LIFE CARE CENTER OF AURORA

A revisit survey was completed on 4/29/24 for all previous deficiencies cited on 2/27/24. The facility is in compliance with all regulations surveyed.

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 04/08/2024 and 04/14/2024, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 04/01/2024 and 04/07/2024, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

INITIAL COMENTS (ID Prefix Tag #K000) are informational only and a representation of the facility's general characteristics. This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.70(a). The facility is one story, Type II (000), construction. The facility is protected throughout by a National Fire Protection Association (NFPA) 13 automatic fire suppression systems and is classified as Fully Sprinklered. The facility was constructed in 1994 and is license for 166 beds. This re-certification survey conducted on March 13, 2024 was for compliance with the National Fire Protection Association, (NFPA 101) Life Safety Code (2012) "Chapter 19, Existing Health Care Occupancies". The deficiencies cited were discussed with the Administrator and Maintenance Director during the exit conference conducted at the end on-site survey. The Administrator reported the daily census to be 102 residents on March 13, 2024.

Based on observation and record review during the survey, it was determined that the facility failed to maintain the kitchen cooking appliance locations in accordance with National Fire Protection Association (NFPA) Standard 96. This was evidenced by the following:1. Kitchen Hood nozzle placement has improper coverage for cooking appliances. NFPA 96, Section 12.1.2.3 The fire-extinguishing system shall not require reevaluation where the cooking appliances are moved for the purposes of maintenance and cleaning, provided the appliances are returned to approved design location prior to cooking operations. NFPA 96, Section 12.1.2.3.1: An approved method shall be provided that will ensure that the appliance is returned to an approved design location. The commercial cooking equipment deficiency has the potential to affect all staff in the kitchen smoke compartments; items were discussed during the survey and again during the exit conference. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the kitchen smoke compartment. Deficient items were discussed with the Maintenance Director and Administrator at the exit conference.

Based on a record review it was determined that the facility failed to maintain the fire alarm system components and devices in accordance with the Life Safety Code Section 9.6 and NFPA 72.1. Smoke Detector Sensitivity Report states there were multiple failures. NFPA 101 19.3.4.1 to comply with section 9.6. Section 9.6.1.3, fire alarm system testing and maintenance to comply with NFPA 72. NFPA 72 14.4.5.3.4; to ensure that each smoke detector or smoke alarm is within its listed and marked sensitivity range, it shall be tested using any of the following methods:(1) Calibrated test method(2) Manufacturer's calibrated sensitivity test instrument(3) Listed control equipment arranged for the purpose(4) Smoke detector/fire alarm control unit arrangement whereby the detector causes a signal at the fire alarm control unit where its sensitivity is outside its listed sensitivity range(5) Other calibrated sensitivity test methods approved by the authority having jurisdictionThis deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the Maintenance Director and Administrator at the exit conference.

Based on observations and records review, it was determined that the facility failed to maintain the automatic sprinkler system in accordance with National Fire Protection Association NFPA 25 and NFPA 1011. Fire Sprinkler Annual Inspection report stated deficiencies of loaded sprinkler heads and painted escutcheon plates. 2. Escutcheon plates are hanging down in the dining room area and throughout the facility. NFPA 101, Section 19.3.5.1 Buildings containing nursing homes shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, unless otherwise permitted by 19.3.5.5. NFPA 25, Section 5.2.1.1.2 Any sprinkler that shows signs of any of the following shall be replaced: (1) Leakage, (2) Corrosion, (3) Physical damage, (4) Loss of fluid in the glass bulb heat responsive element, (5)* Loading (6) Painting unless painted by the sprinkler manufacturer. NFPA 13, Section 6.2.7.1Plates, escutcheons, or other devices used to cover the annular space around a sprinkler shall be metallic or shall be listed for use around a sprinkler. These deficiencies have the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the Maintenance Director and Administrator at the exit conference.

Based on observation and staff interview, it was determined that the facility failed to maintain smoke dampers in accordance with Life Safety Code Section NFPA 1051. 4 Year Fire Damper Testing report was not provided. NFPA 105, 6.5.1 Smoke dampers for dedicated and non-dedicated smoke control systems shall be inspected and tested in accordance with NFPA 92A, Standard for Smoke-Control Systems Utilizing Barriers and Pressure Differences. 6.5.2* Each damper shall be tested and inspected one year after installation. The test and inspection frequency shall then be every 4 years, except in hospitals, where the frequency shallbe every 6 years. 6.5.3 Care shall be exercised that all tests are completed in a safe manner wearing the appropriate personal protective equipment. 6.5.4 Full unobstructed access to the damper shall be verified and corrected as required. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the Maintenance Director and Administrator at the exit conference.

During the survey, it was determined that the facility failed to meet the oxygen safety requirements in accordance with NFPA 101 (2012) and NFPA 99 (2012). This was evidenced by:1. Oxygen rooms on the first floor and second floor have holes in the drywall, leaving the oxygen rooms unprotected and they do not meet the 1-hour fire resistance rating. NFPA 99 11.3.1* Storage for nonflammable gases equal to or greater than 85 m3 (3000 ft3) at STP shall comply with 5.1.3.3.2 and 5.1.3.3.3. 5.1.3.3.2 * Design and Construction. Locations for central supply systems and the storage of positive-pressure gases shall meet the following requirements:(1) They shall be constructed with access to move cylinders, equipment, and so forth, in and out of the location on hand trucks complying with 11.4.3.1.1.(2) They shall be secured with lockable doors or gates or otherwise secured.(3) If outdoors, they shall be provided with an enclosure (wall or fencing) constructed of noncombustible materials with a minimum of two entry/exits.(4) If indoors, they shall be constructed and use interior finishes of noncombustible or limited-combustible materials such that all walls, floors, ceilings, and doors are of a minimum 1-hour fire resistance rating. (5)* They shall be compliant with NFPA 70, National Electrical Code, for ordinary locations.(6) They shall be heated by indirect means (e.g., steam, hot water) if heat is required. (7) They shall be provided with racks, chains, or other fastenings to secure all cylinders from falling, whether connected, unconnected, full, or empty. (8)* They shall be supplied with electrical power compliant with the requirements for essential electrical systems as described in Chapter 6.(9) They shall have racks, shelves, and supports, where provided, constructed of noncombustible materials or limited-combustible materials.(10) They shall protect electrical devices from physical damage. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the Maintenance Director and Administrator at the exit conference.

A recertification survey with complaint #CO34992 and #CO35002 was completed on 2/21/24 to 2/27/24. Ten deficiencies were cited.

An Emergency Preparedness survey was conducted from 2/21/24 to 2/27/24. No deficiencies were cited.

Based on observation, record review and interviews, the facility failed to ensure the self-administration of medications was clinically appropriate for one (#40) resident out of 53 sample residents. Specifically, the facility failed to:-Ensure Resident #40 was assessed for the appropriateness and safety of self-administration of topical medications; and,-Ensure there was a physician order for self-administration of topical medications. Findings include:I. Professional referenceAccording to the Vicks Vaporub drug fact, retrieved on 2/26/24 from: https://assets.ctfassets.net/nvoox4konz4a/2UQyJBdjHzFWUzLsLPELjn/efb8f4729c2477450e30c1defa14e144/VapoRub-Topical-Ointment-Drug-Facts.pdf, "Do not use by mouth, in nostrils, on wounds or damaged skin."II. Facility policy and procedure:The Self Administration of Medication policy and procedure, revised on 11/28/16, was received from the NHA on 2/27/24 at 11:26 a.m. It revealed in pertinent part, "The facility, in conjunction with the interdisciplinary care team, should assess and determine, with respect to each resident, whether self-administration of medication was safe and clinically appropriate, based on residents functionality and health condition."To ensure safe and appropriate self-administration, the facility should educate resident to ensure that the resident was able to: state name, dose, strength, frequency, and purpose of his/her medications; understand the possible side effects of his/her medications and that he/she should notify facility staff if he/she experiences any such side effects; correctly administer, inject or apply his/her medications; correctly store his/her medications in a locked compartment."The facility should document in the residents care plan whether the resident or facility staff were responsible for storage of the residents medications. If the resident was responsible for the storage of his/her medications, the facility should provide a secured compartment for storage of such medications. The medication storage compartments should be located in the residents room so that another resident was not able to access the medications. The storage compartment should be locked when not in use. "The facility staff should document the self administration of medications on the resident's medication administration record (MAR) according to the medication administration schedule."III. Resident #40 A. Resident statusResident #40, older than 65, admitted on 3/29/23. According to the February 2024 CPO, diagnoses included multiple sclerosis (disease affecting the central nervous system), peripheral vascular disease (disease affecting circulation of the lower body), dependent on oxygen, hypertension (high blood pressure) and dysphagia (difficult swallowing). The 2/7/24 MDS assessment revealed the resident was cognitively intact with a brief interview for mental status score of 13 out of 15. She required two person assistance with bed mobility, transfer, dressing and needed set up assistance for personal hygiene and eating. B. Observations and resident interviewOn 2/21/24 at 10:13 a.m. a container of Vicks Vaporub, a box of Icy Hot lidocaine 4% patches with one patch in the box were on the residents night stand and one bottle of saline nasal spray was on the resident's bedside table..Resident #40 said she used the saline nasal spray for her dry nose because she wore oxygen and it dried it out. Resident #40 did not know how many times a day she could use the saline nasal spray. Resident #40 said the Icy Hot patches help her with shoulder or neck pain but had not used them in a while. Resident #40 said she applied the Vicks Vaporub to her dry cracked lips at least twice a day but sometimes more than that. On 2/26/23 at 12:09 p.m. a saline nasal spray, container of Vicks Vaporub and Icy Hot lidocaine patches were in Resident #40's room. C. Record reviewReview of February 2024 revealed an order for:-Lidocaine external patch 4% to be applied to the right shoulder topically every 12hours as needed.-There were no orders for saline nasal spray or the Vicks Vaporub.-Review of the Resident #40's care plan did not identify the resident ability to self administer medications.-Resident #40 was not assessed to self administer medications. IV. Staff interviewsLPN #1 was interviewed on 2/26/24 at 12:12 p.m. She said residents were not to have medications in their rooms. LPN #1 said if a resident wanted to self administer medications they need to have an order from the physician, ensure the pharmacy knows about the medications to ensure no drug-to-drug interactions and the resident ability to self administer the medications hdto be evaluated. LPN #1 reviewed Resident #40's CPO and identified there was only an order for the lidocaine patches and it did not indicate Resident #40 was able to self administer. LPN #1 said there was no order for the Vicks Vaporub or the saline nasal spray. LPN #1 reviewed assessments for Resident #40 and there was no assessment for self administration of medications completed. LPN #1 was unaware of the hazards of using vicks vaporub and oxygen. LPN #1 was interviewed again at 1:59 p.m. She said she went into Resident #40's room and located the three medications. LPN #1 said Resident #40 told her she used the nasal spray for dry nose from oxygen use and she kept it on her bedside table for easy access. LPN #1 reported Resident #40 threw the box of lidocaine patches in the trash can as she had not used them in a long time after she was questioned about them. LPN #1 said she tried to educate Resident #40 about cracked lips was a sign of dehydration and should drink more fluids instead of using the vicks vaporub on her lips. LPN #1 said Resident #40 refused to give up her medications and she would contact the physician for orders and complete an assessment for self administration of medications for Resident #40. The DON was interviewed on 2/26/24 at 2:51 p.m. He said there were to be no medications in a resident room unless they have been assessed for self administration and the physician has approved self administration. The DON was unaware of the risks of using Vicks Vaporub and oxygen. The NHA was interviewed on 2/26/24 at 2:54 p.m. She said Vicks Vaporub should not be used when oxygen was in use due to risks of injury. The DON was interviewed on 2/27/24 at 10:41 a.m. He said Resident #40 had been assessed for self administration of the Vicks Vaporub and saline nasal spray and the physician approved the medications for use. The DON said he spoke with Resident #40 in the morning to educate on the medications and risks. Resident #40 wished to continue use of the vicks despite her use for oxygen. The DON said it would be the responsibility of nursing staff to monitor for the storage of medication in resident rooms but should be kept in a secure place like a drawer to prevent other residents from having access to them.

