. The sample included 12 residents, with five reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to ensure the physician acknowledged and responded to the Consultant Pharmacist's recommendation for the required stop date for Resident (R)19's as needed (PRN) antianxiety (class of medications that calm and relax people) medication. This placed R19 at risk for unintended effects related to psychotropic (alters mood or thoughts) drug medications. Findings include: - R19's Electronic Medical Record (EMR) recorded diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear,) and hypertension (HTN-elevated blood pressure.) R19's Annual Minimum Data Set (MDS), dated [DATE], recorded R19 had moderately impaired cognition. The MDS recorded R19 was independent with most activities of daily living (ADL.) The MDS recorded R19 received an antianxiety and antidepressant (medication used to treat depression) medication during the observation period. R19's Care Plan, dated 01/17/24 recorded R19 had trouble sleeping and behavior problems and received lorazepam (antianxiety medication) two tablets at bedtime, and may take one additional dose in the middle of the night. The care plan documented the staff would monitor the times the resident had insomnia and report any adverse reactions to the anti-anxiety medication. The Physician's Order, dated 03/05/24, directed the staff to administer lorazepam (antianxiety) oral concentrate 0.5 milligrams (mg)/milliliter (ml), Give 0.5 ml every 24 hours PRN for anxiety, one dose during the night. The order lacked a stop date. R19's EMR lacked evidence of a physician-ordered duration which included a rationale for the extended use of the PRN lorazepam. A review of the Consultant Pharmacist's monthly review for R19 revealed on 03/08/24 the pharmacist recommended the lorazepam needed a 14-day stop date. R19's clinical record lacked evidence the physician responded to the recommendation. On 05/14/24 at 07:30 AM, observation revealed R19 sat in a recliner in the 400-hall living room dressed in street clothes watching TV. Continued observation revealed Certified Medication Aide (CMA) U administered the resident's morning medications. On 05/14/24 at 10:00 AM, Administrative Nurse D verified the resident received lorazepam PRN that lacked a stop date. Administrative Nurse D verified the pharmacist had sent monthly reviews to the facility for concerns and had recommended a stop date for the lorazepam. Administrative Nurse D said the recommendation was sent to the physician however he had not responded with a duration for use and rationale or discontinuation of the medication. The facility's Use of Psychotropic Drug Use policy, undated, documented the resident's need for psychotropic medication would be monitored, as well as when the resident received an optional benefit from the medication dose can be lowered or discontinued. Both the physician and the nursing staff would evaluate the effectiveness of PRN orders for psychotropic drugs to manage behaviors. The resident admitted to the facility with a PRN psychotropic medication would have a 14-day stop date. Before the end of the 14 days, the ordering practitioner would assess the resident's response to the PRN medication and would document a thoughtful risk-benefit rationale statement for continued use of the medication. If the assessment indicates continued use of the medication, a specific duration would be included in the re-order of the medication. No PRN antipsychotic may be ordered longer than 14 days. The facility failed to ensure the physician acknowledged and responded to the Consultant Pharmacist's recommendation for R19. This placed the resident at risk for unnecessary psychotropic medication side effects.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 31 residents. The sample included 12 residents, with five reviewed for unnecessary medications. Based on observations, interviews, and record review, the facility failed to ensure a 14-day stop date or a specified duration with rationale for R19's ongoing as-needed (PRN) antianxiety (class of medications that calm and relax people) medication. This placed R19 at risk for unintended effects related to psychotropic (alters mood or thoughts) drug medications. Findings include: - R19's Electronic Medical Record (EMR) recorded diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear,) and hypertension (HTN-elevated blood pressure.) R19's Annual Minimum Data Set (MDS), dated [DATE], recorded R19 had moderately impaired cognition. The MDS recorded R19 was independent with most activities of daily living (ADL.) The MDS recorded R19 received an antianxiety and antidepressant (medication used to treat depression) medication during the observation period. R19's Care Plan, dated 01/17/24 recorded R19 had trouble sleeping and behavior problems and received lorazepam (antianxiety medication) two tablets at bedtime, and may take one additional dose in the middle of the night. The care plan documented the staff would monitor the times the resident had insomnia and report any adverse reactions to the anti-anxiety medication. The Physician's Order, dated 03/05/24, directed the staff to administer lorazepam (antianxiety) oral concentrate 0.5 milligrams (mg)/milliliter (ml), Give 0.5 ml every 24 hours PRN for anxiety, one dose during the night. The order lacked a stop date. R19's EMR lacked evidence of a physician-ordered duration which included a rationale for the extended use of the PRN lorazepam. On 05/14/24 at 07:30 AM, observation revealed R19 sat in a recliner in the 400-hall living room dressed in street clothes watching TV. Continued observation revealed Certified Medication Aide (CMA) U administered the resident's morning medications. On 05/14/24 at 10:00 AM, Administrative Nurse D verified the resident received lorazepam PRN that lacked a stop date. The facility's Use of Psychotropic Drug Use policy, undated, documented the resident's need for psychotropic medication would be monitored, as well as when the resident received an optional benefit from the medication dose can be lowered or discontinued. Both the physician and the nursing staff would evaluate the effectiveness of PRN orders for psychotropic drugs to manage behaviors. The resident admitted to the facility with a PRN psychotropic medication would have a 14-day stop date. Before the end of the 14 days, the ordering practitioner would assess the resident's response to the PRN medication and would document a thoughtful risk-benefit rationale statement for continued use of the medication. If the assessment indicates continued use of the medication, a specific duration would be included in the re-order of the medication. No PRN antipsychotic may be ordered longer than 14 days. The facility failed to ensure R19 lorazepam had a 14-day stop date or a physician-ordered specified duration with the rationale. This placed R19 at risk for adverse psychotropic medication side effects.

The facility had a census of 31 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to store medications appropriately when staff did not label Resident (R)4s' insulin (a hormone that allows cells throughout the body to uptake glucose) flex pens with the date opened and discard date on one treatment cart. These deficient practices placed the affected resident at risk for ineffective medications. Findings included: - On 05/13/24 at 10:30 AM, observation of the treatment cart revealed the following: R4's Basaglar (long-acting insulin) flex pen lacked an open date and discard date. On 05/13/24 at 10:35 AM, Administrative Nurse D verified the nurses were to date the flex pens when opened and discard the expired insulin and expired medications. The facility's Medication Storage and Labeling policy, undated, documented medications and biologicals in medication rooms, carts, boxes, and refrigerators were maintained within secured (locked) locations, clean and sanitary, and maintained temperatures in accordance with manufacture specifications. Insulin pens containing multiple doses of insulin are meant for single-resident use only and must never be used for more than one person. Insulin pens must be clearly labeled with the resident's name and other identifiers to verify that the correct pen is used on the correct resident; insulin pens should be stored in a sanitary manner to prevent cross-contamination. The facility failed to label and date the resident's flex pens with date opened and discard dates placing the residents at risk for ineffective medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 31 residents. The sample included 12 residents with two reviewed for hospice (a type of health care that focuses on the terminally ill patient's pain and symptoms and attending to their emotional and spiritual needs at the end of life) services. Based on observation, record review, and interview, the facility failed to ensure a coordinated plan of care, which coordinated care and services provided by the facility with the care and services provided by hospice, was developed and available for Resident (R)12. This placed R12 at risk for inappropriate end-of-life care. Findings included: - R12's Electronic Health Record (EHR) revealed diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure,) aphasia (a condition with disordered or absent language function), and dementia (progressive mental disorder characterized by failing memory, and confusion. R12's Significant Change Minimum Data Set (MDS), dated [DATE], recorded R12 was admitted to the facility on [DATE] and received hospice treatment. R12's Nursing Care Plan, dated 01/10/24, recorded R12 required pain medication and staff administered per physician order. The care plan documented the resident had behavioral problems, was resistant to care, and would become physically aggressive towards staff. The care plan lacked any information regarding the resident's hospice services and lacked evidence of coordination of care between the hospice and the facility. The facility did not have a communication book or external document. On 04/08/24 at 08:37 AM, Nurse's Note documented the resident with the resident' was admitted to hospice. The facility did not have a communication book or external document related to R12's hospice services. On 05/13/24 at 12:38 PM, observation revealed R12 sat in a high-backed wheelchair at the dining room table. Staff assisted her in eating a pureed ham sandwich, pureed Cheetos, and pureed mixed fruit with thickened water and thickened juice. On 05/15/24 at 10:45 AM, Administrative Nurse D verified the facility had initial hospice admit notes with limited care plan information, however lacked a complete plan of care. Administrative Nurse D verified the facility should have the information at the facility in the electronic health records and said the facility had trouble receiving information from the hospice. Administrative Nurse D verified the facility care plan lacked any information the resident received hospice services and would immediately put the information in the facility care plan and get the notes and updated care plan from hospice. The Hospice Program policy, undated, documented upon admission to hospice care, staff would provide services using an interdisciplinary approach involving appropriate communication between Hospice, resident, family, and external resources. A coordinated comprehensive plan of care would be jointly developed by the facility and hospice personnel including directives for managing pain and other symptoms associated with hospice care and must be revised as necessary to reflect the resident's current clinical, psychosocial, and spiritual condition. Ongoing care plan meetings are to be held quarterly, in-depth meetings annually, and upon significant resident status change, regardless of whether an assessment was recently completed. The policy documented the hospice information would be placed in a 3-ring binder specifically for hospice residents. The facility failed to coordinate care between the facility and the hospice provider for R12, who received hospice services. This deficient practice placed him at risk for inappropriate end-of-life care.

The facility identified a census of 31 residents. The sample included 12 residents with five residents reviewed for immunization. Based on record review and interviews the facility failed to obtain the resident or the DPOA signed consent to receive the influenza immunizations for Resident (R) 4, R13, and R18. This placed the residents at risk for influenza infection and related complications. Findings included: - Review of R4, R13, and R18's clinical medical records lacked evidence the facility or the resident's representative received or was offered the current influenza vaccine during the flu season. On 05/16/24 at 11:00 AM, Administrative Nurse D stated residents were offered the influenza vaccinations yearly and the facility sent out the consent forms. Administrative Nurse D said the facility did not receive all the forms back and did not follow up, so some residents did not receive the yearly flu vaccinations. Administrative Nurse D verified some of the residents' representatives were hard to get ahold of and did not return the forms. The facility's Immunization Policy, revised 03/13/24, documented that all residents would be offered vaccinations on admission and annually. he policy documented each resident's immunization status would be determined, if possible, before vaccination and would be documented in the resident's clinical record. The facility failed to offer or obtain informed declinations for the flu vaccination. This deficient practice placed the residents at risk of acquiring, spreading, and experiencing complications from influenza.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 31 residents. The sample included 12 residents. Based on observation, record review, and interview the facility failed to ensure an environment free from accident hazards with staff left a gallon chemical bottle in an unlocked bottom cabinet in one of three kitchenettes. This placed the 12 cognitively impaired, independently mobile residents at risk for preventable accidents or injuries. Findings included: - On 05/13/24 at 11:44 AM, observation revealed an unlocked cabinet underneath the sink, in a kitchenette, located off the family dining room. The unlocked cabinet contained a plastic gallon bottle of Attack [NAME] Enzyme (a molecule that enhances cleaning performance while decreasing environmental impact) odor digester, drain opener, and maintainer. The label on the bottle reads Keep out of reach of children, avoid contact with eyes, and may cause skin irritation. On 05/13/24 at 11:48 AM, Licensed Nurse (LN) G verified the above finding and stated the cabinet should be locked. LN G took the bottle to the locked housekeeping closet. On 05/15/24 at 11:29 AM, Administrative Nurse D stated she expected staff to store chemicals in a locked cabinet. Upon request, the facility did not provide a chemical storage policy. The facility failed to ensure an environment free from accident hazards when staff stored harmful chemicals in an unlocked cabinet. This placed the 12 cognitively impaired, independently mobile residents at risk for preventable accidents or injuries.

The facility had a census of 31 residents. Based on observation, record review, and interview, the facility failed to provide a full-time Registered Nurse as Director of Nursing (DON) and failed to provide Registered Nurse (RN) coverage eight consecutive hours a day, seven days a week placing all residents who resided in the facility at risk of lack of inadequate care. Findings included: - A review of the January - December 2023 nursing schedule revealed no Registered Nurse for eight consecutive hours on more than 50 dates. On 05/15/24 at 09:44 AM, Administrative Staff A verified the facility did not employ a full-time RN as DON. Administrative Staff A verified the lack of Registered Nurse coverage on the dates reviewed and stated he had not been able to get an RN for eight consecutive hours. Administrative Staff A stated he was unable to get an RN except every once in a while from an agency. The facility's Job Description-Director of Nursing Policy, undated, documented the purpose under the direction of the facility administrator, the DON's primary responsibility was to ensure the provision of quality nursing care on a 24-hour basis to the elders of this facility in accordance with Federal, State and Local standards and regulations. The facility's Nursing Services-Registered Nurse (RN) Policy, revised in February 2023, documented the facility would utilize the services of an RN for at least eight consecutive hours per day, seven days per week. The facility would designate an RN to serve as the Director of Nursing on a full-time basis. The facility failed to employ a full-time DON and failed to have RN coverage for eight consecutive hours daily. This placed the 31 residents at risk for inadequate care.