Based on observations, record review and interviews, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene for one (#33) of five residents reviewed out of 53 sample residents. Specifically, the facility failed to ensure Resident #33 received her scheduled showers, who was dependent on staff for bathing. Findings include:I. Facility policyThe Activities of Daily Living (ADL) policy, revised 8/23/23, was provided by the nursing home administrator (NHA) on 2/26/24 at 2:19 p.m. It read in pertinent part: "The resident will receive assistance with ADLs (bathing, dressing, grooming, and oral care)."II. Resident #33A. Resident statusResident #33, age below 65, was admitted on 9/29/21 and readmitted on 1/30/24. According to the February 2024 computerized physician orders (CPO), diagnoses included multiple sclerosis, muscle weakness, abnormalities of the gait and mobility, dependence on a wheelchair, contracture of the right hand, major depressive disorder and a history of falling. The 2/2/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score (BIMS) of 15 out of 15. She was dependent on staff for toileting and bathing. B. Resident interviewResident #33 was interviewed on 2/21/24 at 11:27 a.m. She said she usually did not receive her shower on Sundays. She said the previous Sunday she did not get her shower because the facility was short staffed. She said she finally received a shower the following Tuesday because she had vomited all over herself. C. Record reviewReview of the January and February shower logs revealed she received only 11 showers and refused one time out of 16 opportunities. -The missing showers were on a Sunday. The ADL care plan, revised on 7/18/22, revealed Resident #33 had a self care performance deficit related to her disease process of multiple sclerosis. Interventions included the resident required assistance by two staff members with bathing/showering twice weekly and as necessary.-Review of the medical record failed to show the resident received her two showers a week according to her care plan. III. Staff interviewsCertified nurse aide (CNA) #1 was interviewed on 2/26/24 at 1:57 p.m. She said the CNA was responsible for giving the residents their showers. She said if staff did not have time to complete the scheduled shower, they would be offered a bed bath or wait until their next scheduled shower. She said showers should be given on the scheduled days to keep the resident clean and odor free. Licensed practical nurse (LPN) #2 was interviewed on 2/26/24 at 2:06 p.m. She said the CNA was responsible for completing scheduled showers. She said the shower was then logged into the medical record. She said if the shower was missed, staff needed to document why it was missed. She said showers should be given on the scheduled days for skin integrity and to keep the resident free from infections. The assistant director of nursing (ADON) was interviewed on 2/26/24 at 2:24 p.m. She said showers should be given on their scheduled days and as needed. She said it was very important for skin integrity and infections. The director of nursing (DON) was interviewed on 2/26/24 at 2:27 p.m. He said management conducted weekly audits and the results were discussed weekly on Thursdays. He said he did not know why Resident #33 had missing showers. He said showers should be given on the scheduled days and as needed for skin integrity.

Based on observations, interviews and record review, the facility failed to assist residents with making appointments and arranging transportation for one (#89) of three residents reviewed for vision/ancillary services out of 53 sample residents. Specifically, the facility failed to offer and make an appointment for optometry services for resident #89. Findings include:I. Facility policyThe Podiatry policy and procedure, revised 9/8/23, was provided by the nursing home administrator (NHA) on 2/27/24 at 11:26 a.m. It revealed in pertinent part, "The facility will ensure residents receive proper treatment and assistive devices to maintain vision abilities."II. Resident statusResident #89, age greater than 65, was admitted on 11/27/23. According to the February 2024 computerized physician orders (CPO), diagnoses included non-pressure chronic ulcer of the left calf with unspecified severity, history of falling and adult failure to thrive. The 12/21/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She was independent with eating. She required setup help with oral hygiene, and partial/moderate assistance with toileting. She required substantial/maximal assistance with showers. The 11/29/23 MDS assessment revealed the resident had impaired vision but did not wear any corrective lenses. III. Resident observation and interviewResident #89 was interviewed on 2/22/24 at 8:50 a.m. The resident was not wearing glasses at the time of the interview. Resident #89 said she had a hard time seeing. She said she could barely read anything on the television and she was unable to read any documents. She said she typically wore glasses, however, she said she did not have any. She said she had contacts with her but they were dried out and the prescription on them needed to be updated. Resident #89 said she had told nursing staff she needed to see the eye doctor a few months ago but no one had followed up with her about an appointment. She said her vision had gotten worse since she was admitted and she would love to see the eye doctor and get a new prescription or updated glasses in order to see again. IV. Record reviewThe February 2024 CPO revealed the following physician's order:Resident may have dental, podiatry, audiology and optometry care as needed. Ordered 11/28/23The nursing progress note dated 11/28/23 at 3:45 p.m. documented in pertinent part, "The resident's vision was impaired for regular print. She can see large print without glasses. She does not have her contacts with her, they are at home. Said she needs to see her eye doctor for a new eye exam."Review of Resident #89's care plan, revised 12/11/23, revealed the resident had impaired visual function related to the aging process. Interventions included: arrange consultation with eye care practitioner as required, observe and report as needed any signs and symptoms of acute eye problems: change in ability to perform activities of daily living (ADL), decline in mobility, sudden visual loss, pupils dilated, gray or milky, complaints of halos around lights, double vision, tunnel vision, blurred or hazy vision and tell the resident where you are placing their items and to be consistent. Review of Resident #89's electronic medical record (EMR) did not reveal the resident was offered or provided access to optometry services until 2/27/24 (during the survey). V. Staff interviewsRegistered nurse (RN) #1 was interviewed on 2/26/24 at 2:04 p.m. RN #1 said she was not aware that Resident #89 had any issues with her vision since she was new to the wing the resident resided on. She said if the resident complained of vision problems she would notify the social services director (SSD) so she could put the resident on the list to be seen by the eye doctor. The SSD was interviewed on 2/26/24 at 2:27 p.m. She said residents and/or the residents' responsible party should be offered ancillary services upon admission and every quarter during the care plan conference. She said it should be documented in the progress notes that ancillary services were offered. She said she was unable to find documentation to indicate Resident #89 and/or her representative were offered optometry services since the resident's admission on 11/27/23. Certified nurse aide (CNA) #2 was interviewed on 2/27/24 at 9:58 a.m. CNA #2 said she was unsure if Resident #89 wore glasses or if she had impaired vision. She said if the resident complained to her about impaired vision she would let the nurse know. She said sometimes it was hard to remember to tell the nurse if she got busy and had to provide care to other residents. RN #2 was interviewed on 2/27/24 at 10:05 a.m. RN #2 said Resident #89 could see without any issues and she wore glasses sometimes. She said she had worked with the resident since her admission to the facility and it was never reported on the nursing report sheet that the resident had impaired vision. The director of nursing (DON) was interviewed on 2/27/24 at 10:46 a.m. The DON said if a resident experienced changes in their vision or had impaired vision the nursing staff should contact the physician for orders. He said nursing staff should notify the SSD in order to place the resident on the ancillary services list to ensure the resident was seen by the optometrist. The DON said he needed to provide an all staff education related to ancillary services. The nursing home administrator (NHA) was interviewed on 2/27/24 at 11:55 a.m. The NHA said the Resident #89 should have been offered all ancillary services which included vision. She said if the resident complained of any vision impairment, nursing care staff should have notified the SSD and the resident would have been placed on a list to be seen by the eye doctor in order to receive vision care.

Based on observations, record review and interviews the facility failed to ensure one (#89) of three residents reviewed for ancillary services, such as podiatry services, out of 53 sample residents received proper foot care and treatment according to standards of practice. Specifically, the facility failed to ensure podiatry care was provided timely and as requested by Resident #89. Findings include:I. Facility policyThe Nail Care policy and procedure, revised 9/8/23 was provided by the nursing home administrator (NHA) on 2/27/24 at 11:26 a.m. It revealed in pertinent part "The facility will provide foot care and treatment, in accordance with professional standards of practice, including to prevent complications from the resident's medical conditions and if necessary, assist the resident in making appointments with a qualified person, and arranging for transportation to and from such appointments."I. Resident statusResident #89, age greater than 65, was admitted on 11/27/23. According to the February 2024 computerized physician orders (CPO), diagnoses included non-pressure chronic ulcer of the left calf with unspecified severity, history of falling and adult failure to thrive. According to the 12/21/23 minimum data set (MDS) assessment, the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She was independent with eating. She required setup help with oral hygiene, and partial/moderate assistance with toileting. She required substantial/maximal assistance with showers. II. Resident observation and interviewOn 2/22/24 at 8:49 a.m., Resident #89 was in her room. The toenails on both of the resident's feet were thick and approximately three inches long. Resident #89 said she liked to keep her toenails cleaned and trimmed. She said she maintained regular visits with the podiatrist before she was admitted to the facility. Resident #89 said she had asked nursing staff to cut her toenails, however, she said the nursing staff told her they are unable to cut her toenails. She said the nursing staff had not told her why they were unable to cut her toenails. She said she did not know why she could not see a podiatrist. Resident #89 said her toenails bothered her and she would love to get them cut. III. Record reviewThe February 2024 CPO revealed the following physician's order:Resident may have dental, podiatry, audiology and optometry care as needed. Ordered 11/28/23. Review of Resident #89's care plan, revised 12/11/23, revealed the resident had an activity of daily living (ADL) self-care performance deficit related to weakness, pain and decreased mobility. Interventions included: checking the resident's nail length and trimming and cleaning nails on bath days and as necessary and t reporting any changes to the nurse. Review of Resident #89's electronic medical record (EMR) did not reveal the resident was offered or provided access to podiatry services until 2/27/24 (during the survey). IV. Staff interviewsRegistered nurse (RN) #1 was interviewed on 2/26/24 at 2:04 p.m. RN #1 said she was not aware that Resident #89 had any issues with her toenails since she was new to the wing the resident resided on. She said if the resident complained of long toenails then nursing staff were able to cut them unless the toenails were too thick and/or too long. RN #1 said nursing staff should not cut a resident's toenails if the resident was a diabetic. She said if the resident had toenail issues that could not be addressed by nursing staff she would notify the social services director (SSD) so she could put the resident on the list to be seen by the podiatrist. The SSD was interviewed on 2/26/24 at 2:27 p.m. The SSD said residents and/or the residents' responsible party should be offered ancillary services upon admission and every quarter during the care plan conference. She said it should be documented in the progress notes that ancillary services were offered. She said she was unable to find documentation to indicate Resident #89 and/or her representative were offered podiatry services since the resident's admission on 11/27/23. Certified nursing assistant (CNA) #2 was interviewed on 2/27/24 at 9:58 a.m. CNA #2 said she was unsure if Resident #89 had long toenails because showers occurred during the evening time. She said if the resident complained to her about long toenails she would let the nurse know. She said sometimes it was hard to remember to tell the nurse if she got busy and had to provide care to other residents. RN #2 was interviewed on 2/27/24 at 10:05 a.m. RN #2 said she did not know if Resident #89 had long toenails because it was never reported to her by CNA staff and it was never passed on to her through nursing report sheets. RN #2 observed the resident's toenails and said she would need to have her seen by a podiatrist to get her toenails cut because the resident's toenails had become too thick and long. The director of nursing (DON) was interviewed on 2/27/24 at 10:46 a.m. The DON said if a resident had long toenails then CNA staff should have informed the nurse. He said nurses were supposed to document long nails on the skin check form. He said nurses were the only staff members allowed to cut nails. He said if a nurse was uncomfortable cutting a resident's nails and/or the resident had toenail issues staff should notify him and contact the physician for podiatry orders. The DON said nursing staff should notify the SSDl in order to place the resident on the ancillary services list to ensure the resident was seen by the podiatrist. The DON said he needed to provide an all staff education related to ancillary services and documentation expectations for the skin check forms. The nursing home administrator (NHA) was interviewed on 2/27/24 at 11:55 a.m. The NHA said the resident should have been offered all ancillary services which included podiatry. She said if the resident complained of any nail issues nursing staff should attempt to cut them only if there were no complex comorbidities such as diabetes. She said the staff should have notified the SSD and the resident would have been placed on a list to be seen by the podiatrist in order to receive foot care.

Based on record review and interviews, the facility failed to ensure the residents' environment remained as free from accident hazards as possible and prevent falls with major injury for two (#46 and #76) of four residents reviewed for falls out of 53 sample residents. Resident #46, who had a known history of falls, had a diagnosis of obesity which required the use of a bariatric (to support substantial weight) bed with extensions to enable the bed frame to be made larger. On 1/29/24, the resident sustained a witnessed fall from her bed when she was being rolled on her side with the assistance of staff during a bed bath. Resident #46 was sent to the hospital for evaluation of left knee pain following the fall where she was discovered to have a fracture of her left femur (thigh bone), which was surgically repaired on 1/30/24. The resident returned to the facility on 2/1/24 and was placed in the same bed she fell from on 1/29/24. The facility did not inspect the bed to ensure the extensions were pulled out appropriately and the mattress fit correctly prior to placing the resident back in the bed. On 2/5/24 (4 days after Resident #46's readmission to the facility), a rental supply company came to the facility to install bed canes (a device which can be utilized to assist a person to reposition themselves in bed). The rental supply company's personnel discovered the extensions on Resident #46's bed had not been pulled out prior to the resident's fall from the bed and the facility had failed to pull the extensions out prior to the resident's readmission to the facility. Additionally, Resident #76, who had diagnoses of muscle weakness and unsteadiness on her feet, was admitted to the facility on 9/30/23. The resident had a history of falls with injuries in the 12 months prior to her admission to the facility. She required partial assistance with her toileting, bathing and moving from a sitting position to a standing position. The facility failed to implement appropriate person-centered fall interventions for the resident upon her admission to the facility. On 10/20/23, Resident #76 sustained a fall after tripping while she was attempting to get clothes from her closet. The resident complained of pain in her right wrist and x-rays were obtained which revealed she sustained a fracture to her right pinky finger and right thumb. The facility put an intervention in place to educate the resident to remember to turn on the overhead light before moving around in her room, however, the resident sustained five more falls following the 10/20/23 fall. The facility failed to put new and effective interventions into place after each fall to prevent the resident from sustaining further falls. Due to the facility's failure to properly evaluate Resident #46's bed frame and mattress for appropriate functionality and fit and the failure to implement timely and effective person-centered fall interventions for Resident #76, both residents sustained falls with major injury and experienced pain. I. Findings include A. Policy and procedureThe Fall Management policy and procedure, reviewed 11/30/22, was provided by the nursing home administrator (NHA) on 2/26/24 at 2:19 p.m. It read in pertinent part: "To promote patient safety and reduce patient falls by proactively identifying, care planning and monitoring of patients' fall indications."The facility must ensure the resident environment remains as free of accident hazards as is possible and each resident receives adequate supervision and assistance devices to prevent accidents. "Residents will be assessed for fall indications upon admission, readmission, quarterly, change in condition, and with any fall utilizing the Fall Risk Assessment."II. Resident #46A. Resident statusResident #46, age 71, was admitted on 6/29/22 and readmitted on 2/1/24. According to the February 2024 computerized physician orders (CPO), diagnoses include chronic respiratory failure, insomnia, chronic pain, bed confinement, colostomy, lowback pain, muscle weakness, lack of coordination, history of falling and body mass index of 45.0 to 49.9 (obesity). The 2/2/24 minimum data set (MDS) assessment revealed the resident had normal cognition with a brief interview for mental status (BIMS) score of 15 out of 15. The resident required two person assistance with dressing, toileting, bathing/showering, bed mobility and use of a mechanical lift with two staff members for transfers. The resident required one person assistance with personal hygiene and was independent for eating. B. Resident interview Resident #46 was interviewed on 2/21/24 at 11:26 a.m. The resident said she had fallen out of bed on 1/29/24. The resident said the problem was the bed. She said she felt as if she were sliding out of the bed when being turned onto her side. She said the staff had not pulled the slide outs/extensions out so the mattress fit correctly. She said she had been in the center of the bed, had started slipping and was unable to catch herself before falling to the floor. She said when she returned from the hospital the bed rental company personnel came to install bed canes and discovered the extensions had not been pulled out. C. Record reviewA nursing note dated 1/29/2024 at 6:51 p.m. documented a witnessed fall. A certified nurses aide (CNA) had yelled for help due to a resident falling from her bed while receiving a bed bath. Upon entering the room the resident was found on the left side of the bed on the ground. The resident was screaming in pain. The resident had swelling and a scrape on her left knee and was not able to move it. The resident was sent to the hospital for evaluation of her left knee. An emergency department (ED) note, dated 1/29/24, documented the resident fell out of bed during a bed bath landing on her left knee which was bruised with joint effusion (swelling). A diagnostic radiology (x-ray) note, dated 1/29/24, documented Resident #46 sustained a comminuted (broken in three or more places) mildly displaced and impacted (a break where the ends are driven into each other) distal (near the knee) femoral fracture. The operative report, dated 1/30/24, documented the operation/procedure of an open reduction (repositioning of pieces of fractured bone) and nailing of the femur fracture. A stryker 13 by 1340 millimeter (mm) nail locked the knee with three advanced locking screws and locked proximally (nearer the body) with one screw. Hospital discharge documentation, dated 2/1/24, documented the resident was discharged back to the facility. A facility readmission note, dated 2/1/24, at 3:35 p.m. documented the resident returned to the facility by stretcher. A bed rental company report, dated 2/5/24, documented the service to Resident #46's bed for placement of assist bars (bed canes). D. Staff interviewsLicenced practice nurse (LPN) #2 was interviewed on 2/26/24 at 1:21 p.m. LPN #2 said the staff should check the bed before residents were admitted to ensure the bed was working properly and the mattress fit correctly. LPN #1 was interviewed on 2/26/24 at 2:06 p.m. LPN #1 said the bariatric (large size) beds, which was the type of bed Resident #46 used, had extensions to make the bed frame larger. She said the bariatric beds with the extensions were delivered to the residents' rooms from the facility's central supply (CS). She said CS personnel were supposed to check the bed to ensure the bed was working properly and the extensions were pulled out to accommodate the mattress. She said the mattress should fit inside the bed frame. LPN #1 said the extensions could be adjusted while the resident was in the bed, however, she said it was better to adjust them before the resident got into the bed. She said if a resident felt something was wrong with the bed, nursing staff should call maintenance to check the bed. The central supply director (CSD) was interviewed on 2/26/24 at 3:03 p.m. The CSD said Resident #46's bed had not been checked due to the resident being readmitted on 2/1/24 to the facility after she had left work for the day. She said the nursing staff should check the frame if the CSD was not available. She said the bed rental personnel had reported the extension bars were not all the way out on one side on 2/5/24 when they came to install the bed canes. The CSD said the extensions were not hard to pull out. She said the staff should report if the mattress was too small for the bed. She said there was no report of problems with the bed until the bed canes were put on by the service provider on 2/5/24. The director of nursing (DON) was interviewed on 2/27/24 at 11:33 a.m. The DON said if a resident was reporting a feeling of slipping in the bed it should be reported and the facility should look into the cause. He said the admissions staff and the CSD ensured the resident had the correct size bed. He said nursing staff was responsible for ensuring the extensions on the bed frame were pulled out and the mattress fit the bed appropriately. He said nurses should look at the frame. He said Resident #46 slipping from the bed could have been a bed frame problem. III. Resident #76A. Resident StatusResident #76, age 80, was admitted on 9/30/23 and readmitted 12/27/23. According to the February 2024 CPO, diagnoses included fracture of the sacrum, fracture of the left pubis (pelvis), multiple fractures of the ribs, history of falling, muscle weakness, unsteadiness on feet, fracture of the fifth metacarpal bone (pinky) and thumb on the right hand, depression, and anxiety. The 12/29/24 MDS assessment revealed, the resident had moderate cognitive impairment with a BIMS score of 11 out of 15. She had impairment to both sides of her lower extremities. She used a walker and wheelchair. She had falls prior to admission as well as falls in the facility. She had a fall with a fracture. She required partial assistance with toileting, bathing, and sitting to standing. B. Resident interviewResident #76 was interviewed on 2/21/24 at 11:15 a.m. She said she had many falls. She said she fell and broke her thumb and pinky when she tripped over the wheel on her wheelchair. She said she also slid off the mattress and asked staff for a different one. She said staff told her all the mattresses were the same. She said when she stood up, she had nothing to hold onto. She asked staff if she could have a side rail and was told facilities were not allowed to put side rails on a resident's bed. C. Record reviewA physician's order, dated 10/20/23, instructed staff to send the resident to the hospital for abnormal x-ray results. A physician's order, dated 10/27/23, documented a fractured right fifth digit (pinky finger). Put the fourth digit together with the fifth digit as a guardian, apply a long cast from the fifth digit to the forearm, secure with ace wrap from finger to forearm. Let the thumb, middle, and ring finger be free from the ace wrap. Leave in place at all times every shift for a right fifth digit fracture. A physician's order, dated 10/27/23, documented a right thumb fracture. Apply an aluminum cast, U shaped and secure with coban. Leave in place at all times for thumb fracture. The hospitalization care plan, initiated 10/16/23, revealed Resident #76 was at risk for rehospitalization due to a history of injurious falls in the past 12 months. The interventions included labs as ordered, provide medications as ordered, registered dietician to evaluate and staff to provide timely communication to the physician regarding any change in resident condition. The fall risk care plan, initiated on 9/30/23 and revised on 10/16/23 revealed Resident #76 had a history of falls with injuries. Interventions included:-Assess if the resident wanted her bed made frequently and place the bed against the wall, initiated 2/12/24;-Assess toileting needs frequently, initiated 1/2/24;-Assist with activities of daily living as needed, initiated 9/30/23;-Bathroom lights to remain on at all times and remind resident to turn overhead light on when walking around the room, initiated 10/20/23;-Keep call light, reacher, and frequently used items within reach, initiated 9/30/23;-Complete a fall risk assessment, initiated 9/30/23;-Provide appropriate footwear/non-skid socks when ambulating, initiated 1/19/24; and,-Physical therapy to evaluate and treat, initiated 1/19/24. Review of Resident #76's falls were reviewed from 10/20/23 to 2/9/24.1. 10/20/23 fallAn event progress note, dated 10/20/23 at 11:15 a.m., revealed Resident #76 was found lying on her right side next to her bed. Her call light was within reach but not activated. The room had poor lighting and the resident did not turn on the light. The resident stated she was trying to get clothes from her closet and tripped. The resident expressed pain to her right wrist and bruising was noted to the left wrist. The physician was notified and x-rays of both wrists were ordered. The intervention was to educate the resident to remember to turn the overhead light on before movement in the room.-There was no fall investigation provided for the 10/20/23 fall. 2. 11/17/23 fallA health status progress note, dated 11/17/23 at 7:45 p.m., revealed the registered nurse (RN) supervisor was called to the unit because Resident #76 was on the floor. She required maximum assistance of two staff members to be lifted off the floor. An abrasion was found to the resident's mid lower back. The fall investigation dated 11/17/23 revealed the resident was found sitting on the floor after losing her balance at bedside. The resident stated she was reaching for an item near her bedside night stand. The intervention was to place frequently used items in reach of the resident. 3. 12/1/23 fallA health status progress note, dated 12/1/23 at 7:08 p.m., revealed Resident #76 had a fall. She was found while eating her dinner. She was sitting in a chair. There was no complaint of pain. The fall investigation dated 12/1/23 revealed the resident's roommate was able to activate the call light and call the nurses station from her cell phone. Resident #76 said she was seated in front of her bedside table and stood up to retrieve her purse. She said she felt she might fall and backed up to her bed. The resident assisted herself up from the floor. She had no injuries. -The intervention was to continue to remind the resident to use her call light to get items at a distance, which was the same intervention implemented for the fall on 11/17/23.-There were no new fall interventions put into place. 4. 12/22/23 fallAn event progress note, dated 12/22/23 at 1:14 p.m,. revealed Resident #76 was found on the floor next to her bed in a sitting position. The resident stated she had tried to reach for her grabber and slid off the bed. The fall investigation dated 12/22/23 revealed the resident had no injuries. The intervention was to make sure her grabber and belongings were within reach. All the staff were aware to check the resident regularly. The resident was reminded to use her call light.-Despite the fall investigation documenting that all staff were aware to check the resident regularly, frequent checks were not implemented as a fall intervention on the resident's care plan. 5. 1/2/24 fallAn event progress note, dated 1/2/24 at 12:33 a.m., revealed Resident #76 was found on the floor by a certified nurse aide (CNA). The resident was lying prone (face down) between the bathroom and the foot of her bed. She had pillows beneath her face. The call light was not activated. The resident's walker was approximately one foot away from her. The bed was soaked with urine. She had a small scratch to her left knee and complained of pain to her left leg and buttocks. The resident stated she exited the bathroom and her weakened hands led to a fall. She was assisted back to bed by three staff members. The fall investigation dated 1/2/24 revealed the resident fell after exiting the bathroom. The intervention was to assess the residents' toileting needs frequently.-The intervention didnot document how frequently the resident should be offered toileting. 6. 2/9/24 fallAn event progress note, dated 2/9/24 at 8:50 p.m., revealed Resident #76 was found on the floor at her bedside. She acknowledged she fell while trying to reach the call button as she was making her bed. There were no injuries noted. The fall investigation dated 2/9/24 revealed the resident was found on the floor and initially denied falling. The intervention was to have staff offer to make her bed when it was untidy or upon the resident's request. She was currently working with therapy to improve strength. D. Staff interviewsCNA #1 was interviewed on 2/26/24 at 1:55 p.m. CNA #1 said Resident #76 was a stand by assist (SBA) for transfers and ambulation. She said the resident used her call light when she needed help. She said she did not know what interventions were put into place to help her from falling. LPN #2 was interviewed on 2/26/24 at 2:07 p.m. LPN #2 said she had worked with Resident #76 a couple weeks ago but was not told what fall interventions were put into place. She said if a resident had a fall, a new intervention should be put into place for each fall. The DON was interviewed on 2/26/24 at 2:29 p.m. The DON said Resident #76 liked to be independent. He said interventions that had been put into place were making sure the bathroom light was on, making her bed regularly, and making sure her grabber was in reach. He said he had thought about placing a bed cane on her bed but was afraid she would hit her head. He said he had not thought about placing a transfer pole at her bedside.