The facility had a census of 31 residents. The sample included 12 residents. Based on observation, record review, and interview the facility failed to implement a water management program for the Legionella disease (Legionella is a bacterium spread through mist, such as from air-conditioning units for large buildings. Adults over the age of 50 and people with weak immune systems, chronic lung disease, or heavy tobacco use are most at risk of developing pneumonia caused by legionella) and other waterborne pathogens. This placed the residents in the facility at risk for infectious disease. Findings Included: - On 05/16/24 at 11:00 AM, Maintenance Staff U verified he was not aware of any routine facility water management checks and verified the 300 hall was presently not in use. Maintenance Sraff U stated staff do not flush water in the unoccupied rooms but did occasionally use the shower room in the 300 hall for one resident at the facility. On 05/16/24 at 11:20 AM, Administrative Staff A verified the city checked the water monthly but stated he did not have any records of the monthly checks. Administrative Staff A verified the facility lacked a system to check regarding standing water and potential growth inside the facility and lacked a system to mitigate the risk of Legionella. The facility's Legionella Surveillance policy, undated, documented the purpose of the policy was to ensure as far as possible, all users of the facility are protected from the incidence of Legionnaire's disease. The Director of Environmental Services is responsible for all relevant details regarding roles and responsibilities and testing regimens contained in the policy and procedure. It is the policy of the facility to ensure that appropriate precautions for the control of Legionella bacteria are identified through the Legionella risk assessment process and appropriate control measures implemented to ensure, so far as is reasonably practicable, the health, safety, and welfare of residents, visitors, staff members, and volunteers. The minimum standards to be met included but not limited to: Carrying out suitable and sufficient Legionella assessments. Description of building water systems. Identification of areas where Legionella could grow and spread. Preparation of an action plan or written scheme for preventing or controlling the risk, where appropriate. (Include in the plan of any area where medical procedures may expose residents to water mists including hydrotherapy and respiratory therapy services.) Implementation. Management monitoring and recording of precautions to include regular inspection, microbiological monitoring, temperature checks, and flushing where appropriate. Plans to intervene when control limits are not met. Continuous monitoring of program compliance. Documentation of all monitoring. Seeking suitable advice and assistance from competent persons and Specialist consultants, where appropriate. Appointment of a person or persons to be managerially responsible for the water system at each premise. The facility has established and maintained, an infection prevention and control group designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The policy further documented the requirements will be met by the following: inspection of water storage tanks, water would be measured at 86 degrees or below after two minutes of running, and hot water storage or distribution would be measured at 122 degrees at outlets after one minute of running. All cases of Legionella would be reported to the local health department and the State health departments. The facility failed to implement a water management program to test and manage waterborne pathogens placing the residents who reside in the facility at risk of contracting Legionella pneumonia.

The facility had a census of 29 residents. The sample included 12 residents, with one reviewed for notification of change. Based on observation, record review, and interview, the facility failed to notify the physician in a timely manner when Resident (R) 18 developed a change from her baseline/normal behaviors. This placed the resident at risk for physical decline and delayed treatment. Findings included: - The Electronic Medical Record (EMR) documented R18 had diagnoses of Parkinson's disease (slowly progressive neurological disorder characterized by resting tremor, rolling of the fingers, mask like faces, shuffling gait, muscle rigidity and weakness). emotional disorder (chronic and often recurrent psychiatric disorders that are associated with significant impairment in quality of life, productivity, and interpersonal functioning), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), and intellectual impairment (problems with general mental abilities that affect functioning, intellectual and functional). The Quarterly Minimum Data Set, dated 05/12/22, documented R18 had severely impaired cognition and was dependent upon two staff for transfers, toileting. R18 required extensive assistance of two staff for bed mobility and dressing. The admission Orders, dated 04/29/22, directed staff to administer Sinemet, 10 milligrams (mg)-100 mg, 1 tablet four times a day. The order further directed staff to administer half a pill every 1.5 hours following the 07:00 AM dose and the last dose to be at 07:00 PM. The April 2022 Medication Administration Record (MAR) directed staff to administer Sinemet, 10 milligrams (mg)-100 mg, 1.5 tablets every 1.5 hours following the 07:00 AM dose and the last dose to be at 07:00 PM. Review of the MAR documented 15 times R18 received the wrong dose of medication. The May 2022 MAR, directed staff to administer Sinemet, 10 milligrams (mg)-100 mg, 1.5 tablets every 1.5 hours following the 07:00 AM dose and the last dose to be at 07:00 PM. Review of the MAR documented 58 times R18 received the wrong dose of medication. The Nurse's Note, dated 05/07/22 at 03:43 PM, documented R18's representative contacted the facility and reported R18 was not acting her normal self. The note further documented R18's representative asked about the resident's Sinemet dose and when staff told her the dosage, R18's representative stated the dosage was not correct. Licensed Nurse (LN) G reviewed the physician order and found the order was incorrect on the MAR. The note documented LN G then contacted the hospital and was directed to contact poison control by the physician and send the resident to the emergency department (ED). The Emergency Department Report, dated 05/07/22, documented R18 presented to the ED due to behavior and movement changes. The resident was supposed to get Sinemet 10/100, 0.5 mg, nine times per day and had been getting 1.5 mg, nine times per day for the last eight days. Poison control was contacted and recommended labs and an electrocardiogram (EKG -records the electrical signals from the heart]). The report documented R18's EKG was normal and her laboratory report was unremarkable; the resident was admitted for observation for dyskinesia (abnormality or impairment of voluntary movement). On 06/15/22 at 02:15 PM, Administrative Nurse D stated she was unsure the status of the resident the day she went to the hospital. She said the LN on duty would be the best person to talk to. Administrative Nurse D further stated two nurses would double check the admission order to make sure it was correctly entered in the MAR. On 06/16/22 at 07:48 AM, LN G stated R18 was more anxious than usual, and would not answer staff appropriately. LN G stated she did not notify R18's physician regarding the change in R18 until R18's representative contacted her. The facility's Doctor Notification and Necessary Assessment policy, undated, documented to ensure that the physician was notified appropriately and proper assessment was done prior to notification to ensure adequate information was given for the physician to make an informed decision. The facility failed to notify the physician in a timely manner when LN staff identified the resident was not acting like normal. This placed the resident at risk for physical decline and delayed treatment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 29 residents. The sample included 12 residents, with one reviewed for restraints (any manual method, physical or mechanical device, equipment, or material that is attached or adjacent to the resident's body, cannot be removed easily by the resident, and restricts the resident's freedom of movement or normal access to his/her body). Based on observation, record review, and interview, the facility failed to provide a physician's order and an assessment for Resident (R) 30's a merry-walker (an enclosed framed wheeled walker), placing the resident at risk for complications related to physical restraints. Findings included: - The Electronic Medical Record (EMR) documented R30 had diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), and dementia without behavioral disturbance (progressive mental disorder characterized by failing memory, confusion). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R30 had severely impaired cognition and required extensive assistance of two staff for bed mobility, transfers, ambulation in room and corridor, dressing, and toileting. The MDS further documented R30 had no mobility devices and no restraints. The Activities of Daily Living [ADLs] Care Plan, dated 03/16/22, documented R30 required assistance of two staff and gait belt to move between surfaces when not in the merry-walker. It directed staff to be cautious of how tight the straps were when R30 was in the merry-walker. The Fall Care Plan, dated 03/16/22, directed staff to place R30 in the merry-walker when she was restless. R30's EMR lacked a physician order or an assessment for the merry-walker. On 06/13/22 at 08:15 AM, observation revealed R30 in her merry-walker facing a wall in Hall 3. Her eyes were closed. Further observation revealed the merry-walker had green tarp material, held in place with Velcro, from the top to the bottom of the sides of the merry-walker. The merry-walker had a cushion attached to the inside front of the merry walker for R30 to lean against when she walked. On 06/13/22 at 04:25 PM, observation revealed R30 sat in her merry-walker in the living room area. On 06/15/22 at 07:51 AM, observation revealed R30, in Hall 4, sat in the merry-walker. Her eyes were closed. Further observation revealed R30 leaned against the cushion on the front of the merry-walker and began to walk with her eyes closed. R30 stopped when the merry-walker got to the wall. On 06/14/22 at 12:54 PM, Administrative Nurse D stated she had not obtained a doctor's order or completed an assessment for use of the merry-walker as she did not feel the merry-walker was a restraint. (Administrative Nurse D further stated the merry-walker allowed R30 to move around independently. On 06/15/22 at 09:25 AM, Certified Nurse Aide (CNA) N stated the material on the sides of the merry-walker was put into place so R30 could not stick her feet out of the sides of the merry-walker. On 06/15/22 at 01:00 PM, Licensed Nurse G stated the merry-walker helped the resident not to fall and verified R30 would not be able to get out of the merry-walker on her own. On 06/16/22 at 08:12 AM, CNA M stated R30 had falls and administrative staff felt the merry-walker helped R30 not to fall; it also allowed R30 to be mobile. CNA M further stated R30 would not be able to get out of the merry walker on her own. The facility's undated Restraint Reduction policy documented each resident had the right to be free from any physical or chemical restraint imposed for purposes of discipline or convenience of staff, and not required to treat the resident's medical symptoms. The policy further documented a physician's order was required to apply any/all restraints including indication for restraint and medical symptom to be controlled by restraint and specific shortest possible duration. The interdisciplinary team would monitor the resident while the restraint was ordered, and the resident's environment would be fully assessed for any safety hazards that may prevent the resident from being restraint free. The resident's environment would be fully assessed for any safety hazards that may prevent the resident from being restraint free. The interdisciplinary team would determine the frequency of observing and assessing the restrained resident but would never exceed 2 hours and would be removed or released at least every 2 hours. A physical restraint elimination assessment was completed at least quarterly, and more often if indicated for all resident who have any type of restraint ordered. The facility failed to assess and get a physician order for R30's merry walker which acted as a physical restraint, placing the resident at risk for injury or complications related to physical restraints.