Based on observations, record review, and interviews, the facility failed to ensure residents with a gastrostomy tube received appropriate treatment and services to prevent complications for one (#18) of three residents reviewed for tube feeding management out of 53 sample residents. Specifically, the facility failed to label Resident #18's tube feeding bag with the date and time the tube feeding bag was hung, the initials of the nurse hanging the tube feeding bag, the type of tube feeding the resident was receiving and the flow rate for the tube feeding administration. Findings include: I. Facility policy and procedure The Enteral Nutrition Therapy (Bolus) policy, dated 8/8/23, was provided by the nursing home administrator (NHA) on 2/27/24 at 12:35 p.m. It read in pertinent part, "The facility will provide bolus enteral nutrition therapy in accordance with physician orders and professional standards of practice. The facility will utilize the Lippincott procedure." II. Resident status Resident #18, age greater than 65, was admitted on 9/20/23. According to the February 2024 computerized physician orders (CPO), diagnoses included pressure ulcer of sacral region, stage 4, pressure ulcer of right buttock, stage 4, pressure ulcer of left buttock, stage 4,unspecified severe protein-calorie malnutrition, encounter for attention to gastrostomy, multiple sclerosis and dependence on wheelchair. According to the 12/27/23 minimum data set (MDS) assessment, the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She required setup help with oral hygiene and required substantial/maximal assistance with showers and toileting. The assessment revealed the resident had a feeding tube. III. ObservationsOn 2/22/24 at 8:05 a.m., the resident's tube feeding pump was observed connected to her while she laid in bed. The tube feeding pump was connected to an intravenous (IV) pole with one tube feeding bag hanging from the pole. The tube feeding formula bag was transparent without any labels. The tube feeding appeared to be a brown colored liquid that was not identified.-The tube feeding bag was not labeled with the date and time the tube feeding was hung, the initials of the nurse that hung the tube feeding bag, the type of tube feeding the resident was receiving and the flow rate for the tube feeding administration. III. Record review The 12/27/23 physician's order documented in pertinent part, "Enteral Feed at bedtime for PEG (percutaneous endoscopic gastrostomy) tube Jevity 1.5 (tube feeding formula) at 70 ml (milliliters) per hour for 12 hours, on at 9:00 p.m. and off at 9:00 a.m.. Water 100 ml every four hours for 12 hours. Total of 840 ml tube feeding and 300 ml free water flush."IV. Staff interviewsRegistered nurse (RN) #1 was interviewed on 2/22/24 at 8:15 a.m. RN #1 said she had not connected Resident #18's enteral nutrition since she came on shift at 6:00 a.m. She said when the tube feeding formula was hung a label should be placed on the bag with the nurse's initials, time it was initiated, the formula and rate. She said she was unable to identify the fluid that was inside the tube feeding bag. She said when she disconnected the tube feeding connector from the PEG tube she ensured the connector was cleaned and stored away covered with no residual left on it. The assistant director of nursing (ADON) was interviewed on 2/22/24 at 8:30 a.m. The ADON said she identified the unlabeled tube feeding bag and relabeled it. She said she was able to identify the liquid was Jevity 1.5 because she called the nurse that hung it and verified that she poured Jevity 1.5 but she forgot to label the tube feeding bag. The director of nursing (DON) was interviewed on 2/27/24 at 3:20 p.m. The DON said the tube feeding should have been paused once the day shift nurse identified the unlabeled bag and then contacted the physician to notify them and followed the physician's instructions.

Based on observations, record review and interviews, the facility failed to ensure two (#62 and #68) of four residents who required respiratory care received care consistent with professional standards of practice out of 53 sample residents. Specifically, the facility failed to:-Follow manufacturer recommendations to maintain, clean, sanitize and store Resident #62 and Resident #68's continuous positive airway pressure (CPAP) mask and machine;-Accurately complete section O in the minimum data set (MDS) assessment under respiratory treatments for Resident #62 and Resident #68;-Ensure a care plan was in place to include settings, cleaning, disinfecting and storage of the CPAP for Resident #62; and, -Ensure Resident #68's CPAP mask sealed properly because it was torn. Findings include:I. Facility policy and proceduresThe BiPAP/CPAP Administration policy, revised 9/26/23, was provided by the nursing home administrator (NHA) on 2/26/24 at 11:01 a.m. The policy revealed in pertinent part: "The reservoir should be filled daily with sterile or distilled water to the fill line. Each day when the resident is removed from the machine the reservoir should be emptied and left to air dry. To clean the face mask, alcohol prep pads or warm soapy water can be used as needed. If the mask/tubing is washed with warm soapy water, they should be air dried completely."II. Resident #62 A. Resident statusResident #62, age above 65, was admitted on 10/5/2020 and readmitted on 9/8/23. According to the February 2024 computerized physician orders (CPO), diagnoses included congestive heart failure, atrial fibrillation (abnormal heart beat), pulmonary hypertension (affects arteries in the lungs), dependence on supplemental oxygen, shortness of breath and obstructive sleep apnea. The 12/4/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score (BIMS) of 15 out of 15. She was dependent on staff for toileting, showering, and personal hygiene. She used oxygen. -The use of the CPAP was not triggered/coded on the MDS assessment under section O.B. Resident interviewResident #62 was interviewed on 2/21/24 at 2:20 p.m. She said she did not know how often her CPAP mask was supposed to be cleaned by staff. She said she cleaned the mask herself daily. She said she cleaned the mask with a skin wash towelette that she kept in a Styrofoam cup on her overbed table. She said the mask was always stored on top of her CPAP machine but not in a plastic bag. C. ObservationsThe CPAP was observed on 2/21/24, 2/22/24 and 2/26/24 on the resident's night stand next to her bed. The CPAP mask was attached to the tubing and placed on top of the night stand laying across the CPAP machine. D. Record reviewReview of the February 2024 treatment administration record (TAR) revealed the following orders:-Clean mask with warm soapy water, rinse, set out to dry every day shift. The order was dated 12/5/23.-Clean reservoir with warm soapy water, rinse, set out to dry everyday shift on Saturday. The order was dated 12/2/23. -There was not a care plan addressing the use of the CPAP. III. Resident #68 A. Resident statusResident #68, age above 65, was admitted on 5/17/22 and readmitted 11/13/23. According to the February 2024 CPO, diagnoses included severe morbid obesity, acute and chronic respiratory failure, dependence on supplemental oxygen, anxiety disorder and obstructive sleep apnea. The 1/5/24 MDS assessment revealed the resident was cognitively intact with a BIMS of 15 out of 15. She required maximum assistance with transfers. She used oxygen. -The use of the CPAP was not triggered/coded on the MDS assessment under section O.B. Resident interviewResident #68 was interviewed on 2/21/24 at 10:53 a.m. She said she did not know when or if her CPAP tubing had been changed. She said she did not know how often the mask should be cleaned or cleaned with. She said she had not seen staff clean her mask. She said her mask had beentorn for a while and did not seal properly. She said she was embarrassed because it made so many noises from not sealing properly. She said she had let staff know she needed a new mask. C. ObservationsThe CPAP was observed on 2/21/24, 2/22/24, and 2/26/24 before noon on the resident's night stand next to her bed. The CPAP mask was attached to the tubing and placed on top of the night stand laying across the CPAP machine. D. Record reviewReview of the February 2024 TAR revealed the following orders:-Clean mask with warm soapy water, rinse, set out to dry every day shift. The order was dated 12/5/23.-Clean reservoir with warm soapy water, rinse, set out to dry every seven days. The order was dated 11/13/23. The CPAP care plan, revised on 12/5/23, revealed Resident #68 used a CPAP for obstructive sleep apnea. The interventions included:-Assess for signs and symptoms of hypoxia (low oxygen).-BiPAP on when sleeping and off while awake-BiPAP with following settings: AVAPS, Tidal volume 500mL, FiO2% 40, Measured IPAP 23 cmH2O, set EPAP/CPAP 10 cmH2O, set rate 24, P max 25 cmH2O, P min 15 cmH2O, I-time 0.9 sec, rise time 3 sec.-Wash BIPAP mask with warm soapy water, rinse and air dry.-Wash BIPAP Reservoir with warm soapy water, rinse and air dry. IV. Staff interviewsCertified nurse aide (CNA) #1 was interviewed on 2/26/24 at 1:50 p.m. She said the nurse was responsible for cleaning and storing the CPAP mask. She said she did not know how the mask should be stored. Licensed practical nurse (LPN) #2 was interviewed on 2/26/24 at 2:05 p.m. She said the nurse was responsible for cleaning the CPAP mask daily. She said the mask should be stored in a clear plastic bag. -LPN #2 observed the CPAP mask for Resident #62 and Resident #68 not stored in a plastic bag. LPN #2 said if a mask had a tear in it, or did not fit properly, the nurse would call the physician and get an order for the resident to be refitted for a new mask. The assistant director of nursing (ADON) was interviewed on 2/26/24 at 2:12 p.m. She said the nurses were responsible for cleaning and storing the CPAP and mask. She said the mask should be cleaned daily according to the physician's order. She said the reservoir should be cleaned weekly on Sunday with warm soapy water. She said the tubing should be changed weekly. She said the mask should fit properly to avoid leaks. The ADON said Resident #68 last had a respiratory visit in November 2023. She said the mask should be cleaned daily and stored in a clear plastic bag to avoid respiratory infections. The director of nursing (DON) was interviewed on 2/26/24 at 2:22 p.m. He said the nurses were responsible for cleaning and storing the CPAP and mask. He said the mask should be cleaned daily according to the physician's order. He said the mask should fit properly to avoid leaks. The DON said the mask should be cleaned daily and stored in a clear plastic bag to avoid respiratory infections. V. Facility follow upA progress note dated 2/24/24 at 5:06 p.m. documented the respiratory company was notified of the torn mask and a new mask would be sent overnight for Resident #68. A progress note dated 2/26/24 at 3:09 p.m. documented the respiratory company was notified a second time of the torn mask and a new mask would be sent overnight for Resident #68.