The facility had a census of 29 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to report an injury of unknown origin to administration staff for one sampled resident, Resident (R) 19, who had a skin tear of unknown origin on his right hand. This placed the resident at risk for further injury and unidentified abuse or mistreatment. Findings included: - The Electronic Medical Record (EMR) for R19 recorded diagnoses of hemiplegia (paralysis of one side of the body), hemiparesis (muscular weakness of one half of the body) affecting the left non-dominant side, dementia without behavioral disturbance (progressive mental disorder characterized by failing memory, confusion), and contracture of the left hand (abnormal permanent fixation of a joint. The Quarterly Minimum Data Set, dated 05/12/22, documented R19 had severely impaired cognition and was dependent upon two staff for transfers, toileting and extensive assistance of two staff for bed mobility and dressing. The MDS further documented R19 did not have any skin tears. The Skin Integrity Care Plan, dated 05/17/22, documented R19 was at risk for impaired skin integrity and directed staff to evaluate skin integrity monthly and as needed by a nurse. The Nurse's Note, dated 06/08/22 at 11:34 AM, documented a skin tear (a traumatic wound caused by mechanical forces) of unknown origin, on top of R19's right hand. The half-moon shape skin tear measured 0.5 centimeters (cm) x 3 cm. The note documented the area was cleaned, dried, triple antibiotic ointment applied and wrapped in gauze. The note further documented R19's physician was notified. The Physician Order, dated 06/11/22, directed staff to cleanse the skin tear to right hand with normal saline, apply triple antibiotic ointment, and cover the wound with tegaderm (a transparent medical dressing used to cover and protect wounds). The order further directed staff to change every other day until healed. The Nurse's Note, dated 06/16/22 at 10:00 AM, documented R19 had an open wound to the base of his left thumb with a small amount of yellowish-brown drainage. The note further documented R19 had an old skin tear to the right elbow that had reopened. The Physician Order, dated 06/16/22, directed staff to obtain a wound culture (a test to find germs that cause an infection) on the skin tear, and administer doxycycline (an antibiotic), 100 milligrams (mg), by mouth, daily for seven days. The medical record lacked documentation how R19 received the skin tear to his right hand and lacked evidence preventive measures were evaluated and implemented. On 06/13/22 at 10:30 AM, observation of R19 revealed a moon shaped skin tear on his right hand, without a dressing. On 6/16/22 at 07:42 AM, observation revealed a skin tear on R19's right hand. Further observation revealed brown drainage under the transparent dressing. On 06/15/22 at 07:47 AM, Administrative Nurse D verified an incident or investigation had not been completed for the skin tear and should have been investigated. Administrative Nurse D verified she was not aware the resident had a skin tear on his hand. On 06/15/22 at 12:57 PM, Licensed Nurse (LN) G stated she did not know how R19 received the skin tear on his right hand and further stated R19's dressing was changed every other day. On 06/16/22 at 08:15 AM, Certified Nurse Aide (CNA) M stated she was unaware how R19 had obtained the skin tear on his hand. CNA M further stated, when a resident had an injury, she would tell her charge nurse. The facility's Skin Injury policy, undated, documented, in support of the abuse and neglect policies, staff must be aware that any injury as a result of possible abuse or neglect must be reported immediately to the supervisor, don, and administrator. All incidents, whether considered significant or not requires completion of a facility incident report and investigation to determine causal factors for the incident and interventions implemented to prevent any further occurrences in the future. The facility's Prevention Abuse, Neglect, and Exploitation policy, dated 08/18/16, documented inquiries concerning Abuse, Neglect, and Exploitation reporting and investigating should be referred to the Administrator and/or Director of Nursing. The facility failed to report a skin tear of unknown origin to administration staff for cognitively impaired R19, placing him at risk for further injury and unidentified abuse or mistreatment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** - The Electronic Medical Record (EMR) for R19 recorded diagnoses of hemiplegia (paralysis of one side of the body), hemiparesis (muscular weakness of one half of the body) affecting the left non-dominant side, dementia without behavioral disturbance (progressive mental disorder characterized by failing memory, confusion), and contracture of the left hand (abnormal permanent fixation of a joint. The Quarterly Minimum Data Set, dated 05/12/22, documented R19 had severely impaired cognition and was dependent upon two staff for transfers, toileting and extensive assistance of two staff for bed mobility and dressing. The MDS further documented R19 did not have any skin tears. The Skin Integrity Care Plan, dated 05/17/22, documented R19 was at risk for impaired skin integrity and directed staff to evaluate skin integrity monthly and as needed by a nurse. The Nurse's Note, dated 06/08/22 at 11:34 AM, documented a skin tear (a traumatic wound caused by mechanical forces) of unknown origin, on top of R19's right hand. The half-moon shape skin tear measured 0.5 centimeters (cm) x 3 cm. The note documented the area was cleaned, dried, triple antibiotic ointment applied and wrapped in gauze. The note further documented R19's physician was notified. The Physician Order, dated 06/11/22, directed staff to cleanse the skin tear to right hand with normal saline, apply triple antibiotic ointment, and cover the wound with tegaderm (a transparent medical dressing used to cover and protect wounds). The order further directed staff to change every other day until healed. The Nurse's Note, dated 06/16/22 at 10:00 AM, documented R19 had an open wound to the base of his left thumb with a small amount of yellowish-brown drainage. The note further documented R19 had an old skin tear to the right elbow that had reopened. The Physician Order, dated 06/16/22, directed staff to obtain a wound culture (a test to find germs that cause an infection) on the skin tear, and administer doxycycline (an antibiotic), 100 milligrams (mg), by mouth, daily for seven days. The medical record lacked documentation how R19 received the skin tear to his right hand and lacked evidence preventive measures were evaluated and implemented. On 06/13/22 at 10:30 AM, observation of R19 revealed a moon shaped skin tear on his right hand, without a dressing. On 6/16/22 at 07:42 AM, observation revealed a skin tear on R19's right hand. Further observation revealed brown drainage under the transparent dressing. On 06/15/22 at 07:47 AM, Administrative Nurse D verified an incident or investigation had not been completed for the skin tear and should have been investigated. Administrative Nurse D verified she was not aware the resident had a skin tear on his hand. On 06/15/22 at 12:57 PM, Licensed Nurse (LN) G stated she did not know how R19 received the skin tear on his right hand and further stated R19's dressing was changed every other day. On 06/16/22 at 08:15 AM, Certified Nurse Aide (CNA) M stated she was unaware how R19 had obtained the skin tear on his hand. CNA M further stated, when a resident had an injury, she would tell her charge nurse. The facility's skin injury policy, undated, documented the facility would routinely monitor the skin condition and identify if the condition became significant and the physician notified. All injuries will be monitored routinely until resolved and staff must be aware that any injury as a result of possible abuse or neglect must be reported immediately to the supervisor, don, and administrator. The policy further documented, all incidents, whether considered significant or not require completion of a facility incident report and investigation to determine causal factors for the incident and interventions implemented to prevent any further occurrences in the future. The facility failed to implement interventions to prevent skin tears for R19, who obtained a skin tear of unknown origin, placing the resident at risk for further injury. The facility had a census of 29 residents. The sample included 12 residents with two reviewed for skin issues. Based on observation, interview and record review the facility failed to provide preventative interventions related to skin issues for two sampled residents, Resident (R)25 who developed a non-pressure skin issues and R19, who experienced a skin tear of unknown origin. This deficient practice placed R25 and R19 at increased risk for skin injuries. Findings included: - R25's Physician Order Sheet (POS), dated 05/17/22, documented diagnoses of an open wound to the buttock. The Quarterly MDS, dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of one which indicated severely impaired cognition. The MDS documented R25 required supervision for eating and extensive assistance of one staff for bed mobility, transfers, and dressing. The MDS documented R25 had an open lesion on her buttocks. The Pressure Ulcer Care Area Assessment (CAA), dated 02/20/22, documented R25 had a diagnosis of open wound to gluteal cleft (groove between the buttocks). The health care provider assessed the wound and stated that it was not a pressure ulcer. The Skin Care Plan, dated 09/01/21, documented the resident was able to reposition self in her recliner. R25 had a bed in her room that she chose not to sleep in. The care plan lacked further intervention to prevent skin issues. The Skin Care Plan, dated 06/01/22 after wound development, documented potential for pressure ulcer (damage to an area of the skin caused by constant pressure on the area for a long time) development. It directed staff to provide treatments as ordered and monitor for effectiveness; inform the resident/family/caregivers of any new area of skin breakdown. The care plan directed staff to monitor wound dressing with all cares to ensure it is intact and adhering, report loose dressing to the treatment nurse. The Physician Note, dated 11/16/21, documented an open wound in the gluteal (buttocks) fold along the right buttock. The note documented a history of a pressure ulcer which required skin graft and skin flap repair in December 2020. The note documented the open area was near the old surgical incision. The resident complained of pain. The Skin Evaluation, dated 02/01/22, documented a skin issue with full thickness tissue loss. The note recorded there was odor and tunneling present and the wound was painful. The Progress Note, dated 03/26/22, documented R25 continued to receive antibiotics for wound infection. The Nursing History and Physical, dated 05/25/22, documented a non-pressure wound to the gluteal cleft, with nightly dressing changes. On 06/15/22 at 10:20 AM, Licensed Nurse (LN) G found the wound on the resident's coccyx area had no dressing. Observation revealed a hole in the skin, approximately 0.5 cm round and unknown depth, between the anus and the coccyx. R25 complained of pain when the nurse touched her on her buttocks. R25 stated ouch numerous times during the wound care and attempted to stop the nurse with her hands twice. Nurse G cleaned the wound and applied the dressing. On 06/15/22 at 10:39 AM, Administrative Nurse D verified nursing missed the weekly skin assessment the week of May 8-14 and June 5 -11 too. Administrative Nurse D verified R25's care plan lacked pressure relief interventions to protect R25's coccyx area. The facility's undated Skin Integrity policy documented if the elder was determined to be at risk or has developed any skin integrity abnormalities, the nurse will implement action to prevent injury to the elder by maintaining and improving tissue tolerance to pressure in order to prevent injury. The nurse and the interdisciplinary team will plan and implement preventive care to avoid complications resulting from an elder's inactivity, including measures for pressure redistribution for bed and, chair, repositioning at specific, consistent and frequent intervals, The facility failed to provide interventions to prevent the development of the skin issue, placing R25 at risk for complications related to wounds.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 29 residents. The sample included 12 residents with two reviewed for pain. Based on observation, interview and record review the facility failed to provide interventions during wound care to manage Resident (R) 25's distress and pain. This placed the resident at risk for prolonged and unnecessary pain or distress. Findings included: - R25's Physician Order Sheet (POS), dated 05/17/22, documented diagnoses of open wound of buttock, and dementia (the loss of cognitive functioning). The Quarterly MDS, dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of one which indicated severely impaired cognition. The MDS documented R25 required supervision for eating and extensive assistance of one staff for bed mobility, transfers, and dressing. The MDS documented R25 had an open lesion on her buttocks, received scheduled pain medication, had vocal complaints of pain daily, and received opioid medication seven days of the look back period. The Pressure Ulcer Care Area Assessment (CAA), dated 02/20/22, documented R25 had a diagnosis of open wound to gluteal cleft.(area between the buttocks) The health care provider assessed the wound and stated that it is not a pressure ulcer. The Skin Care Plan, dated 09/01/21, documented the resident was able to reposition self in her recliner. R25 had a bed in her room that she chose not to sleep in. The Skin Care Plan, dated 06/01/22, documented potential for pressure ulcer (damage to an area of the skin caused by constant pressure on the area for a long time) development. It directed staff to provide treatments as ordered and monitor for effectiveness; inform the resident/family/caregivers of any new area of skin breakdown. The care plan directed staff to monitor wound dressing with all cares to ensure it is intact and adhering, report loose dressing to the treatment nurse. The Pain Care Plan, dated 06/01/22, directed staff to administer pain medications per order, and if non-medication interventions were ineffective, evaluate for non-verbal indicators of pain. Monitor for factors that precipitate or aggravate pain. Apply hot or cold packs for comfort. The Physician Note, dated 11/16/21, documented an open wound in the gluteal (buttocks) fold along the right buttock. The note documented a history of a pressure ulcer which required skin graft and skin flap repair in December 2020. The note documented the open area was near the old surgical incision. The resident complained of pain. The Progress Note, dated 12/7/21 at 11:08 PM, documented R25 was agitated and combative with cares when the staff member attempted to reapply the dressing to R25's coccyx. R25 hit the staff member multiple times with a newspaper and then threw water on the staff. Staff were unable to encourage the resident to allow dressing placement. The Skin Evaluation, dated 02/01/22, documented a skin issue with full thickness tissue loss. The note recorded there was odor and tunneling present and the wound was painful. The Progress Note, dated 03/09/22 at 02:30 AM, documented staff noted R25 had discomfort during the packing of the wound. The Progress Note, dated 03/19/22 at 09:49 AM, documented R25 used protective body movements, reported pain occurred multiple times a day, and the wound to her coccyx was a pain level of five ( 0-10 scale with zero as no pain and ten at the worst pain imaginable). The Progress Note, dated 03/26/22, documented R25 continued to receive antibiotics for wound infection. The note documented the wound dressing came off, and noted the resident had pain with dressing change with the resident stating ouch multiple times. The Progress Note, dated 03/27/22 at 02:04 AM, documented R25 had moderate discomfort noted with dressing placement. The Progress Note, dated 03/30/22 at 02:31 AM, documented R25 complained of pain with the dressing change. The Progress Note, dated 03/31/22 at 11:15 AM, documented R25 stated ouch during the dressing change. The Skin Evaluations, dated 05/16/22 and 05/23/22, documented R25 had an open lesion of the buttocks and constant pain. The Nursing History and Physical, dated 05/25/22, documented a non-pressure wound to the gluteal cleft, with nightly dressing changes. The note recorded R25 had facial grimacing with peri care to the buttocks. The Pain Assessment, dated 05/28/22 at 10:16 PM, documented vocal complaints of pain daily; non-medication interventions did not provide relief. The note recorded scheduled medication were provided and R25 stated ouch with peri care to buttocks. The EMR recorded a Physician's order for Norco (narcotic pain medication), 5/325 milligrams (mg), three times per day, started 03/16/22. The Physician Standing Orders, dated 01/10/22, ordered Tylenol 650 mg, every four hours as needed (PRN). Review of March, April, May, and June 2022 Medication Administration Record (MAR) revealed the PRN Tylenol had not been administered since 03/13/22. On 06/15/22 at 10:20 AM, Licensed Nurse (LN) G found the wound on the resident's coccyx area had no dressing. Observation revealed a hole in the skin, approximately 0.5 cm round and unknown depth, between the anus and the coccyx. R25 complained of pain when the nurse touched her on her buttocks. R25 stated ouch numerous times during the wound care and attempted to stop the nurse with her hands twice. Nurse G cleaned the wound and applied the dressing. LN G did not offer pain medication. On 06/14/22 at 07:50 AM, LNG stated the resident did not like the wound dressing change as it was painful to her. The dressing changes were scheduled for night shift. On 06/15/22 at 10:39 AM, Administrative Nurse D agreed nurses should notify the provider of unrelieved pain during wound care and request pain intervention orders. On 06/15/22 at 03:52 PM, Certified Nurse Aide (CNA) P stated when staff changed R25's brief, the resident became agitated and stated it hurts. On 06/16/22 at 04:30 PM, Consultant GG verified she expected nursing staff to administer pain medication prior to wound care and to notify her if the resident's complaints of pain during the wound care continued. The facility's undated Pain policy and Procedure documented at any point that pain is communicated either verbally or non-verbally treatment will be rendered in the form of medication or non-medication intervention. This will be documented on the PRN Pain Assessment form or in the nurse's notes if non-medical intervention is used. Pain medication may be prescribed for the resident from our standing orders. if pain persists or is not controlled, the physician will be notified for further orders or assessment. The facility failed to provide pain interventions during wound care to manage R25's distress and pain. This placed the resident at risk for prolonged and unnecessary pain or distress