Based on observations, record review and interviews, the facility failed to ensure the medication error rate was less than five percent. Specifically, the facility had a medication error rate of 14.29%, which was five errors out of 35 opportunities for error. Findings include:I. Professional referenceAccording to Potter, P.A., Perry, A.G., et.al., Fundamentals of Nursing, 10 ed. (2020), E.sevier, St. Louis Missouri, pp. 606-607. "Take appropriate actions to ensure the patient receives medication as prescribed and within the times prescribed and in the appropriate environment. Professional Standards such as nursing scope and standards of practice apply to the activity of medication administration. To prevent medication errors, follow the seven rights of medication administration consistently every time you administer medications. Many medication errors can be linked in some way to an inconsistency in adhering to these seven rights: 1. The right medication 2. The right dose 3. The right patient 4. The right route 5. The right time 6. The right documentation 7. The right indication."According to the Instructions for use Alvesco Inhalation Aerosol, retrieved on 2/27/24 from: https://www.alvesco.us/_resources/Alvesco-InstructionsForUse.pdf. It revealed in pertinent part, "Rinse your mouth out with water and spit it out. Do not swallow."II. Facility policy and procedureThe Administration of Medications policy, revised 7/14/21, was received from the nursing home administrator (NHA) on 2/26/24 at 11:01 a.m. It revealed in pertinent part, "All medications were administered safely and appropriately per physician order to address residents' diagnosis and signs and symptoms. "Medication error means the observed or identified preparation for administration of medication or biologicals which is not in accordance with the prescribers order."III. Observations and staff interviewsOn 2/26/24 at 8:03 a.m. licensed practical nurse (LPN) #2 was observed preparing and administering medications to Resident #23. LPN #2 dispensed a 100 milligram (mg) tablet of Seroquel (antipsychotic) to the medication cup and checked off Glipizide (used for high blood glucose) 10 mg. The order indicated Glipizide 10 mg to be administered twice daily and according to the resident's medication administration record (MAR) administered at 7:30 a.m. and 4:30 p.m. The Seroquel 100 mg was ordered twice daily and ordered to be administered at 6:00 a.m. and 8:00 p.m. according to the resident's MAR.LPN #2 dispensed Sertraline (antidepressant) 100 mg into the medication cup and checked off Losartan (blood pressure medication). The MAR documented Losartan 100 mg daily at 8:00 a.m. and Sertraline 100 mg daily at 8:00 p.m. LPN #2 dispensed one Senna (used for constipation) 8.6 mg tablet into the medication cup and checked off Senna plus (used for constipation) 50-8.6 mg in the resident's MAR.LPN #2 dispensed three medications ordered incorrectly. LPN #2 said she was ready to go administer the medication in the cup to Resident #23. LPN #2 reviewed the medications in the medication cup after being prompted. LPN #2 failed to identify what the medications were in the cup and had to be prompted to identify the medication using the tablet identifiers engraved on the tablets. The Seroquel, Sertraline and Senna were removed from the medication cup and replaced with the correct medications ordered one Glipizide 10 mg tablet, one Losartan 100 mg and one Senna plus 50-8.6 mg tablet. LPN #2 entered Resident #23 room for medication administration. LPN #2 started with an Alvesco inhalation aerosol solution that instructed the resident to take two puffs/inhalations of the medication. Resident #23 completed the two inhalations and then took all other medications to complete her morning medications.-LPN #2 failed to have Resident #23 rinse and spit after the administration of the Alvesco inhaler. LPN #2 was interviewed directly after administration of the medication. She said Resident #23 should have rinsed out her mouth after the inhaler to help prevent the resident from developing thrush (a yeast infection in her mouth). LPN #2 said she should have looked at the MAR and the cards she dispensed the medication from more closely to ensure she was dispensing and administering the correct medications to the residents. LPN #2 said it was her responsibility to follow the seven rights of medication administration. LPN #2 was observed administering medications on 2/26/24 at 8:43 to Resident #102. LPN #2 applied a Lidocaine 4 % patch to the resident's right hip. The order documented the Lidocaine 4% patch was to be applied to Resident #102 right ribs.-LPN #2 applied the lidocaine patch to the incorrect location on the resident. LPN #2 went back to Resident #102 room at 9:05 a.m. and informed the resident she applied the patch to the wrong location. LPN #2 then removed the patch from the resident's right hip and placed it on her right side ribs. LPN #2 said it was important to place a topical medication in the correct place on a resident's body to ensure it was being used correctly. The director of nursing (DON) was interviewed on 2/27/24 at 10:21 a.m. He said nurses were to follow the seven rights of medication administration otherwise a medication error could occur. The DON said if a medication error occurred it placed a resident at risk for interactions or complications. The DON said if a medication error occurred the resident, power of attorney and physician needed to be notified and the resident was to be monitored for side effects. The DON said some inhalers require the resident mouth be rinsed out to prevent thrush. The DON said medication orders for topicals should indicate the location it was to be applied and should only be applied to the indicated site to be effective for the resident's needs.

Based on observation and interviews, the facility failed to ensure medications and biologicals were stored and labeled properly on one of four medication carts. Specifically, the facility failed to:-Ensure medication was not left unattended on the medication cart; and,-Ensure tuberculin (medication to test for tuberculosis, a lung bacteria) vials were dated with open dates. Findings include:I. Professional referenceAccording to the Tubersol package insert, retrieved 2/27/24 from: https://www.fda.gov/media/74866/download, "A vial of Tubersol which has been entered and in use for 30 days should be discarded."II. Facility policy and proceduresThe Storage and Expiration Dating of Medications and Biologics policy and procedures, revised 7/21/22, received from the nursing home administrator (NHA) on 2/26/24 at 11:01 a.m. It revealed in pertinent part, "The facility should ensure that all medications and biologics, including treatment items, were securely stored in a locked cabinet/cart or locked medication room that was inaccessible by residents and visitors. "Once any medication or biologic package was opened, the facility should follow manufactures/suppliers guidelines with respect to expiration dates for opened medications. The facility should record the date opened on the primary medication container (vial, bottle, inhaler) when the medication has a shortened expiration date once opened."If a multiple dose vial of an injectable medication has been opened or accessed (needle puncture), the vial should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for the opened vial."III. Observations and staff interviewsOn 2/22/24 at 12:27 p.m. the second floor medication room was reviewed with registered nurse (RN) #4. There was one vial of Tubersol open and undated. RN #4 was not sure when the vial was opened and she was unsure how many days the vial was good for before expiring after it was opened. RN #4 said vials should be dated once opened because they did expire before the expiration date the manufacturer places on the vial. On 2/26/24 at 8:20 a.m. licensed practical nurse (LPN) #2 one 100mg tablet of Seroquel (antipsychotic) and one 100 mg tablet of sertraline (antidepressant) on her medication cart unattended. An unidentified certified nurse aide (CNA) walked by the unattended medication. LPN #2 was interviewed on 2/26/24 at 8:30 a.m. She said she should have not left the medication on the cart. LPN #2 said she should have locked up the medications until she could place them in the drug buster for destruction. LPN #2 said a resident could have picked up the medication left on the cart and taken it. LPN #2 said if a resident took a medication not ordered for them they could have a medication interaction and sustain side effects. The director of nursing (DON) was interviewed on 2/27/24 at 10:21 a.m. He said he was not aware of the tuberculin expiration date once the vial was opened. He said multi-dose vials should be dated so nurses know when it expired because a medication may not be as effective if used past the expiration date. The DON said medications should not be left unattended because a resident could get ahold of them and take them leading to possible side effects if not prescribed to them. The DON said the facility had residents, who had cognitive impairment, that could potentially get ahold of medications if left unattended.

Based on observations, record review and interviews, the facility failed to ensure one (#89) of three residents reviewed for ancillary services, such as dental services, out of 53 sample residents received routine dental care obtaining routine and 24-hour emergency dental care. Specifically, the facility failed to refer Resident #89 to the dentist to replace lost dentures and repair loose fitting dentures. Findings include:I. Facility policyThe Dental Services policy and procedure revised 8/23/23, was provided by the nursing home administrator (NHA) on 2/27/24 at 11:26 a.m. It revealed in pertinent part, The facility will assist residents in obtaining routine and 24-hour emergency dental care. The facility will provide and obtain routine and emergency dental services to meet the needs of each resident. The facility will assist the resident as necessary or as requested in making appointments; and by arranging for transportation to and from the dental services location; and promptly refer residents with lost or damaged dentures for dental services."I. Resident statusResident #89, age greater than 65, was admitted on 11/27/23. According to the February 2024 computerized physician orders (CPO), diagnoses included non-pressure chronic ulcer of the left calf with unspecified severity, history of falling and adult failure to thrive. According to the 12/21/23 minimum data set (MDS) assessment, the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She was independent with eating. She required setup help with oral hygiene, and partial/moderate assistance with toileting. She required substantial/maximal assistance with showers. II. Resident observation and interviewOn 2/22/23 at 8:49 a.m., Resident #89 was in her room. The resident was missing her bottom set of dentures and her top dentures were loose and moved as she talked. Resident #89 said she lost her dentures before she was admitted to the facility. She said she needed to get her bottom dentures replaced and have her top denture readjusted because they were loose. Resident #89 said she was unaware the facility was able to assist her with dental care. III. Record reviewThe February 2024 CPO revealed the following physician's order:Resident may have dental, podiatry, audiology and optometry care as needed. Ordered 11/28/23. A nursing progress note, dated 11/28/23 at 3:45 p.m., documented in pertinent part, "The resident was missing her bottom dentures, has the top dentures. Eating softer food here. Denied swallowing problems, answered all swallowing questions with a no."Review of Resident #89's care plan, revised 12/11/23, revealed the resident had oral/dental health problems related to the aging process. Interventions included: the resident will comply with mouth care at least daily, administer medications as ordered, coordinate arrangements for dental care, transportation as needed/as ordered, diet as ordered and consult with dietitian as needed. Review of Resident #89's electronic medical record (EMR) did not reveal the resident was offered or provided access to dental care. IV. Staff interviewsThe social services director (SSD) was interviewed on 2/26/24 at 2:27 p.m. The SSD said residents and/or the residents' responsible party should be offered ancillary services upon admission and every quarter during the care plan conference. She said it should be documented in the progress notes that ancillary services were offered. She said she was unable to find documentation to indicate Resident #89 and/or her representative were offered dental services since the resident's admission on 11/27/23. Certified nursing assistant (CNA) #2 was interviewed on 2/27/24 at 9:58 a.m. CNA #2 said she was unsure if Resident #89 had issues with her dentures. Registered nurse (RN) #2 was interviewed on 2/27/24 at 10:05 a.m. RN #2 said she was aware Resident #89 had lost her bottom dentures prior to being admitted to the facility. She said the resident's diet had been changed to a mechanical soft texture (diet which needs very little chewing) to help her eat. RN #2 said she did not refer the resident to the dentist and Resident #89 did not complain of any issues about her top dentures. The director of nursing (DON) was interviewed on 2/27/24 at 10:46 a.m. The DON said Resident #89 should have been referred to the dentist upon admission to replace her bottom dentures and to ensure the top dentures were not loose. The DON said it was not an appropriate intervention to change her diet in lieu of replacing her dentures. The DON said the nursing staff should notify the SSD in order to place the resident on the ancillary services list to ensure the resident was seen by the dentist if she had any dental complaints. The DON said he needed to provide an all staff education related to ancillary services. The nursing home administrator (NHA) was interviewed on 2/27/24 at 11:55 a.m. The NHA said Resident #89 should have been offered all ancillary services which included dental services. She said if the resident complained of any dental issues nursing staff should have notified the SSD and the resident would have been placed on a list to be seen by the dentist in order to have her dentures readjusted and replaced.

A licensure survey was completed on 2/21/24 to 2/27/24. One deficiency was cited.