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 29 residents. The sample included 12 residents with one reviewed for side rails. Based on observation, interview, and record review the facility failed to assess Resident (R) 17's bed side rails for safety, This deficient practice placed R17 at risk for entrapment or injury. Findings included: - R17 was admitted to the facility 04/28/22 for skilled care related to muscle weakness. The admission Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The MDS documented R17 required assistance of two staff for bed mobility, transfers, toileting, and dressing. The MDS documented R17 had a fall prior to admission, no falls since admission, and no restraints were used. The ADL Care Area Assessment (CAA), dated 05/11/22, documented R17 needed staff assistance to get in and out of bed and was independent in rolling left and right once in bed. The Care Plan, dated 04/28/22, lacked side rail information. R17's medical record lacked a side rail safety assessment. The Lift/Transfer Evaluation, dated 05/24/22, documented R17's right side was stronger, she did not have upper extremity strength, and was partially able to assist with repositioning in bed. On 06/13/22 at 09:46 AM, observation revealed a side rail on each side of R17's bed with large openings of 12 x 12 inches. R17 stated she brought them to the facility from home because she wanted her own side rails. R17 stated she cannot sit up in bed or get out of bed on her own. On 06/15/22 at 03:52 PM, Certified Nurse Aide (CNA) P stated the resident used the side rails on her bed during transfers. On 06/13/22 at 03:20 PM, Administrative Nurse D verified staff should have assessed R17's bed side rails for safety and gaps. The facility's undated Use of Side Rails policy documented the facility's regular maintenance program will include regular inspections of all bed systems including rails, of each bed to ensure a safe environment. The facility will also ensure individual side rail assessments and evaluations are performed on a regular basis. The policy stated side rails would only be applied per manufacturer's instructions, using all cautions noted by the manufacturer and supplier. The policy documented gap measurements would be performed prior to implementation and at least quarterly to ensure safety from potential entrapment following FDA guidelines for acceptable gaps as follows: recommendations for any open space between the perimeters of the rail or between the rail and mattress should be less than 4 and 3/4 inches. The policy documented all side rails and mobility enhancers would be checked by maintenance at least monthly and documented on maintenance logs. The facility failed to assess R17's bed side rails for safety, placing the resident at risk for entrapment or injury.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 29 residents. The sample included 12 residents with five reviewed for unnecessary medications. Based on observation, interview, and record review the facility failed to respond to the consultant pharmacist (CP) notification of the inappropriate diagnosis for antipsychotic medications (type of psychiatric medication which are available on prescription to treat psychosis and are licensed to treat certain types of mental illness) for two of five residents reviewed, Resident (R)5 and R10. This deficient practice placed R10 and R5 at risk for continued use of antipsychotic medications without an appropriate diagnosis. Findings included: - R5's Physician Order Sheet (POS), dated 05/10/22, documented diagnoses of anxiety disorder (persistent feeling of anxiety or dread), vascular dementia (dementia caused by an impaired supply of blood to the brain), and recurrent major depression (persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). The Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 12, indicating moderately impaired cognition. The MDS documented R5 was independent with eating, required staff assistance for all other activities of daily living and received antipsychotic medication seven days of the lookback period. The Medication Care Plan, dated 05/14/22, documented R5 had a behavior problem of excessive crying and her depression was exacerbated by reminiscing of history of abuse done to her. When the resident was crying, staff were to just sit and listen to resident and allow her to vent and validate her feeling. The care plan directed staff to monitor the amount of times R5 had excessive crying, and difficulty sleeping. The care plan documented the consult pharmacist to review medications, staff were to review pharmacy consult recommendations and follow up as indicated. The Physician Order, dated 12/09/21, directed staff to administer Abilify (antipsychotic), 5 milligrams (mg) at bedtime for depression and anxiety. Pharmacist reviews from 01/04/22 through 03/07/22, documented no concerns with R5's medications. The 04/11/22 (four months after the start of the antipsychotic) pharmacist consultant requested an appropriate diagnosis and gradual dose reduction (GDR) for Abilify. The physician replied antipsychotics should have GDRs attempted, please have R5 see a psychiatric consult. The Psychiatric Nurse Practitioner Notes, dated 05/05/22 and 06/07/22, documented the resident received Abilify and ordered staff to continue the medication without changing the diagnosis. On 06/14/22 at 08:00 AM, observation revealed Certified Medication aide (CMA) R administered ten medications to R5 in her room. On 06/15/22 at 09:40 AM, Administrative Nurse D verified Abilify lacked an appropriate diagnosis and verified the Pharmacist consultant had not recommended change to appropriate diagnosis until April 2022 (4 months after start). The facility's 10/04/2016 policy for Pharmacist Consultant Policy and Procedure documented recommendations for providers will be taken to the resident's primary care provider for physician review and if no response within 10 days, nurse management will follow up with a phone call or fax to the physician and documented date and time. Upon receipt of the primary care provider's orders nurse management will note and implement any changes and if no changes ordered, will note the risk versus benefit in the nurse's notes. If no risk versus benefit statement is provided, the pharmacist recommendation will be returned to the provider with a request for the risk versus benefit statement. The 10/04/2016 policy for Proper Diagnosis for Antipsychotic Medications documented upon finding improper diagnosis for antipsychotic medications, nurse management will notify the prescribing physician in writing and advise of acceptable diagnoses of Huntington's, Tourette's, or schizophrenia for antipsychotic medications per CMS. If no new order or acceptable diagnosis is received, nurse management will follow up with the pharmacist consultant at the next monthly in-house visit. The facility failed to act upon the CP's notification of the inappropriate diagnosis for the antipsychotic medication Abilify, placing R5 at risk of inappropriate use of the antipsychotic. - R10's Physician Order Sheet (POS), dated 05/10/22, documented diagnoses of dementia with behavioral disturbance (chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning), restlessness and agitation. The admission Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of seven, indicating severely impaired cognition. The MDS documented no mood or behavior issues. R10 was independent with eating and required limited assistance of one staff for all other activities of daily living (ADL). The MDS documented R10 had impaired balance, used a walker, had history of falls, and one non-injury fall since prior assessment. The MDS documented R10 received antipsychotic medication seven days of the lookback period. The Psychotropic Drug Use, Care Area Assessment (CAA), dated 04/20/22, documented behaviors were noted while R10 was in the hospital and R10 has had no behaviors since admission to the facility. R10 was admitted with an order for Zyprexa (antipsychotic medication). The Medication Care Plan, dated 04/20/22, documented the consultant pharmacist was to review medications. The resident will have fewer episodes of yelling weekly due to use of Zyprexa. The Physician Order, dated 04/11/22, directed staff to administer Zyprexa 5 milligrams (mg) (1/2 tab) at bedtime for restlessness and agitation. The Pharmacist Consult Review, dated 05/04/22, recommended an appropriate diagnosis for Zyprexa. The physician replied the resident needed an appointment with the psychiatric nurse practitioner, please schedule. On 06/13/22 at 09:20 AM, observation revealed Certified Medication Aide (CMA) R administered medications to R10 who took the pills whole with bites of pudding. R10 did not speak during the observation and no agitation was noted. On 06/15/22 at 02:36 PM, Administrative Nurse D verified the diagnosis for Zyprexa was not correct per regulations and the pharmacist had noted that 05/04/22. She stated the physician ordered a psychiatric consult to obtain the correct diagnosis, but the resident had not seen the psychiatric practitioner yet. The facility's undated policy for Physician Orders for Medications and Treatments documented orders for medication will include clinical rationale or diagnosis for the order. The facility's 10/04/2016 policy for Pharmacist Consultant Policy and Procedure documented recommendations for providers will be taken to the resident's primary care provider for physician review and if no response within 10 days, nurse management will follow up with a phone call or fax to the physician and documented date and time. Upon receipt of the primary care provider's orders nurse management will note and implement any changes and if no changes ordered, will note the risk versus benefit in the nurse's notes. If no risk versus benefit statement is provided, the pharmacist recommendation will be returned to the provider with a request for the risk versus benefit statement. The 10/04/2016 policy for Proper Diagnosis for Antipsychotic Medications documented upon finding improper diagnosis for antipsychotic medications, nurse management will notify the prescribing physician in writing and advise of acceptable diagnoses of Huntington's, Tourette's, or schizophrenia for antipsychotic medications per CMS. If no new order or acceptable diagnosis is received, nurse management will follow up with the pharmacist consultant at the next monthly in house visit. The facility failed to respond to the CP's notification of the inappropriate diagnosis for the antipsychotic medication Zyprexa, placing R10 at risk of inappropriate use of the antipsychotic.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 29 residents. The sample included 12 residents with five reviewed for unnecessary medications. Based on observation, interview, and record review two of five residents reviewed, Resident (R)5 and R10 had an inappropriate diagnosis for antipsychotic medications (type of psychiatric medication which are available on prescription to treat psychosis and are licensed to treat certain types of mental illness). This deficient practice placed R5 and R10 at risk for continued use of antipsychotic medications without an appropriate diagnosis. Findings included: - R5's Physician Order Sheet (POS), dated 05/10/22, documented diagnoses of anxiety disorder (persistent feeling of anxiety or dread), vascular dementia (dementia caused by an impaired supply of blood to the brain), and recurrent major depression (persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). The Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 12, indicating moderately impaired cognition. The MDS documented R5 was independent with eating, required staff assistance for all other activities of daily living and received antipsychotic medication seven days of the lookback period. The Medication Care Plan, dated 05/14/22, documented R5 had a behavior problem of excessive crying and her depression was exacerbated by reminiscing of history of abuse done to her. When the resident was noted to be crying, staff were to just sit and listen to resident and allow her to vent and validate her feeling. The care plan directed staff to monitor the amount of times R5 had excessive crying, and difficulty sleeping. The care plan documented the consult pharmacist to review medications, staff were to review pharmacy consult recommendations and follow up as indicated. The Physician Order, dated 12/09/21, directed staff to administer Abilify (antipsychotic), 5 milligrams (mg) at bedtime for depression and anxiety. The Psychiatric Nurse Practitioner Notes, dated 05/05/22 and 06/07/22, documented the resident received Abilify and ordered staff to continue the medication without changing the diagnosis. On 06/14/22 at 08:00 AM, observation revealed Certified Medication aide (CMA) R administered ten medications to R5 in her room. On 06/15/22 at 09:40 AM, Administrative Nurse D verified Abilify lacked an appropriate diagnosis. The facility's policy for Proper Diagnosis for Antipsychotic Medications, dated 10/04/2016, documented upon finding improper diagnosis for antipsychotic medications, nurse management will notify the prescribing physician in writing and advise of acceptable diagnoses of Huntington's, Tourette's, or schizophrenia for antipsychotic medications per CMS. The facility failed to obtain an appropriate diagnosis for the antipsychotic medication Abilify, placing R5 at risk of inappropriate use of the antipsychotic. - R10's Physician Order Sheet (POS), dated 05/10/22, documented diagnoses of dementia with behavioral disturbance (chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning), restlessness and agitation. The admission Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of seven, indicating severely impaired cognition. The MDS documented no mood or behavior issues, R10 independent with eating and required limited assistance of one staff for all other activities of daily living (ADL). The MDS documented R10 had impaired balance, used a walker, had history of falls, and one non-injury fall since prior assessment. The MDS documented R10 received antipsychotic medication seven days of the lookback period. The Psychotropic Drug Use, Care Area Assessment (CAA), dated 04/20/22, documented behaviors were noted while R10 was in the hospital and R10 has had no behaviors since admission to the facility. R10 was admitted with an order for Zyprexa (antipsychotic medication). The Medication Care Plan, dated 04/20/22, documented the consultant pharmacist was to review medications. The resident will have fewer episodes of yelling weekly due to use of Zyprexa. The Physician Order, dated 04/11/22, directed staff to administer Zyprexa 5 milligrams (mg) (1/2 tab) at bedtime for restlessness and agitation. On 06/13/22 at 09:20 AM, observation revealed Certified Medication Aide (CMA) R administered medications to R10 who took the pills whole with bites of pudding. R10 did not speak during the observation and no agitation was noted. On 06/15/22 at 02:36 PM, Administrative Nurse D verified the diagnosis for Zyprexa was not correct per regulations and the pharmacist had noted that 05/04/22. She stated the physician ordered a psychiatric consult to obtain the correct diagnosis, but the resident had not seen the psychiatric practitioner yet. The facility's undated policy for Physician Orders for Medications and Treatments documented orders for medication will include clinical rationale or diagnosis for the order. The policy for Proper Diagnosis for Antipsychotic Medications, dated10/04/2016, documented upon finding improper diagnosis for antipsychotic medications, nurse management will notify the prescribing physician in writing and advise of acceptable diagnoses of Huntington's, Tourette's, or schizophrenia for antipsychotic medications per CMS. The facility failed to obtain an appropriate diagnosis for the antipsychotic medication Zyprexa, placing R10 at risk of inappropriate use of the antipsychotic.