Based on record review and interviews, the facility failed to ensure the residents' environment remained as free from accident hazards as possible and prevent falls with major injury for two (#46 and #76) of four residents reviewed for falls out of 53 sample residents. Resident #46, who had a known history of falls, had a diagnosis of obesity which required the use of a bariatric (to support substantial weight) bed with extensions to enable the bed frame to be made larger. On 1/29/24, the resident sustained a witnessed fall from her bed when she was being rolled on her side with the assistance of staff during a bed bath. Resident #46 was sent to the hospital for evaluation of left knee pain following the fall where she was discovered to have a fracture of her left femur (thigh bone), which was surgically repaired on 1/30/24. The resident returned to the facility on 2/1/24 and was placed in the same bed she fell from on 1/29/24. The facility did not inspect the bed to ensure the extensions were pulled out appropriately and the mattress fit correctly prior to placing the resident back in the bed. On 2/5/24 (4 days after Resident #46's readmission to the facility), a rental supply company came to the facility to install bed canes (a device which can be utilized to assist a person to reposition themselves in bed). The rental supply company's personnel discovered the extensions on Resident #46's bed had not been pulled out prior to the resident's fall from the bed and the facility had failed to pull the extensions out prior to the resident's readmission to the facility. Additionally, Resident #76, who had diagnoses of muscle weakness and unsteadiness on her feet, was admitted to the facility on 9/30/23. The resident had a history of falls with injuries in the 12 months prior to her admission to the facility. She required partial assistance with her toileting, bathing and moving from a sitting position to a standing position. The facility failed to implement appropriate person-centered fall interventions for the resident upon her admission to the facility. On 10/20/23, Resident #76 sustained a fall after tripping while she was attempting to get clothes from her closet. The resident complained of pain in her right wrist and x-rays were obtained which revealed she sustained a fracture to her right pinky finger and right thumb. The facility put an intervention in place to educate the resident to remember to turn on the overhead light before moving around in her room, however, the resident sustained five more falls following the 10/20/23 fall. The facility failed to put new and effective interventions into place after each fall to prevent the resident from sustaining further falls. Due to the facility's failure to properly evaluate Resident #46's bed frame and mattress for appropriate functionality and fit and the failure to implement timely and effective person-centered fall interventions for Resident #76, both residents sustained falls with major injury and experienced pain. I. Findings include A. Policy and procedureThe Fall Management policy and procedure, reviewed 11/30/22, was provided by the nursing home administrator (NHA) on 2/26/24 at 2:19 p.m. It read in pertinent part: "To promote patient safety and reduce patient falls by proactively identifying, care planning and monitoring of patients' fall indications."The facility must ensure the resident environment remains as free of accident hazards as is possible and each resident receives adequate supervision and assistance devices to prevent accidents. "Residents will be assessed for fall indications upon admission, readmission, quarterly, change in condition, and with any fall utilizing the Fall Risk Assessment."II. Resident #46A. Resident statusResident #46, age 71, was admitted on 6/29/22 and readmitted on 2/1/24. According to the February 2024 computerized physician orders (CPO), diagnoses include chronic respiratory failure, insomnia, chronic pain, bed confinement, colostomy, low back pain, muscle weakness, lack of coordination, history of falling and body mass index of 45.0 to 49.9 (obesity). The 2/2/24 facility assessment revealed the resident had normal cognition with a brief interview for mental status (BIMS) score of 15 out of 15. The resident required two person assistance with dressing, toileting, bathing/showering, bed mobility and use of a mechanical lift with two staff members for transfers. The resident required one person assistance with personal hygiene and was independent for eating. B. Resident interview Resident #46 was interviewed on 2/21/24 at 11:26 a.m. The resident said she had fallen out of bed on 1/29/24. The resident said the problem was the bed. She said she felt as if she were sliding out of the bed when being turned onto her side. She said the staff had not pulled the slide outs/extensions out so the mattress fit correctly. She said she had been in the center of the bed, had started slipping and was unable to catch herself before falling to the floor. She said when she returned from the hospital the bed rental company personnel came to install bed canes and discovered the extensions had not been pulled out. C. Record reviewA nursing note dated 1/29/2024 at 6:51 p.m. documented a witnessed fall. A certified nurses aide (CNA) had yelled for help due to a resident falling from her bed while receiving a bed bath. Upon entering the room the resident was found on the left side of the bed on the ground. The resident was screaming in pain. The resident had swelling and a scrape on her left knee and was not able to move it. The resident was sent to the hospital for evaluation of her left knee. An emergency department (ED) note, dated 1/29/24, documented the resident fell out of bed during a bed bath landing on her left knee which was bruised with joint effusion (swelling). A diagnostic radiology (x-ray) note, dated 1/29/24, documented Resident #46 sustained a comminuted (broken in three or more places) mildly displaced and impacted (a break where the ends are driven into each other) distal (near the knee) femoral fracture. The operative report, dated 1/30/24, documented the operation/procedure of an open reduction (repositioning of pieces of fractured bone) and nailing of the femur fracture. A stryker 13 by 1340 millimeter (mm) nail locked the knee with three advanced locking screws and locked proximally (nearer the body) with one screw. Hospital discharge documentation, dated 2/1/24, documented the resident was discharged back to the facility. A facility readmission note, dated 2/1/24, at 3:35 p.m. documented the resident returned to the facility by stretcher. A bed rental company report, dated 2/5/24, documented the service to Resident #46's bed for placement of assist bars (bed canes). D. Staff interviewsLicenced practice nurse (LPN) #2 was interviewed on 2/26/24 at 1:21 p.m. LPN #2 said the staff should check the bed before residents were admitted to ensure the bed was working properly and the mattress fit correctly. LPN #1 was interviewed on 2/26/24 at 2:06 p.m. LPN #1 said the bariatric (large size) beds, which was the type of bed Resident #46 used, had extensions to make the bed frame larger. She said the bariatric beds with the extensions were delivered to the residents' rooms from the facility's central supply (CS). She said CS personnel were supposed to check the bed to ensure the bed was working properly and the extensions were pulled out to accommodate the mattress. She said the mattress should fit inside the bed frame. LPN #1 said the extensions could be adjusted while the resident was in the bed, however, she said it was better to adjust them before the resident got into the bed. She said if a resident felt something was wrong with the bed, nursing staff should call maintenance to check the bed. The central supply director (CSD) was interviewed on 2/26/24 at 3:03 p.m. The CSD said Resident #46's bed had not been checked due to the resident being readmitted on 2/1/24 to thefacility after she had left work for the day. She said the nursing staff should check the frame if the CSD was not available. She said the bed rental personnel had reported the extension bars were not all the way out on one side on 2/5/24 when they came to install the bed canes. The CSD said the extensions were not hard to pull out. She said the staff should report if the mattress was too small for the bed. She said there was no report of problems with the bed until the bed canes were put on by the service provider on 2/5/24. The director of nursing (DON) was interviewed on 2/27/24 at 11:33 a.m. The DON said if a resident was reporting a feeling of slipping in the bed it should be reported and the facility should look into the cause. He said the admissions staff and the CSD ensured the resident had the correct size bed. He said nursing staff was responsible for ensuring the extensions on the bed frame were pulled out and the mattress fit the bed appropriately. He said nurses should look at the frame. He said Resident #46 slipping from the bed could have been a bed frame problem. III. Resident #76A. Resident StatusResident #76, age 80, was admitted on 9/30/23 and readmitted 12/27/23. According to the February 2024 CPO, diagnoses included fracture of the sacrum, fracture of the left pubis (pelvis), multiple fractures of the ribs, history of falling, muscle weakness, unsteadiness on feet, fracture of the fifth metacarpal bone (pinky) and thumb on the right hand, depression, and anxiety. The 12/29/24 facility assessment revealed, the resident had moderate cognitive impairment with a BIMS score of 11 out of 15. She had impairment to both sides of her lower extremities. She used a walker and wheelchair. She had falls prior to admission as well as falls in the facility. She had a fall with a fracture. She required partial assistance with toileting, bathing, and sitting to standing. B. Resident interviewResident #76 was interviewed on 2/21/24 at 11:15 a.m. She said she had many falls. She said she fell and broke her thumb and pinky when she tripped over the wheel on her wheelchair. She said she also slid off the mattress and asked staff for a different one. She said staff told her all the mattresses were the same. She said when she stood up, she had nothing to hold onto. She asked staff if she could have a side rail and was told facilities were not allowed to put side rails on a resident's bed. C. Record reviewA physician's order, dated 10/20/23, instructed staff to send the resident to the hospital for abnormal x-ray results. A physician's order, dated 10/27/23, documented a fractured right fifth digit (pinky finger). Put the fourth digit together with the fifth digit as a guardian, apply a long cast from the fifth digit to the forearm, secure with ace wrap from finger to forearm. Let the thumb, middle, and ring finger be free from the ace wrap. Leave in place at all times every shift for a right fifth digit fracture. A physician's order, dated 10/27/23, documented a right thumb fracture. Apply an aluminum cast, U shaped and secure with coban. Leave in place at all times for thumb fracture. The hospitalization care plan, initiated 10/16/23, revealed Resident #76 was at risk for rehospitalization due to a history of injurious falls in the past 12 months. The interventions included labs as ordered, provide medications as ordered, registered dietician to evaluate and staff to provide timely communication to the physician regarding any change in resident condition. The fall risk care plan, initiated on 9/30/23 and revised on 10/16/23 revealed Resident #76 had a history of falls with injuries. Interventions included:-Assess if the resident wanted her bed made frequently and place the bed against the wall, initiated 2/12/24;-Assess toileting needs frequently, initiated 1/2/24;-Assist with activities of daily living as needed, initiated 9/30/23;-Bathroom lights to remain on at all times and remind resident to turn overhead light on when walking around the room, initiated 10/20/23;-Keep call light, reacher, and frequently used items within reach, initiated 9/30/23;-Complete a fall risk assessment, initiated 9/30/23;-Provide appropriate footwear/non-skid socks when ambulating, initiated 1/19/24; and,-Physical therapy to evaluate and treat, initiated 1/19/24. Review of Resident #76's falls were reviewed from 10/20/23 to 2/9/24.1. 10/20/23 fallAn event progress note, dated 10/20/23 at 11:15 a.m., revealed Resident #76 was found lying on her right side next to her bed. Her call light was within reach but not activated. The room had poor lighting and the resident did not turn on the light. The resident stated she was trying to get clothes from her closet and tripped. The resident expressed pain to her right wrist and bruising was noted to the left wrist. The physician was notified and x-rays of both wrists were ordered. The intervention was to educate the resident to remember to turn the overhead light on before movement in the room.-There was no fall investigation provided for the 10/20/23 fall. 2. 11/17/23 fallA health status progress note, dated 11/17/23 at 7:45 p.m., revealed the registered nurse (RN) supervisor was called to the unit because Resident #76 was on the floor. She required maximum assistance of two staff members to be lifted off the floor. An abrasion was found to the resident's mid lower back. The fall investigation dated 11/17/23 revealed the resident was found sitting on the floor after losing her balance at bedside. The resident stated she was reaching for an item near her bedside night stand. The intervention was to place frequently used items in reach of the resident. 3. 12/1/23 fallA health status progress note, dated 12/1/23 at 7:08 p.m., revealed Resident #76 had a fall. She was found while eating her dinner. She was sitting in a chair. There was no complaint of pain. The fall investigation dated 12/1/23 revealed the resident's roommate was able to activate the call light and call the nurses station from her cell phone. Resident #76 said she was seated in front of her bedside table and stood up to retrieve her purse. She said she felt she might fall and backed up to her bed. The resident assisted herself up from the floor. She had no injuries. -The intervention was to continue to remind the resident to use her call light to get items at a distance, which was the same intervention implemented for the fall on 11/17/23.-There were no new fall interventions put into place. 4. 12/22/23 fallAn event progress note, dated 12/22/23 at 1:14 p.m,. revealed Resident #76 was found on the floor next to her bed in a sitting position. The resident stated she had tried to reach for her grabber and slid off the bed. The fall investigation dated 12/22/23 revealed the resident had no injuries. The intervention was to make sure her grabber and belongings were within reach. All the staff were aware to check the resident regularly. The resident was reminded to use her call light.-Despite the fall investigation documenting that all staff were aware to check the resident regularly, frequent checks were not implemented as a fall intervention on the resident's care plan. 5. 1/2/24 fallAn event progress note, dated 1/2/24 at 12:33 a.m., revealed Resident #76 was found on the floor by a certified nurse aide (CNA). The resident was lying prone (face down) between the bathroom and the foot of her bed. She had pillows beneath her face. The call light was not activated. The resident's walker was approximately one foot away from her. The bed was soaked with urine. She had a small scratch to her left knee and complained of pain to her left leg and buttocks. The resident stated she exited the bathroom and her weakened hands led to a fall. She was assisted back to bed by three staff members. The fall investigation dated 1/2/24 revealed the resident fell after exiting the bathroom. The intervention was to assess the residents' toileting needs frequently.-The intervention did not document how frequently the resident should be offered toileting. 6. 2/9/24 fallAn event progress note, dated 2/9/24 at 8:50 p.m., revealed Resident #76 was found on the floor at her bedside. She acknowledged she fell while trying to reach the call button as she was making her bed. There were no injuries noted. The fall investigation dated 2/9/24 revealed the resident was found on the floor and initially denied falling. The intervention was to have staff offer to make her bed when it was untidy or upon the resident's request. She was currently working with therapy to improve strength. D. Staff interviewsCNA #1 was interviewed on 2/26/24 at 1:55 p.m. CNA #1 said Resident #76 was a stand by assist (SBA) for transfers and ambulation. She said the resident used her call light when she needed help. She said she did not know what interventions were put into place to help her from falling. LPN #2 was interviewed on 2/26/24 at 2:07 p.m. LPN #2 said she had worked with Resident #76 a couple weeks ago but was not told what fall interventions were put into place. She said if a resident had a fall, a new intervention should be put into place for each fall. The DON was interviewed on 2/26/24 at 2:29 p.m. The DON said Resident #76 liked to be independent. He said interventions that had been put into place were making sure the bathroom light was on, making her bed regularly, and making sure her grabber was in reach. He said he had thought about placing a bed cane on her bed but was afraid she would hit her head. He said he had not thought about placing a transfer pole at her bedside.

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 01/22/2024 and 01/28/2024, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

A revisit survey was completed on 12/18/23 for all previous deficiencies cited on 10/17/23. The facility is in compliance with all regulations surveyed.

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 10/09/2023 and 10/15/2023, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

A complaint survey, prompted by #CO33761 was conducted on 10/4/23-10/9/23. One deficiency was cited.