The facility had a census of 29 residents. The sample included 12 residents. Based on record review and interview, the facility failed to ensure medication was administered per physician orders for Resident (R) 18, who received the wrong dosage of Sinemet (dopamine promoter medication) nine times a day for eight days. This placed R18 at risk for adverse side effects and complications related to medications errors. Findings included: - The Electronic Medical Record (EMR) documented R18 had diagnoses of Parkinson's disease (slowly progressive neurological disorder characterized by resting tremor, rolling of the fingers, mask like faces, shuffling gait, muscle rigidity and weakness). emotional disorder (chronic and often recurrent psychiatric disorders that are associated with significant impairment in quality of life, productivity, and interpersonal functioning), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), and intellectual impairment (problems with general mental abilities that affect functioning, intellectual and functional). The Quarterly Minimum Data Set, dated 05/12/22, documented R18 had severely impaired cognition and was dependent upon two staff for transfers, toileting. R18 requried extensive assistance of two staff for bed mobility and dressing. The admission Orders, dated 04/29/22, directed staff to administer Sinemet, 10 milligrams (mg)-100 mg, 1 tablet four times a day. The order further directed staff to administer half a pill every 1.5 hours following the 07:00 AM dose and the last dose to be at 07:00 PM. The April 2022 Medication Administration Record (MAR) directed staff to administer Sinemet, 10 milligrams (mg)-100 mg, 1.5 tablets every 1.5 hours following the 07:00 AM dose and the last dose to be at 07:00 PM. Review of the MAR documented 15 times R18 received the wrong dose of medication. The May 2022 MAR, directed staff to administer Sinemet, 10 milligrams (mg)-100 mg, 1.5 tablets every 1.5 hours following the 07:00 AM dose and the last dose to be at 07:00 PM. Review of the MAR documented 58 times R18 received the wrong dose of medication. The Nurse's Note, dated 05/07/22 at 03:43 PM, documented R18's representative contacted the facility and reported R18 was not acting her normal self. The note further documented R18's representative asked about the resident's Sinemet dose and when staff told her the dosage, R18's representative stated the dosage was not correct. Licensed Nurse (LN) G reviewed the physician order and found the order was incorrect on the MAR. The note documented LN G contacted the the hospital and was directed to contact poison control by the physician and send the resident to the emergency department (ED). The Emergency Department Report, dated 05/07/22, documented R18 presented to the ED due to behavior and movement changes. The resident was supposed to get Sinemet 10/100, 0.5 mg, nine times per day and had been getting 1.5 mg, nine times per day for the last eight days. Poison control was contacted and recommended labs and an electrocardiogram (EKG -records the electrical signals from the heart]). The report documented R18's EKG was normal and her laboratory report was unremarkable; the resident was admitted for observation for dyskinesia (abnormality or impairment of voluntary movement). The ED Report, dated 05/08/22, documented R18 was very somnolent (sleepy) and would open her eyes briefly and go back to sleep. The note further documented the resident would be discharged back to the facility 05/09/22. The Nurse's Note, dated 05/09/22 at 12:17 PM, documented R18 returned to the facility and to resume the Sinemet per admission order. On 06/15/22 at 02:15 PM, Administrative Nurse D stated she was unsure the status of the resident the day she went to the hospital. She said the LN on duty would be the best person to talk to. Administrative Nurse D further stated two nurses would double check the admission order to make sure it was correctly entered in the MAR. On 06/16/22 at 07:48 AM, LN G stated R18 was more anxious than usual, and would not answer staff appropriately. LN G stated she did not notify R18's physician regarding the change in R18 until R18's representative contacted her. The facility's Medication Error policy, undated, documented when an error of administration, transcription or documentation occurs, the error would be written up on a medication error form. The medication error tool would be employed to determine the severity of the occurrence. Appropriate care of the resident and documentation of events would be provided in every situation. The facility's Physician Orders for Medications and Treatment policy, undated, documented written orders would be implemented in the resident MAR and Treatment Administration Record (TAR). The order would be noted and placed in the scanned folder and when orders were received, a second nurse would verify the orders. The facility failed to administer the proper dosage of R18's Sinemet medication as ordered upon admission to the facility for eight days, placing the resident at risk for physical and psychosocial decline.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 29 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to revise the care plan with interventions to prevent accidents for three sampled residents, Resident (R) 11, R18, R30 and R10, who had falls. This placed the residents at risk for further injury and skin breakdown. Findings included: - The Electronic Medical Record (EMR) documented R11 had diagnoses of dementia with behavioral disturbance (progressive mental disorder characterized by failing memory and confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), depression ( abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness, and hypertension (high blood pressure). The Quarterly Minimum Data Set (MDS) dated [DATE], documented R11 had severely impaired cognition, required extensive assistance of one staff for bed mobility and was independent with transfers, ambulation. The MDS further documented R11 had unsteady balance, no functional impairment, and had two or more non injury falls and one injury fall. The Fall Risk Assessments, dated 07/20/21, 10/22/21, 01/20/22, and 04/20/22 documented the resident a high risk for falls. The revised Care Plan, dated 05/04/21, originally dated 06/25/21, directed staff to put grip tape on the floor in front of the bed, slipper socks on when in bed, and put R11's laundry away. The update, dated 03/16/22, directed staff to place a scooped mattress (special mattress with raised sides). The update, dated, 05/04/22, directed staff to keep bed in lowest position. The Post Fall Evaluation, dated 10/20/21 at 06:02 PM, documented R11 stumbled over her own feet and fell during ambulation to the dining room. The evaluation further documented the resident received a bruise to her left hand. R11's clinical record lacked evidence of a resident centered intervention put into place to prevent further falls. The Post Fall Evaluation, dated 03/30/22 at 06:01 PM, documented R11 fell while ambulating in the hallway without her walker. The evaluation further documented R11 did not receive any injuries from the fall. R11's clinical record lacked evidence of a resident centered intervention put into place to prevent further falls. The Post Fall Evaluation, dated 04/05/22 at 07:40 PM, documented R11 had a witnessed fall in the Hall 4 dining room. The evaluation further documented R11 was agitated and fell in the dining room. R11's clinical record lacked evidence of a resident centered intervention put into place to prevent further falls. The Post Fall Evaluation, dated 04/12/22 at 03:28 PM, documented R11 fell while ambulating in the hallway without her walker. R11's clinical record lacked evidence of a resident centered intervention put into place to prevent further falls. On 06/15/22 at 08:39 AM, observation revealed R11 ambulated, with her walker, into the Hall 4 dining room. Certified Nurse Aide (CNA) O walked beside the resident. Further observation revealed R11's gait was unsteady, and CNA O assisted the resident into a chair. On 06/16/22 at 09:00 AM, observation revealed R11 independently ambulated down Hall 4 with her walker. Further observation revealed R11's gait was steady. On 06/15/22 at 01:16, CNA O stated R11 did not walk independently because of falls and R11 was unsteady. On 06/16/22 at 08:23 AM, CNA M stated R11 had days she ambulated independently. CNA M said staff assisted the resident during the morning but R11 could ambulate alone later in the morning. CNA M further stated R11 had falls when she lost her balance or when she would forget to use her walker. On 06/15/22 at 8:50 AM, Administrative Nurse D verified R11 had several falls and verified there were not interventions for her falls in the resident's care plan. The facility's Elder Directed Care Plans policy, undated, documented the facility provided an individualized, interdisciplinary plan of care for all elders that was appropriate to the elders needs, strengths, limitations and goals based on initial, recurrent and continued needs of the elder. The care plan further documented the facility regularly reviewed and revised the plan of care, treatment and service, and the plan of care would be individualized to the needs of the elder. The failed to revise R11's care plan with interventions to prevent further falls, placing the resident at risk for further falls and injury. - The Electronic Medical Record (EMR) documented R18 had diagnoses of Parkinson's disease (slowly progressive neurological disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness). emotional disorder (chronic and often recurrent psychiatric disorders that are associated with significant impairment in quality of life, productivity, and interpersonal functioning), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), and intellectual impairment (problems with general mental abilities that affect functioning, intellectual and functional). The admission Minimum Data Set (MDS), dated [DATE], documented R18 had severely impaired cognition and required limited assistance of one staff for toileting, independent with transfers and ambulation. The MDS further documented R18 had no falls since admission. The Fall Risk Assessment, dated 04/29/22, documented R18 was a high risk for falls. The Fall Care Plan, dated 05/11/22, directed staff to determine the resident's ability to transfer. The care plan directed if a fall occurred, alert R18's provider, and obtain frequent neurological checks (a series of questions and tests to check brain, spinal cord, and nerve function). The Post Fall Evaluation, dated 05/14/22 at 05:24 AM, documented R18 was in her room, moving her television, and lost her balance. The evaluation further documented R18 received an abrasion to her back. R18's clinical record lacked evidence of a resident centered intervention put into place to prevent further falls. The Post Fall Evaluation, dated 05/16/22 at 08:50 PM, documented R18 fell in her room while ambulating. The evaluation further documented R18 did not receive any injuries. R18's clinical record lacked evidence of a resident centered intervention put into place to prevent further falls. On 06/14/22 at 08:00 AM, observation revealed R18 had trouble navigating (plan or direct a route) her walker through her door. Further observation revealed R18 asked for assistance to get out of her door and a Certified Nurse Aide (CNA) walked with her to the dining room. On 06/16/22 at 08:01 AM, observation revealed R18 independently ambulated, with her walker, down the hall. On 06/15/22 at 01:00 PM, Licensed Nurse (LN) G stated she was on involved with determining any new interventions for the resident. On 06/15/22 at 02:15 PM, Administrative Nurse D verified there was not any interventions to prevent further falls on her care plan. The facility's Elder Directed Care Plans policy, undated, documented the facility provided an individualized, interdisciplinary plan of care for all elders that was appropriate to the elders needs, strengths, limitations and goals based on initial, recurrent and continued needs of the elder. The care plan further documented the facility regularly reviewed and revised the plan of care, treatment and service, and the plan of care would be individualized to the needs of the elder. The failed to revise R18's care plan with interventions to prevent further falls, placing the resident at risk for further falls and injury. - The Electronic Medical Record (EMR) documented R30 had diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), and dementia without behavioral disturbance (progressive mental disorder characterized by failing memory, confusion). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R30 had severely impaired cognition and required extensive assistance of two staff for bed mobility, transfers, ambulation in room and corridor, dressing, and toileting. The MDS further documented R30 had no mobility devices and had no falls since last MDS. The Fall Assessment, dated 09/13/21, documented R30 a high risk for falls. The revised Limited Physical Mobility Care Plan, dated 03/16/22, originally dated, 12/29/21, documented R30 had a merry-walker (an enclosed framed wheeled walker) with a seat and a strap that fastened between R30's legs and a table to allow resident independence in standing, sitting, and walking. The update, dated 01/02/22, directed staff to place R30 in her merry-walker if she became restless. The Post Fall Evaluation, dated 11/12/21, documented the merry-walker tipped over onto its side and the resident attempted to wiggle across the floor. The evaluation further documented R30 did not receive any injury and three staff assisted the resident off of the floor with the use of a mechanical lift (a device used to transfer residents). R30's care plan lacked direction to staff on interventions to prevent falls when she was in the merry-walker. On 06/15/22 at 07:51 AM, observation revealed R30, in Hall 4, sat in the merry-walker with her eyes are closed. Further observation revealed R30 leaned against the cushion in front of the merry-walker, began to walk with her eyes closed. She stopped when the merry-walker got to the wall. On 06/14/22 at 12:54 PM, Administrative Nurse D verified there was not any interventions to prevent further falls from the merry walker. On 06/15/22 at 01:00 PM, Licensed Nurse (LN) G stated she was on involved with determining any new interventions for the resident. On 06/16/22 at 08:12 AM, CNA M stated R30 was at the nurse's station and tipped the merry-walker over. R30 did not receive any injury, and staff used a lift to get her up off the floor. CMA M further stated she did not know of any intervention in place after the fall. The facility's Elder Directed Care Plans policy, undated, documented the facility provided an individualized, interdisciplinary plan of care for all elders that was appropriate to the elders needs, strengths, limitations and goals based on initial, recurrent and continued needs of the elder. The care plan further documented the facility regularly reviewed and revised the plan of care, treatment and service, and the plan of care would be individualized to the needs of the elder. The failed to revise R30's care plan with interventions to prevent further falls, placing the resident at risk for further falls and injury. - R10's Physician Order Sheet (POS), dated 05/10/22, documented diagnoses of dementia (group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment), restlessness and agitation. The admission Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of seven, indicating severely impaired cognition. The MDS documented R10 was independent with eating and required limited assistance of one staff for bed mobility, transfers, walking, and toileting. The MDS documented R10 had impaired balance, used a walker, had history of falls, and one non-injury fall since the prior assessment. The Fall Care Area Assessment (CAA), dated 04/18/22, documented R10 had a prior fall while and home and one fall since admission. The initial care plan lacked interventions for fall prevention until 04/19/22. The Fall Care Plan, dated 04/20/22, directed staff to evaluate fall risk on admission and as needed (PRN). If a fall occured, alert provider, initiate frequent neurological checks and bleeding evaluation per facility protocol. The care plan stated R10 wore short slipper socks when not wearing shoes. The 06/15/22 care plan update directed staff to apply grip strips on the floor in front of door to R10's room. The Fall Note, dated 04/12/2022 at 07:30 AM, documented the fall was not witnessed, occurred in the resident's room while the resident was attempting to self-toilet. Upon entering room it was noted that resident was laying on her back in front of the bed closest to the door, wearing slipper socks that were twisted to the side. Her walker was sitting upright by her head. Resident stated, I wanted to go to the bathroom. Able to move all extremities. The note documented the resident was incontinent at the time of the fall. No injuries noted The Fall Note, dated 04/30/22 at 02:20 PM, documented R10's fall was not witnessed and occurred in her room. The resident was wearing shoes, not using her walker as instructed, and her blankets were beside her recliner. No injuries noted. The Fall Note, dated 05/18/2022 at 08:45 PM, documented the fall was unwitnessed in her room while she was ambulating without her walker. The resident was found sitting on floor in doorway with legs crossed and hands on knees. She stated, I just got up to look out and see what was going on and my feet slipped out from under me. I didn't fall, I just slid down. No injuries were noted. On 06/14/22 at 04:37 PM, observation revealed R10 sat in a recliner in her room, eyes open, feet on the floor, shoes/socks on, glasses on, and walker in reach. She stated the baby had ice cream and went to sleep. No agitation or restlessness was noted. On 06/15/22 at 03:43 PM, Administrative Nurse D stated she and the restorative staff discuss falls in a meeting after a fall. Administrative Nurse D verified staff had not put all new interventions on the resident's care plan. The facility's undated Fall Follow-Up Protocol documented every resident would be assessed for the causal risk factors for falling after every fall in the facility to develop interventions to prevent further falls. The fall would be documented on the care plan with interventions to prevent further falls. The facility failed to review and revise R10's care plan after each fall with resident-centered interventions aimed to prevent further falls, placing the resident at risk for further falls.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 29 residents. The sample included 12 residents, with nine reviewed for falls. Based on observation, record review, and interview, the facility failed to provide a safe, accident free environment when the facility failed to prevent a skin tear and loss of a toenail while getting Resident (R)19 into the facility whirlpool, failed to implement meaningful, resident centered interventions for four sampled residents, R11, R18, R30 and R10, who were at risk and had falls. The facility further failed to ensure environment was as free of hazards as possible when the facility stored chemicals in unsecured areas accessible to residents. This placed the residents at risk for falls, and accident related injury . Findings included: - The Electronic Medical Record (EMR) for R19 recorded diagnoses of hemiplegia (paralysis of one side of the body), hemiparesis (muscular weakness of one half of the body) affecting the left non-dominant side, dementia without behavioral disturbance (progressive mental disorder characterized by failing memory, confusion), contracture of the left hand (abnormal permanent fixation of a joint, and cerebrovascular accident (CVA-sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain). The Quarterly Minimum Data Set, dated 05/12/22, documented R19 had severely impaired cognition and was dependent upon two staff for transfers, toileting and extensive assistance of two staff for bed mobility and dressing. The MDS further documented R19 did not have any skin tears. The Skin Integrity Care Plan, dated 05/17/22, documented R19 was at risk for impaired skin integrity and directed staff to evaluate skin integrity monthly and as needed by a nurse. The Risk for Unilateral Neglect Cerebrovascular Accident (CVA), dated 05/17/22, directed staff to ensure a safe environment, and evaluate R19's awareness of affected side. The Nurse's Note, dated 05/16/22 at 07:16 AM, documented R19's left pinky toenail got caught in the whirlpool (a therapeutic bath in which all or part of the body is exposed to forceful whirling currents of hot water) and came off. The note further documented there was a moderate amount of blood, and a pressure dressing (a bandage that is designed to apply pressure to a area of the body) was applied to stop the bleeding. The note documented R19 received a skin tear (a traumatic wound caused by mechanical forces) to his left upper arm which measured 7.2-centimeter (cm) x 4.5 cm, with most of the skin gone. It had a moderate amount of blood, and a pressure dressing was applied. The Physician Order, dated 05/16/22, directed staff to apply pressure dressing to left pinky toes for 24 hours, then cleanse the wound with normal saline (used to cleanse wounds), apply triple antibiotic ointment (TAO) and cover with a band aide daily until healed. The order further directed staff to apply a pressure dressing to R19's left upper arm for 24 hours, cleanse with normal saline, apply tao, cover with a nonstick pad, and wrap with coban (a self-adherent compression bandage used for protection), daily, until healed. Review of the EMR lacked documentation an investigation or skin assessment was completed for the resident's injuries. On 06/16/22 at 07:42 AM, observation revealed the skin tear to R19's upper left arm was open to air and was almost healed. On 06/15/22 at 07:47 AM, Administrative Nurse D verified an investigation was completed for any residents' injuries and stated one should have been completed for R19's injuries On 06/15/22 at 12:57 PM, Licensed Nurse (LN) G stated R19 received a skin tear when staff were had gotten out of the whirlpool . LN G further stated she thought his pinky toe got caught in the whirlpool door because R19 cannot move his left side. LN G verified an investigation was not completed for the injuries. On 06/16/22 at 08:15 AM, Certified Nurse Aide (CNA) M stated she did not know how the resident received the skin tear to his left arm. CNA M said R19 cannot use his left side. The facility's Skin Injury policy, undated, documented the facility would routinely monitor the skin condition and identify if the condition became significant and the physician notified. All injuries will be monitored routinely until resolved and staff must be aware that any injury as a result of possible abuse or neglect must be reported immediately to the supervisor, don, and administrator. The policy further documented, all incidents, whether considered significant or not, require completion of a facility incident report and investigation to determine causal factors for the incident and interventions implemented to prevent any further occurrences in the future. The facility failed to implement interventions to prevent further skin tears and injuries to toes for R19, who had hemiplegia to his left side, placing the resident at risk for further injury. - The Electronic Medical Record (EMR) documented R11 had diagnoses of dementia with behavioral disturbance (progressive mental disorder characterized by failing memory and confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), depression ( abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness, and hypertension (high blood pressure). The Quarterly Minimum Data Set (MDS) dated [DATE], documented R11 had severely impaired cognition, required extensive assistance of one staff for bed mobility and was independent with transfers, ambulation. The MDS further documented R11 had unsteady balance, no functional impairment, and had two or more non injury falls and one injury fall. The Fall Risk Assessments, dated 07/20/21, 10/22/21, 01/20/22, and 04/20/22 documented the resident a high risk for falls. The revised Care Plan, dated 05/04/21, originally dated 06/25/21, directed staff to put grip taped placed on the floor in front of the bed, slipper socks on when in bed, and put R11's laundry away. The update, dated 03/16/22, directed staff to place a scooped mattress (special mattress with raised sides). The update, dated, 05/04/22, directed staff to keep bed in lowest position. The Post Fall Evaluation, dated 10/20/21 at 06:02 PM, documented R11 stumbled over her own feet and fell during ambulation to the dining room. The evaluation further documented the resident received a bruise to her left hand. R11's clinical record lacked evidence of a resident centered intervention put into place to prevent further falls. The Post Fall Evaluation, dated 03/30/22 at 06:01 PM, documented R11 fell while ambulating in the hallway without her walker. The evaluation further documented R11 did not receive any injuries from the fall. R11's clinical record lacked evidence of a resident centered intervention put into place to prevent further falls. The Post Fall Evaluation, dated 04/05/22 at 07:40 PM, documented R11 had a witnessed fall in the Hall 4 dining room. The evaluation further documented R11 was agitated and fell in the dining room. R11's clinical record lacked evidence of a resident centered intervention put into place to prevent further falls. The Post Fall Evaluation, dated 04/12/22 at 03:28 PM, documented R11 fell while ambulating in the hallway without her walker. R11's clinical record lacked evidence of a resident centered intervention put into place to prevent further falls. On 06/15/22 at 08:39 AM, observation revealed R11 ambulated, with her walker, into the Hall 4 dining room. Certified Nurse Aide (CNA) O walked beside the resident. Further observation revealed R11's gait was unsteady, and CNA O assisted the resident into a chair. On 06/16/22 at 09:00 AM, observation revealed R11 independently ambulated down Hall 4 with her walker. Further observation revealed R11's gait was steady. On 06/15/22 at 01:16, CNA O stated R11 did not walk independently because of falls and R11 was unsteady. On 06/16/22 at 08:23 AM, CNA M stated R11 had days she ambulated independently. CNA M said staff assisted the resident during the morning but R11 could ambulate alone later in the morning. CNA M further stated R11 had falls when she lost her balance or when she would forget to use her walker. On 06/15/22 at 8:50 AM, Administrative Nurse D verified R11 had several falls and verified there were not interventions for her falls in the resident's care plan The facility's Fall Follow Up Protocol undated policy documented each resident who resided at the facility would be provided services and care that ensured that the resident's environment remained as free from accident hazards as was possible and each resident received adequate supervision and assuasive devices to prevent accidents. Every resident would be assessed for the causal risk factors for falling at the time of admission, upon return from a health care facility and after every fall in the facility. Each resident of this facility who experienced a fall would be treated and assessed to adequately treat any current injuries, whether physical or psychosocial, and comprehensively assessed to determine causal effects of the fall to develop interventions to prevent further falls. The fall was documented on the care plan with interventions to prevent further falls based on the determined causal factors. The facility failed to implement meaningful, resident centered interventions for cognitively impaired R11, who had multiple falls, placing the resident at risk for further falls and injury. - The Electronic Medical Record (EMR) documented R18 had diagnoses of Parkinson's disease (slowly progressive neurological disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness). emotional disorder (chronic and often recurrent psychiatric disorders that are associated with significant impairment in quality of life, productivity, and interpersonal functioning), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), and intellectual impairment (problems with general mental abilities that affect functioning, intellectual and functional). The admission Minimum Data Set (MDS), dated [DATE], documented R18 had severely impaired cognition and required limited assistance of one staff for toileting, independent with transfers and ambulation. The MDS further documented R18 had no falls since admission. The Fall Risk Assessment, dated 04/29/22, documented R18 was a high risk for falls. The Fall Care Plan, dated 05/11/22, directed staff to determine the resident's ability to transfer. The care plan directed if a fall occurred, alert R18's provider, and obtain frequent neurological checks (a series of questions and tests to check brain, spinal cord, and nerve function). The Post Fall Evaluation, dated 05/14/22 at 05:24 AM, documented R18 was in her room, moving her television, and lost her balance. The evaluation further documented R18 received an abrasion to her back. R18's clinical record lacked evidence of a resident centered intervention put into place to prevent further falls. The Post Fall Evaluation, dated 05/16/22 at 08:50 PM, documented R18 fell in her room while ambulating. The evaluation further documented R18 did not receive any injuries. R18's clinical record lacked evidence of a resident centered intervention put into place to prevent further falls. On 06/14/22 at 08:00 AM, observation revealed R18 had trouble navigating (plan or direct a route) her walker through her door. Further observation revealed R18 asked for assistance to get out of her door and a Certified Nurse Aide (CNA) walked with her to the dining room. On 06/16/22 at 08:01 AM, observation revealed R18 independently ambulated, with her walker, down the hall. On 06/15/22 at 01:00 PM, Licensed Nurse (LN) G stated when R18's gait and balance were off, she would fall. On 06/15/22 at 02:15 PM, Administrative Nurse D verified there was not any interventions to prevent further falls on her care plan. On 06/16/22 at 08:26 AM, CNA M stated R18 was independent with ambulation and did not know anything about her falls. CNA M further stated she was not involved with determining interventions to prevent further falls. The facility's Fall Follow Up Protocol undated policy documented each resident who resided at the facility would be provided services and care that ensured that the resident's environment remained as free from accident hazards as was possible and each resident received adequate supervision and assistive devices to prevent accidents. Every resident would be assessed for the causal risk factors for falling at the time of admission, upon return from a health care facility and after every fall in the facility. Each resident of this facility who experienced a fall would be treated and assessed to adequately treat any current injuries, whether physical or psychosocial, and comprehensively assessed to determine causal effects of the fall to develop interventions to prevent further falls. The fall was documented on the care plan with interventions to prevent further falls based on the determined causal factors. The facility failed to implement meaningful, resident centered interventions for cognitively impaired R18, who had falls, placing the resident at risk for further falls and injury. - The Electronic Medical Record (EMR) documented R30 had diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), and dementia without behavioral disturbance (progressive mental disorder characterized by failing memory, confusion). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R30 had severely impaired cognition and required extensive assistance of two staff for bed mobility, transfers, ambulation in room and corridor, dressing, and toileting. The MDS further documented R30 had no mobility devices and had no falls since last MDS. The Fall Assessment, dated 09/13/21, documented R30 a high risk for falls. The revised Limited Physical Mobility Care Plan, dated 03/16/22, originally dated, 12/29/21, documented R30 had a merry-walker (an enclosed framed wheeled walker) with a seat and a strap that fastened between R30's legs and a table to allow resident independence in standing, sitting, and walking. The update, dated 01/02/22, directed staff to place R30 in her merry walker if she became restless. The Post Fall Evaluation, dated 11/12/21, documented the merry walker tipped over onto its side and the resident attempted to wiggle across the floor. The evaluation further documented R30 did not receive any injury and three staff assisted the resident off of the floor with the use of a mechanical lift (a device used to transfer residents). R30's care plan lacked direction to staff on interventions to prevent falls when she was in the merry-walker. On 06/15/22 at 07:51 AM, observation revealed R30, in Hall 4, sat in the merry walker with her eyes are closed. Further observation revealed R30 leaned against the cushion in front of the merry walker, began to walk with her eyes closed. She stopped when the merry walker got to the wall. On 06/14/22 at 12:54 PM, Administrative Nurse D verified R30 had a fall while in the merry walker. She stated she wanted the resident to be able to be in the walker when R30 was anxious so that the resident could move around independently. On 06/15/22 at 01:00 PM, Licensed Nurse G stated R30 did have a fall while in the merry-walker, but the merry-walker allowed the resident to be more independent. On 06/16/22 at 08:12 AM, CNA M stated R30 was at the nurse's station and tipped the merry walker over. R30 did not receive any injury, and staff used a lift to get her up off the floor. CMA M further stated she did not know of any intervention in place after the fall. The facility's Fall Follow Up Protocol undated policy documented each resident who resided at the facility would be provided services and care that ensured that the resident's environment remained as free from accident hazards as was possible and each resident received adequate supervision and assistive devices to prevent accidents. Every resident would be assessed for the causal risk factors for falling at the time of admission, upon return from a health care facility and after every fall in the facility. Each resident of this facility who experienced a fall would be treated and assessed to adequately treat any current injuries, whether physical or psychosocial, and comprehensively assessed to determine causal effects of the fall to develop interventions to prevent further falls. The fall was documented on the care plan with interventions to prevent further falls based on the determined causal factors. The facility failed to implement a meaningful, resident centered intervention for cognitively impaired R30, who had a fall while in her merry walker, placing the resident at risk for further falls and injury. - On 06/13/22 at 09:10 AM, during the initial tour, observation revealed an unlocked bathroom door on the 300 hall. The following items were observed in the cabinet under the sink: 1 15 ounce (oz) aerosol can of [NAME] Disinfectant spray, with the warning label keep out of reach of children, hazardous to humans and domestic animals. 1 6.7 oz container of Mystic Woods automatic spray refill with the warning label keep out of reach of children and avoid contact with eyes. Continued observation revealed an unlocked soiled utility room door on the 300 hall. The following items were observed in a cabinet under the sink in the unlocked soiled utility room: 1 22 oz spray can of Resolve carpet cleaner with the warning Keep out of Reach of Children, may cause eye irritation, hazardous chemical. 1 128 oz T Cleaner -Neutral all-purpose cleaner Keep out of reach of children. On 06/14/22 at 10:40 AM, Administrative Nurse E verified the chemicals and products with the warning labels should be locked up and or out of reach of the residents. The facilities Control of Hazardous Chemicals, policy undated, documented the facility is committed to eliminate and controlling hazards that could cause injury or illness to elders, employees, vendors, volunteers, and visitors. The policy documented all containers of hazardous chemicals in each workplace would be conspicuously labeled with the identity of the chemical and the appropriate hazard warning. All substance with warning labels, including but not exclusive to Keep out of reach of children, would always be locked and inaccessible. All hazardous chemicals were always to be locked to avoid accessibility of and elder in the facility. The facility failed to ensure chemicals were kept in a locked room, placing the four cognitively impaired, independently mobile residents who reside in the facility, at risk for injury. - R10's Physician Order Sheet (POS), dated 05/10/22, documented diagnoses of dementia (group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment), restlessness and agitation. The admission Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of seven, indicating severely impaired cognition. The MDS documented R10 was independent with eating and required limited assistance of one staff for bed mobility, transfers, walking, and toileting. The MDS documented R10 had impaired balance, used a walker, had history of falls, and one non-injury fall since the prior assessment. The Fall Care Area Assessment (CAA), dated 04/18/22, documented R10 had a prior fall while and home and one fall since admission. The initial care plan lacked interventions for fall prevention until 04/19/22. The Fall Care Plan, dated 04/20/22, directed staff to evaluate fall risk on admission and as needed (PRN). If fall occurs, alert provider, initiate frequent neurological checks and bleeding evaluation per facility protocol. The care plan stated R10 wore short slipper socks when not wearing shoes. The 06/15/22 care plan update directed staff to apply Grip strips on the floor in front of door to R10's room. The Fall Note, dated 04/12/2022 at 07:30 AM, documented the fall was not witnessed, occurred in the resident's room while the resident was attempting to self-toilet. Upon entering room it was noted that resident was laying on her back in front of the bed closest to the door, wearing slipper socks that were twisted to the side. Her walker was sitting upright by her head. Resident stated, I wanted to go to the bathroom. Able to move all extremities. The note documented the resident incontinent at the time of the fall. No injuries noted The Fall Note, dated 04/30/22 at 02:20 PM, documented R10's fall was not witnessed and occurred in her room. The resident was wearing shoes, not using her walker as instructed, and her blankets were beside her recliner. No injuries noted. The Fall Note, dated 05/18/2022 at 08:45 PM, documented the fall was unwitnessed in her room while she was ambulating without her walker. The resident was found sitting on floor in doorway with legs crossed and hands on knees. She stated, I just got up to look out and see what was going on and my feet slipped out from under me. I didn't fall, I just slid down. No injuries noted. On 06/14/22 at 04:37 PM, observation revealed R10 sat in a recliner in her room, eyes open, feet on the floor, shoes/socks on, glasses on, and walker in reach. She stated the baby had ice cream and went to sleep. No agitation or restlessness noted. On 06/15/22 at 03:43 PM, Administrative Nurse D stated she and the restorative staff discuss falls in a meeting after a fall. Administrative Nurse D verified staff had not put all new interventions on the resident's care plan. The facility's undated Fall Follow-Up Protocol documented every resident would be assessed for the causal risk factors for falling after every fall in the facility to develop interventions to prevent further falls. The fall would be documented on the care plan with interventions to prevent further falls. The facility failed to identify and implement resident-centered interventions aimed to prevent further falls after three falls in the facility, placing the resident at risk for further falls.

The facility had a census of 29 residents. The sample included 12 residents. Based on observation, record review, and interview the facility failed to prepare, store, distribute, and serve food under sanitary conditions for the 29 residents in the facility who received their meals from the facility kitchen. This placed the residents at risk for foodborne illness. Findings included: - On 06/12/22 at 07:45 AM, during initial tour, observation revealed the following: Seven 18 inches by 3 foot fluorescent lights, located above the food preparation area, with plastic light covers, with a brownish speckled discolored material in the light cover with one light cover with approximately eight inch crack. Continued observation revealed the stove hood had a grey fuzzy substance along the edges of the hood with grey fuzzy substance covering the two fire suppression spigots over the stove and on the louvers of the stove hood exhaust. On 06/13/22 at 01:10 PM, Administrative Staff A verified the overhead fluorescent light fixture with brown substance in the covers and one cracked light cover. Administrative Staff A verified the stove hood had grey lint around the perimeter of the hood and in the exhaust louvers, and grey fuzzy substance coated the black fire suppression water spigots and lines. The facility's Dietary Cleaning Procedures policy, undated, documented the facility would store, prepare, distribute and serve food under sanitary conditions to ensure that proper sanitation and food handling practices to prevent the outbreak of foodborne illnesses is attained continuously. The policy documented staff would report any defective equipment to the Environmental Service. The facility failed to prepare, store, distribute and serve food under sanitary conditions for the 29 residents residing in the facility, who received meals from the facility kitchen.