Based on record review and interviews the facility failed to clarify basic life support choices, including cardiopulmonary resuscitation (CPR), prior to the arrival of emergency medical personnel according to the advance directive for one resident (#2) out of three residents reviewed for CPR out of six sample residents. Specifically, the facility failed to:-Follow the advance directive on Resident #2's medical orders for scope of treatment (MOST) form by having emergency medical personnel perform CPR on the resident when her code status was Do Not Resuscitate (DNR); -Assist the roommate and family out of the room while CPR was being performed on Resident #2 until prompted by emergency medical services (EMS); and, -Ensure resident's MOST forms were readily accessible and in the right location. Findings include:I. Facility policyThe Cardiopulmonary Resuscitation (CPR) policy and procedure, reviewed 9/14/23, provided by the nursing home administrator (NHA) on 10/4/23 at 6:09 p.m. It read in pertinent part, "Definitions: Do Not Resuscitate (DNR) order refers to a medical order issued by a physician or other authorized non-physician practitioner that directs healthcare providers not to administer CPR in the event of cardiac or respiratory arrest."The facility should ensure resident preferences and physician orders related to CPR and other advanced directive issues are communicated so that staff know immediately what action to take or not take when an emergency arises."The Area of Focus: Resident Rights policy and procedure, reviewed 11/21/22, provided by the NHA 10/9/23 at 1:57 p.m. It read in pertinent part, "A resident had a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section."A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident."The Advance Directives and Advance Care Planning policy and procedure, reviewed 9/14/23, provided by the NHA on 10/4/23 at 6:09 p.m. It read in pertinent part, "The director of nursing or designees establishes a system to inform all direct care staff of the resident's DNR status."II. Resident #2A. Resident statusResident #2, age 70, was admitted on 6/12/2020 and passed away 6/26/23. According to the June 2023 computerized physician orders (CPO), diagnoses included alcoholic cirrhosis of liver, hepatic failure (liver) and chronic pain syndrome. The 4/21/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. She required supervision assistance with two persons for bed mobility, transfers, dressing, toilet use and personal hygiene. The resident was not in hospice care. B. Record reviewThe emergency medical services (EMS) patient care report was reviewed for the date of service on 6/26/23 for Resident #2. It revealed in pertinent part, "the paramedics were dispatched to the facility at 5:30 p.m. Nature of call: Unconscious/fainting (near) ineffective breathing. Response was immediate with lights and siren. Arrived at the patient at 5:34 p.m. Patient was found lying supine on the ground with a blood pressure cuff on. Paramedics reported that facility staff did not start CPR. The facility staff was attempting to produce DNR paperwork but did not have it immediately available. Medics started compressions and ventilated with a bag valve mask. Facility staff presented a valid DNR form showing the patient was a DNR. Physician approved the cessation of effort. Time of death was called at 5:37 p.m."The police report was reviewed for date of service 6/26/23 at 5:28 p.m. It revealed in pertinent part, "the facility activated 911 and the caller saidpatient was trying to use the bathroom and fell on the floor and was unresponsive. The police arrived on scene at approximately 5:33 p.m. and it was a confirmed cardiopulmonary resuscitation. Police were later advised by the facility that the patient had a DNR." The Medical Orders for Scope of Treatment (MOST) form for Resident #2 revealed "No CPR: Do not attempt resuscitation" and was signed by the resident and physician 8/5/21. The advanced directive care plan, initiated 10/18/2020, revealed the resident had an advanced directive DNR. The goal was for the advanced directive to be honored. The interventions included that the code status would be reviewed quarterly and as needed and the resident had signed a DNR, date initiated 10/18/2020. A review of Resident #2's progress notes on 6/26/23 revealed in pertinent part, "At 7:32 a.m. nurse practitioner follow-up visit to assess pain and weakness. Nursing staff did report the patient was very weak this morning and did require assistance with transfers. Patient does state that she is tired today but otherwise denies further acute specific complaints.""At 1:38 p.m. health status note, resident reported feeling weak. She was not able to help herself through her ADLs (Activities of daily living) without assistance from the CNA (certified nurse aide). Her baseline is completely independent. She also has not been taking her medication as prescribed and has been educated about the importance of doing so many times by myself and other nurses. The physician is aware of this behavior as well as her continued decline." "At 7:56 p.m. event note, resident passed away at 5:37 p.m. provider was notified as well as family, DON (director of nursing) and administrator. Coroner forms faxed, pending coroner arrival.""At 8:21 p.m. event note, resident was very weak during the day shift reported by the outgoing nurse. Nurse practitioner came to see the patient and recommended her Tizanidine medication to be increased. Patient was getting up by herself when the CNA (certified nurse aide) saw her and helped patient to the bathroom. After she finished from using the toilet, she sat in the w/c (wheelchair). The CNA came and informed the nurse that the patient was in the chair because she was trying to get up and was too weak. Nurse went to the patient room and reminded her that she needed to call for help. Minutes after coming out of the patient's room, the roommate's son came and informed the nurse that the patient was on the floor. Nurse called the weekend supervisor (RN #1), and the paramedic. Patient had no vital signs and was pronounced dead. On call physician pronounced the patient deceased at 5:37 p.m. and the patient's son was contacted to choose the mortuary and he said the patient's body will be given to (mortuary name). County coroner paper was completed and faxed."-However, there was no documentation by the nurse staff of when the paramedics arrived, or what care they gave. There was no documentation of the resident's DNR status and if the resident's wishes were honored. There was no documentation of the nursing staff starting CPR while the code status was being determined."At 8:49 p.m. event note, weekend nurse (RN #1) informed the DON (director of nursing), executive director of the incident.""On 6/27/23 at 2:32 a.m. health status note, resident's remains were picked up by (mortuary name) at approximately 2:30 p.m. Son is aware, has spoken to (mortuary name), and given consent.""On 6/27/23 at 10:05 a.m. health status note, at approximately 6:00 p.m. on 6/26/23 said writer was informed by team member that resident #2 had passed, said writer entered Resident #2's room and there two law enforcement officers were standing directly inside of the door to her room. Said writer asked, I wanted to check with you how soon we might be able to complete her post mortem care, officer states, we already have a call into the coroner's office and we will complete our investigation. At that time Resident #2 was in view of said writer, be aware Resident #2 is lying on the floor next to the bed, lying vertical to bed with her head at the foot of the bed. Resident #2's eyes are wide open, mouth is wide open, both hands are on her chest with her hands open. Said writer directs question to officer's, so you will let us be aware when you are completed and then we can complete our care. Officer's state, yes we will."-On 10/4/23 at 4:42 p.m. requested the facility investigation, risk management report, IDT (interdisciplinary team) notes, police report, or incident report. The NHA verified the facility did not have any of the requested documents and there had been no review of the incident by the facility. III. Facility observations On 10/4/23 at 2:05 p.m. observation of East nurse station revealed the resident hard charts which held the original MOST forms were not placed in the designated room number slots, they were placed in random slot boxes with room numbers that did not match the room numbers for the chart. At 2:24 p.m. observation of the West nurse station revealed the hard charts that hold each of the resident's original MOST forms were disorderly on two bookshelves at the nurses station. Slot box labeled room 144A held chart for room 141; Slot box labeled room 143 held chart for room 144; Slot box labeled for room 145A held chart for room 146B.IV. InterviewsRN #2 was interviewed on 10/4/23 at 2:28 p.m. at the West nurse station. She said she was not sure why the charts were disorganized; it had always been that way. RN #2 said the staff should put the charts in the room number slot to match with the chart room number for better organization. RN#2 said if she needed to find a resident's hard chart she would need to look at two entire book cases of hard charts one by one in order to find the correct resident. RN #2 said it could lead to confusion when needing to find the hard chart quickly. The NHA and DON were interviewed on 10/4/23 at 3:03 p.m. They said when there was a medical emergency the nurse called 911, another nurse stayed with the resident and another nurse printed medical records such as medication list and copied MOST form. They said the nurse would make sure if a full code to initiate CPR if needed, while waiting for the paramedics. They said the staff should clear the hallway for the paramedics and if the resident had a roommate the staff would ask them to leave for the privacy of the resident having the emergency. They said it could be traumatic for the roommate to see. They said when the paramedics arrived the facility had a staff member stay with the paramedics in case they needed something and another nurse would get the paperwork. They said the original MOST form was in the hard chart and the nurse would take out and copy. They said the incident would be documented in the progress notes and the note would document very detailed times, and interventions. They said the nurse would document in detail if they started CPR, used an automated external defibrillator (AED), Ambu bag or oxygen. The NHA and medical records director (MR) #1 were interviewed on 10/4/23 at 4:42 p.m. They said the facility did not have a police report, incident report, risk management report, IDT note, or report of an unexpected death. They said we would rely on the nurses to document completely what happened but there was no information about the paramedics after they were called and if they provided any care. They said there was no documentation of when the paramedics arrived and when they left or what care the facility staff gave. They said the progress notes said the nurse called 911 but they were not sure why the nurses would call if she thought she was a DNR. Licensed practical nurse (LPN) #2 was interviewed on 10/4 /23 at 5:51 p.m. She said had called 911 for Resident #2. She said roommates son came and told her the resident was on the floor and she went to Resident #2 first. She said then she called her supervisor (RN #1) with her portable phone. She said RN #1 came and stayed with Resident #2 and that was when she went to the nurses station to call 911. LPN #2 said she thought she was the one who looked for the MOST form but she was not sure. She said she thought the paramedics needed a copy to look at. She said she was not sure if any staff initiated CPR with Resident #2 because she was not with the resident. LPN #2 said she was not sure if the paramedics initiated CPR because she was not there with them. LPN #2 said the police arrived with the paramedics and went to assess the resident. LPN #2 said when the paramedics came the paramedics did what they needed and the nurses stepped out and the nurses did not stay with them. LPN #2 said Resident #2 had a roommate and the staff had taken them out of the room. LPN #1 was interviewed on 10/4/23 at 6:03 p.m. She said the paramedics had left when she came by the nurse station so she did not see them. The clinical consultant (CC) #1 and NHA were interviewed on 10/5/23 at 12:09 p.m. The CC#1 said there was no policy or procedure for when 911 was activated. CC #1 said once that happened EMS showed up, and the staff stepped back and took orders from the paramedics. CC#1 said the nurse did what she could for the resident and the nurse's role would be to maintain safety. CC#1 said there was nothing that said who was to greet the EMS and all that. CC#1 said there was no procedure of what to do when EMS was called. The NHA said there was no facility policy and procedure for when 911/EMS was called and when the paramedics came to the facility. Paramedic (PAR) #1 was interviewed on 10/5/23 at 10:45 a.m. He said upon arrival to the facility for Resident #2, the facility did not provide advanced directive information to the paramedics so they started CPR. He said later the facility provided the DNR documentation. He said when he arrived the facility staff were standing around, they did not have the advanced directive information yet but however the staff had not initiated CPR. He said when he had walked into the facility he had asked various staff members about Resident #2's code status and he received an answer of "I don't know, not my patient" multiple times. RN #1/weekend supervisor was interviewed on 10/5/23 at 2:21 p.m. She said she remembered the event and that LPN # 2 called her because the Resident #2 was found unconscious in the room. She said she went into the room with LPN #2 and an unnamed CNA and the resident had passed out from the wheelchair onto the floor. She said LPN #2 went to call 911. RN#1 said she and the CNA straightened out the resident on the floor. RN #1 said she got the vitals machine and started an assessment. RN#1 said she took blood pressure, oxygen saturation and pulse and she was not breathing. RN #1 said she was not aware of what Resident #2's CPR status was. RN #1 said she was waiting for LPN #2 to verify if the resident was full code or a DNR before starting CPR, but then the paramedics came so she had not started CPR. RN #1 said she let the paramedics know there was no pulse and no vitals showing. RN #1 said LPN #2 still had not told her what the code status was at that time. RN #1 said she did not remember if the paramedics started CPR but they probably did. RN #1 said in seconds the paramedics came and took over and asked right away for the code status but it was not available yet. RN #1 said later LPN #2 came and told the paramedics Resident #2 was a DNR and gave them a copy of the MOST form to verify. RN #1 said when the paramedics arrived she had to usher the roommate and guest out of the room because the paramedics had asked her to and they needed the room. RN #1 said had not had the experience of removing a roommate and guest for an emergency before. She said after the paramedics arrived no other nurse staff had stayed to check if the paramedics needed anything. She had gone to take the roommate and guest to the television room. Medical director (MD) #1 was interviewed on 10/9/23 at 12:22p.m. She said she was not familiar with the facility's process or procedure when EMS services were called. She said as the medical director she had not been involved with that process. MD #1 said CPR should not be given to a resident with a DNR order. MD #1 said after calling 911 the code status should be determined while the paramedics were on their way if not before. MD #1 said a staff member should be getting the code status, while another staff member called EMS. MD #1 said the facility should have the medical paperwork ready for EMS when they arrive. MD #1 said the nurses and care staff should have up-to-date CPR certification as they were required to know that. MD #1 said during a medical emergency if the resident had a roommate they should be escorted out to give the resident privacy, give room to the EMS staff and because it was frightening and could be traumatizing for those that were not involved. MD #1 said finding charts in the facility could be a problem; she said they were messy in the facility. She said in an emergent situation having the charts organized would be helpful in finding important information such as the resident's MOST forms.