The facility had a census of 29 residents. The sample included 12 residents. Based on record review and interview the facility failed to deliver mail to the facility residents on Saturdays. This placed the residents at risk for impaired psychosocial wellbeing. Findings included: - On 06/13/22 at 01:00 PM during the resident council meeting, the residents verbalized there was no mail delivery on Saturdays. On 06/13/22 at 01:45 PM, Administrative Staff A stated the housekeeping staff were supposed to get the mail on the weekend, then deliver the mail to the residents. Administrative Staff A verified the mail should consistently be delivered to the residents on Saturdays; Admisnitrative Staff A verified the facility did not always deliver mail to the residents on Saturdays. The undated facility policy Resident Rights, documented the resident has the right to send and receive mail, and to receive letters, packages, and other materials delivered to the facility through any other means than a postal service. The facility failed to deliver mail to the residents in the facility on Saturdays, placing the residents at risk for impaired psychosocial wellbeing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 34 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to notify the Ombudsman for one sampled resident discharged to the hospital, Resident (R) (4). Findings included: - R4's Physician Order Sheet (POS), dated 09/30/20, documented diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion), cerebral vascular accident (CVA-stroke-sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), psychosis (any major mental disorder characterized by a gross impairment in reality testing), major depressions (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). The Quarterly Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of five, indicating severe cognitive impairment. The MDS documented the resident required extensive assistance of one staff with most activities of daily living (ADLs). The Medication Care Plan, dated 07/09/20, directed staff to inform the physician of any problems, and monitor for possible signs and symptoms of adverse drug reactions (falls, weight loss, fatigue, incontinence, and gastric upset). The Nurses Note, dated 07/18/20 at 11:50 PM, documented at 03:00 PM staff called the nurse into the dining room to assess R4's temperature of 101.7 degrees Fahrenheit (F) (normal 97-99 degrees F), oxygen saturation at 86% (normal 97-99%), difficulty breathing and diminished lung sounds. Staff notified the resident's family member of the resident's condition and she requested the resident be evaluated at the emergency room (ER). The note documented the nurse notified the physician, and at 06:30 PM Emergency Medical Services (EMS) arrived and transported the resident to the hospital. The Nurses Note, dated 07/21/20 documented the resident returned to the facility with a diagnosis of pneumonia (lung inflammation caused by bacterial or viral infection) and sepsis (life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs). The Nurses Note, dated 07/22/20 at 04:39 AM, documented the resident had temperatures that ranged from 98-99 degrees F, oxygen saturation from 70% to 90%, shallow respirations, pale color, and unable to answer questions or respond verbally. Staff notified the resident's family member of the resident's condition and she requested the resident be evaluated at the ER. The note documented the nurse notified the physician, and at 07:39 PM EMS arrived and transported the resident to the hospital. The Nurses Note, dated 07/22/20 at 10:59 AM, documented the resident returned from the hospital late yesterday, went to the ER this morning, and was re-admitted to the hospital for observation. The Nurses Note, dated 07/25/20 at 01:02 PM, documented the nurse notified the physician the resident's oxygen saturation levels dropped while oxygen was increased from 2 to 4 liters and the nurse sent the resident to the ER due to declining health. The note documented at 01:38 PM, EMS arrived at the facility and transported the resident to the hospital. The Nurses Note, dated 08/03/20, at 01:24 PM, transportation provided for the resident as she returned from the hospital. The Nurses Note, dated 08/07/20 at 10:42 PM, documented at 09:00 PM the resident ran a low-grade fever with temperature of 100.4 degrees F. At 09:50 PM the resident had a blood pressure reading 76/48 mg Hg (normal 120/80 mg Hg), pulse 85 beats per minute (bpm-normal resting 60 bpm), respirations 24 breaths per minute (normal 12-16 breaths per minute) and oxygen saturation level of 92%. The note documented the facility transported the resident to the hospital. The Nurses Note, dated 08/08/20, documented the resident returned to the facility with a diagnosis of fever, low blood sugar, and hypoxia (inadequate supply of oxygen.) R4's Medical Record lacked documentation staff notified the ombudsman of the resident's hospitalizations. On 10/12/20 at 10:30 AM, observation revealed R4 sat in a recliner in common area. Observation revealed the nurse attempted to get the resident to wear a face mask, but was not successful. On 10/14/20 at 12:04 PM, Administrative Nurse D stated she did not send the ombudsman notice for the resident's discharges in July and August 2020, but was aware the facility should send the notices. Upon request, the facility was unable to provide a discharge policy. The facility failed to notify the Ombudsman's office of R4's discharges to the hospital, placing the resident at risk to not have Ombudsman advocate for him.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 34 residents. The sample included 12 residents with one reviewed for urinary catheter. Based on observation, record review, and interview, the facility failed to revise Resident (R) 19's care plan with interventions to include urinary catheter (insertion of a tube into the bladder to drain the urine into a collection bag) care and services. Findings included: - R19's Physician Order Sheet (POS), dated 08/19/20, documented diagnoses of urinary tract infection (UTI-infection in any part of your urinary system) and neurogenital implants (material placed in the urethra (small tubular structure that drains urine from the bladder) to help control urine leakage). The Quarterly Minimum Data Set (MDS), dated [DATE], documented the resident required total staff assistance for all activities of daily living (ADLs) except eating. The MDS documented the resident frequently incontinent of urine, no catheter, and received diuretic (medication to promote the formation and excretion of urine) and antibiotic (substance active against bacteria) medication seven days of the look back period. The Urinary Care Area Assessment (CAA), dated 11/20/19, documented the resident dependent on staff for toileting, changing of incontinence products, and providing perineal care. The Urinary Care Plan, dated 09/02/20, directed staff to use disposable incontinence briefs, change with each incontinence episode, and monitor for signs and symptoms of UTIs. The update, dated 09/08/20, directed staff to change the resident's urinary catheter monthly, position catheter bag and tubing below the level of the bladder, and ensure drainage bag covered. The care plan directed staff to monitor and document the resident's urinary output per facility policy, monitor for pain or discomfort due to catheter, and report to the physician signs or symptoms of UTI. The care plan further directed staff to administer antibiotic therapy as prescribed, encourage fluids if not contraindicated, monitor for cognitive changes, laboratory results, and evaluate urine characteristics. The Physician Visit Note, dated 08/19/20, documented the resident had recurrent UTIs and seizure activity that went along with the UTIs. The note documented it was difficult to diagnose a UTI until at times seizure activity occurred, versus fevers and change in vital signs. Once the resident was treated and the infection cleared, seizure activity ceased. The note documented the resident recently had a suspected UTI, culture was negative, a repeat urinalysis (examination of urine) came back worse, and while awaiting the culture results the resident had seizure activity and was sent to the emergency room (ER). The Communication to Physician, dated 08/31/20 at 09:40 AM, documented the resident returned from the hospital 08/26/20 with a urinary catheter without orders for catheter care, how often to change catheter, or a diagnosis for the catheter. The Physician's Order, dated 08/31/20, directed staff to document the resident's catheter output every shift. R19's August Treatment Administration Record (TAR) lacked documentation of urinary catheter output, or care provided, 08/26/20 through 08/31/20. The Progress Note, dated 08/31/20 at 03:12 PM, documented the resident pulled out her catheter this morning. The Physician's Order, dated 08/31/20, directed staff to wait one week, then replace the resident's urinary catheter. On 10/14/20 at 11:38 AM, observation revealed Certified Nurse Aide (CNA) N provided catheter cares appropriately and emptied the catheter drainage bag. CNA N cleaned the catheter port with an alcohol wipe before and after emptying the bag. CNA N held the measuring container and drainage bag off the floor the whole time and practiced proper infection control. On 10/12/20 at 02:30 PM, Licensed Nurse (LN) G verified she had not updated R19's care plan to include the urinary catheter when the resident returned from the hospital on [DATE]. On 10/12/20 at 04:05 PM, CMA R stated staff checked care plans for information about the resident's care. On 10/14/20 at 12:07 PM, Administrative Nurse D verified the facility readmitted R19 on 08/26/20 with a urinary catheter and staff did not obtain catheter care orders for five days or document routine catheter care or output during those five days. Upon request, the facility did not provide a care plan revision policy. The facility failed to revise R19's care plan to include interventions for a urinary catheter for five days after R19 returned from the hospital with a new urinary catheter, placing the resident at risk for urinary catheter complications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 34 residents. The sample included 12 residents with one reviewed for urinary catheter. Based on observation, record review, and interview, the facility failed to provide care and services for Resident (R) 19's urinary catheter. Findings included: - R19's Physician Order Sheet (POS), dated 08/19/20, documented diagnoses of urinary tract infection (UTI) (infection in any part of your urinary system) and neurogenital implants (material placed in the urethra (small tubular structure that drains urine from the bladder) to help control urine leakage). The Quarterly Minimum Data Set (MDS), dated [DATE], documented the resident required total staff assistance for all activities of daily living (ADLs) except eating. The MDS documented the resident frequently incontinent of urine, no catheter, and received diuretic (medication to promote the formation and excretion of urine) and antibiotic (substance active against bacteria) medication seven days of the look back period. The Urinary Care Area Assessment (CAA), dated 11/20/19, documented the resident dependent on staff for toileting, changing of incontinence products, and providing perineal care. The Urinary Care Plan, dated 09/02/20, directed staff to use disposable incontinence briefs, change with each incontinent episode, and monitor for signs and symptoms of UTIs. The update, dated 09/08/20, directed staff to change urinary catheter monthly, position catheter bag and tubing below the level of the bladder and ensure drainage bag covered. The care plan directed staff to monitor and document the resident's output per facility policy, monitor for pain or discomfort due to catheter, and report to the physician signs or symptoms of UTI. The care plan further directed staff to administer antibiotic therapy as prescribed, encourage fluids, if not contraindicated, and monitor for cognitive changes, laboratory results, and evaluate urine characteristics, The Physician Visit Note, dated 08/19/20, documented the resident had recurrent UTIs and seizure activity that went along with the UTIs. The note documented it was difficult to diagnose a UTI until at times seizure activity occurred, versus fevers and change in vital signs. Once the resident was treated and the infection cleared, seizure activity ceased. The note documented the resident recently had a suspected UTI, culture was negative, a repeat urinalysis (examination of urine) came back worse, and while awaiting the culture results the resident had seizure activity and was sent to the emergency room (ER). The Communication to Physician, dated 08/31/20 at 09:40 AM, documented the resident returned from the hospital 08/26/20 with a urinary catheter without orders for catheter care, how often to change catheter, or a diagnosis for the catheter. The Physician's Order, dated 08/31/20, directed staff to document catheter output every shift. R19's August Treatment Administration Record (TAR) lacked documentation of urinary catheter output, or care provided, 08/26/20 through 08/31/20. The Progress Note, dated 08/31/20 at 03:12 PM, documented the resident pulled out her catheter this morning. The Physician's Order, dated 08/31/20, directed staff to wait one week, then replace the resident's urinary catheter. The Progress Note, dated 09/08/20 at 09:57 AM, documented staff inserted a urinary catheter into R19 this morning. On 10/12/20 at 11:20 AM, observation revealed R19 in a recliner in the living room, legs elevated, and eyes closed. Further observation revealed urinary catheter drainage bag in a privacy bag to dependent drainage in the side pocket of the recliner. On 10/14/20 at 11:38 AM, observation revealed Certified Nurse Aide (CNA) N provided catheter cares appropriately and emptied the catheter drainage bag. CNA N cleaned the catheter port with an alcohol wipe before and after emptying the bag. CNA N held the measuring container and drainage bag off the floor the whole time and practiced proper infection control. On 10/14/20 at 12:07 PM, Administrative Nurse D verified the facility readmitted R19 on 08/26/20 with a urinary catheter and staff did not obtain catheter care orders for five days or document routine catheter care or output during those five days. The facility's undated Catheter Care policy lacked direction for staff on how often to provide catheter care and document urinary output. The facility failed to obtain urinary catheter orders for care and services upon R19's return to the facility with a urinary catheter, placing the resident at risk for infection and urinary catheter complications.

The facility had a census of 34 residents. Based on observation, record review, and interview, the facility failed to provide food prepared by methods that conserve nutritive value, flavor and appearance for six of six pureed meals. Findings included: - On 10/12/20 at 10:50 AM, observation during pureed food preparation revealed Dietary Staff (DS) BB used a pasta spoon and placed six scoops of spaghetti, measured six-4 ounce (oz) scoops of meat sauce, two cups of heated tomato juice from stove top, and three slices of bread into the blender and blended to pudding consistency. DS BB then poured the mixture into the warmer on the steam table. On 10/12/20 10:50 AM, DS BB presented a pureed recipe book containing a recipe for pureed vegetables, pureed meat, and pureed fruit. The notebook did not contain a pureed recipe for spaghetti. DS BB stated she did not have a recipe for pureed spaghetti. On 10/12/20 at 11:10 AM, DS BB placed a 4 oz scoop of the pureed spaghetti on six residents plates. On 10/12/20 at 11:15 AM, DS BB verified she did not have a pureed recipe for spaghetti. The facility's revised Preparation of Altered Consistency Diets policy, dated 03/19/2015, documented pureed recipes are to be consulted and followed. The facility failed to provide pureed foods prepared by methods that conserve nutritive value, flavor and appearance for six of six residents on pureed consistency diets, placing the residents at risk for impaired nutrition.

The facility had a census of 34 residents. Based on observation, record review, and interview, the facility failed to prepare food in accordance with professional standards for food service safety in the facility kitchen. Findings included: - On 10/12/20 at 11:35 AM, observation during noon meal preparation revealed Dietary Staff (DS) BB performed hand hygiene at a sink in the kitchen, applied gloves, and began placing food on residents' plates. DS BB obtained food portions to place on resident plates, touched the measured utensils, then used the same gloved hand to obtain bread and placed the bread on the resident's plate. On 10/12/20 at 01:50 PM, DS CC produced the Dishwasher PPM test strips (accurately measures the concentration of the sanitizing solution in dishwasher) and noted an expiration date of March 2020 on the test strips. On 10/12/20 at 11:35 AM, DS BB stated she was not aware that using the same gloves to obtain the bread would contaminate the bread and obtained tongs to place the bread on the resident's plates. On 10/12/20 at 01:50 PM, DS CC stated the Dishwasher PPM test strips that were attached to the outside of the dishwasher had an expiration date of March 2020 and were the ones staff used to test the dishwasher sanitizing solution. The facility's Food Safety-Food Service Manager's Responsibility policy, dated 2013 documented the food service manager assures good sanitary food handling practices and sanitary conditions are maintained in the storage, preparation and serving areas. The facility failed to prepare food in accordance with professional standards for food service safety, placing the 34 residents who received food from the facility kitchen at risk for food borne illness.