A revisit survey was completed on 7/13/23 for all previous deficiencies cited on 5/4/23. The facility is in compliance with all regulations surveyed.

A complaint survey, prompted by #CO31892 was conducted on 5/3/23 and 5/4/23. Two deficiencies were cited.

Based on record review and interviews, the facility failed to implement an effective discharge planning process for four (#1, #2, #3 and #4) of six residents reviewed out of nine sample residents. Specifically, the facility failed complete the following for Resident #1, #2, #3 and #4:-Focus on the resident's discharge goals;-Ensure the discharge needs were identified that resulted in the development of a discharge plan; and, -Involve the interdisciplinary team in the ongoing discharge process. Findings include:I. Facility policy and procedureThe Discharge Plan policy, last revised on 8/18/22, was received from the nursing home administrator on 5/4/23. The policy read in pertinent part, "The discharge planning process will address each resident's discharge goals and needs, including caregiver support and referrals to local contact agencies, as appropriate, and involves the resident and if applicable, the resident representative and the interdisciplinary team in developing the discharge plan. The discharge plan is incorporated into the interdisciplinary care plan. It originates on the baseline care plan and will be included on the patient's comprehensive care plan, once developed." II. Failure to ensure discharge planning was completed 1. Resident #4A. Resident statusResident #4, age 94, was admitted on 4/17/23. According to the May 2023 CPO diagnoses included dementia, atrial fibrillation, kidney disease and malnutrition. The 4/19/23 MDS assessment showed the resident had moderate cognitive impairment with a score of seven out of 15 on the BIMS. The resident required extensive assistance of two with activities of daily living and personal hygiene. B. Resident representative interview The power of attorney (POA) was interviewed on 5/4/23 at 11:00 a.m. The POA said when Resident #4 was first admitted the plan was for her to return home, where he provided the care. However, he said that both he and Resident #4 had decided she would need to transition to long term care after being discharged from skilled services. He said he could not provide the care to her that she required. The POA said he had one discussion with the case manager (CM), but otherwise had not heard any further plans for the resident to transition to the long term care rather than return home. C. Record reviewThe care plan dated 4/19/23 showed a discharge care plan and the resident's desire to return home. The goal was to develop and follow a full discharge plan. -There were no approaches listed on the care plan. The care plan has not been updated. -Review of the resident's progress notes failed to show any additional discharge planning for Resident #4. The progress notes were as follows:The progress note dated 4/24/23 documented, "spoke with son (name of son) about his mother needing more help. He has been her care giver and is realizing that he may not be able to meet her care needs. I referred him to (name of agency) for living options. Referral packet faxed."2. Resident #1A. Resident statusResident #1, age 80, was admitted on 11/23/22 and discharged 1/17/23. According to the January 2023 computerized physician orders (CPO) diagnoses included osteoarthritis and prosthetic joint infection. The 11/30/22 minimum data set (MDS) assessment showed the resident had no cognitive impairments with a score of 15 out of 15 on the brief interview for mental status (BIMS). The resident required extensive assistance of two with activities of daily living and personal hygiene. B. Resident representative interviewThe daughter was interviewed on 5/3/23 at 4:11 p.m. The daughter said the family had decided it was best for Resident #1 to stay in the facility. She said she had spoken to the CM about transitioning to the long term care section of the facility. She said she was told they did not have any rooms but would find her alternative placement. She said she thought the arrangement had been made, then she was notified that Resident #1 was being discharged on 1/17/23 to home. C. Record reviewThe care plan dated 12/2/22 showed a discharge care plan and the resident's desire to return home. The goal was to develop and follow a full discharge plan. -There were no approaches listed on the care plan. The care plan was not updated.-Review of the resident's progress notes failed to show that discharge planning was completed. When the resident was admitted, returning home was the goal. However, the goal from the family was to have the resident transition to long term care when she was discharged from skilled nursing. The resident was discharged home on 1/17/23 and the medical record failed to show how the resident went from referrals to long term care facilities to home. The progress notes were as follows:-12/16/22 documented the daughter was spoken with regarding the transition to long term care when discharged from the skilled nursing. -1/12/23 at 11:45 a.m. documented referral packets were sent to three long term care facilities to find alternative placement. -1/12/23 at 3:11 p.m. documented another facility could accept Resident #1 but not until the following week. -1/17/23 documented the resident was discharged home with home health services. D. InterviewThe CM was interviewed on 5/4/23 at 10:00 a.m. The CM said the resident's initial goal was to go home when skilled nursing was completed. After reviewing the medical record, she acknowledged she had sent referrals to other long term care facilities. She said she could not remember the reason for the resident discharging home. She acknowledged the resident's medical record failed to show the sequence of events that led to the resident discharging home. 3. Resident #3A. Resident statusResident #3, age 77, was admitted on 4/19/23 and discharged 4/25/23. According to the April 2023 CPO diagnoses included fractures of the neck of the right femur (hip) and history of falling. The 4/21/23 MDS assessment showed the resident had no cognitive impairment with a score of 15 out of 15 on the BIMS. The resident required extensive assistance of two with activities of daily living and personal hygiene. B. Record reviewThe care plan dated 4/24/23 showed a discharge care plan and the resident's desire to return home. The goal was to develop and follow a full discharge plan. -There were no approaches listed on the care plan. The care plan was not updated. -Review of the resident's progress notes failed to show a discharge plan for Resident #3. The initial goal was for the resident to return home. However, the progress notes showed the resident was discharged to another long term care facility. The medical record failed to show the reasons for the discharge and who had made the decision. The progress notes were as follows:-4/21/23 documented the resident had expressed many customer service based complaints about the care she was receiving. -4/25/23 at 7:28 a.m. documented the resident was seen by the primary care geriatric provider, and the resident was being discharged to another long term care facility. The resident was frustrated she was unaware of this transfer per her report. -4/25/23 at 2:24 p.m. the resident was discharged to the alternate long term care facility. 4. Resident #2A. Resident statusResident #2, age 91, was admitted on 2/7/23 and discharged 2/24/23. According to the February 2023 CPO diagnoses included pneumonia, congestive heart failure, atrial fibrillation and hypokalemia (decreased potassium levels). The 1/20/23 MDS assessment showed the resident had mild cognitive impairment with a score of 12 out of 15 on the BIMS. The resident required extensive assistance of two with activities of daily living and personal hygiene. B. Record reviewThe care plan dated 1/5/23 showed a discharge care plan and the resident's desire to return home. The goal was to develop and follow a full discharge plan. -There were no approaches listed on the care plan. The care plan was not updated. -Review of the resident's progress notes failed to show a discharge plan for Resident #2. The initial goal was for the resident to return home. However, the progress notes showed the resident was discharged to her independent living community with hospice. The medical record failed to show the reasons for the discharge with hospice services. The progress notes were as follows:-2/24/23 progress note documented the resident was being discharged home with hospice services later in the afternoon. III. Additional interviewsThe CM was interviewed on 5/4/23 at 10:00 a.m. The CM said for skilled services she was the primary discharge planner. She said she did not involve the social service department. She said that she made the arrangements for any outside agencies the resident may need upon discharge. She was the one who spoke to the families in regards to discharge planning. She said the care plans were to be updated by the nursing or social service department. The social service director (SSD) and social service assistant were interviewed on 5/4/23 at 11:34 a.m. The SSD said the CM handled all the discharge planning for residents while they were receiving the skilled services. She said the social service department primarily worked with the long term care residents.

Based on record review and interviews, the facility failed to ensure a discharge summary was in place for four (#1, #2, #3 and #5) out of five sample residents reviewed for discharge out of nine sample residents. Specifically, the facility failed to ensure discharge summaries included a recapitulation of the resident's stay, a final summary of the resident's status, and recapitulation of the residents stay at the facility for Resident #1, #2, #3 and #5. Cross-reference F660 discharge planningFindings include:I. Facility policy and procedureThe Discharge Summary policy, last revised on 8/18/22, was received from the nursing home administrator on 5/4/23. The policy read in percent part, "The Social Services and Nursing staff, as members of the interdisciplinary team (IDT), participate in developing a discharge summary when a resident is discharged to a private residence, another nursing facility, or another type of residential facility."The discharge summary provides a recapitulation of the resident's stay and the resident's status at the time of discharge to ensure continuity of care. Facilities will complete the Discharge Summary located in (name of electronic medical record) unless state policy request the use of a state mandated Discharge Summary form."II. Failure to complete a complete and though discharge summary 1. Resident #5A. Resident statusResident #5, age 89, was admitted on 2/15/23. She was discharged on 4/22/23. According to the February 2023 computerized physician orders (CPO) diagnoses included pain left leg and history of falling. The 2/19/23 minimum data set (MDS) showed the resident had mild cognitive impairment with a score of 12 out of 15 on the brief interview for mental status (BIMS). The resident required limited assistance with activities of daily living. B. Record reviewThe discharge summary dated 4/22/23 documented the resident was discharged to another long term care facility. The discharge summary failed to show all areas on the form were completed. The following were missing:-Physical and mental functional status including activities of daily living (ADLs)-Continence-Skin condition-Vision-Special treatment and procedures-Dental -Activities pursuit-Resident needs, strengths and goals-Resident's customary routine-Summary information on and additional areas-Pertinent lab test results-Rehabilitation follow up or potential-Recapitulation of stay specifically social service and activitiesThe resident was discharged with Eliquis (blood thinner). -The discharge summary did not include any information about the risks and benefits of this medication. 2. Resident #1A. Resident statusResident #1, age 80, was admitted on 11/23/22 and discharged 1/17/23. According to the January 2023 CPO diagnoses included osteoarthritis and prosthetic joint infection. The 11/30/22 MDS showed the resident had no cognitive impairments with a score of 15 out of 15 on the BIMS. The resident required extensive assistance of two with activities of daily living and personal hygiene. B. Record reviewThe discharge summary dated 1/17/23 documented the resident was discharged to another long term care facility. The discharge summary failed to show all areas on the form were completed. The following were missing:-Physical and mental functional status including ADLs,-Special treatments and procedures -Nutritional Status/requirements and current diet-Skin condition-Special treatment and procedures-Activities pursuit-Resident needs, strengths and goals-Resident's customary routine-Summary information on and additional areas-Pertinent lab test results-Rehabilitation follow up or potential-Recapitulation of stay specifically social service and activities-The discharge summary sent with the resident to home failed to give directions on the use of the Eliquis (blood thinner). 3. Resident #3A. Resident statusResident #3, age 77, was admitted on 4/19/23 and discharged 4/25/23. According to the April 2023 CPO diagnoses included fractures of the neck of the right femur and history of falling. The 4/21/23 MDS showed the resident had no cognitive impairment with a score of 15 out of 15 on the BIMS. The resident required extensive assistance of two with activities of daily living and personal hygiene. B. Record reviewThe discharge summary dated 4/25/23 documented the resident was discharged to another long term care facility. The discharge summary failed to show all areas on the form were completed. The following were missing:-Physical and mental functional status including ADLs-Mental, psychosocial and behavior status-Cognitive status-Special treatment and procedures-Activities pursuit-Resident needs, strengths and goals-Resident's customary routine-Summary information on and additional areas-Pertinent lab test results-Rehabilitation follow up or potential-Recapitulation of stay specifically social service and activitiesThe medical record showed the resident had an order for oxygen 2 liters per minute.-However, oxygen was not on the summary. 4. Resident #2A. Resident statusResident #2, age 91, was admitted on 2/7/23 and discharged 2/24/23. According to the February 2023 CPO diagnoses included pneumonia, congestive heart failure, atrial fibrillation and hypokalemia (decreased potassium levels). The 1/20/23 MDS showed the resident had mild cognitive impairment with a score of 12 out of 15 on the BIMS. The resident required extensive assistance of two with activities of daily living and personal hygiene. B. Record reviewThe discharge summary dated 2/22/23 documented the resident was discharged home and would be evaluated for hospice care. The discharge summary failed to show all areas on the form were completed. The following were missing:-Physical and mental functional status including ADLs-Special treatment and procedures-Activities pursuit-Resident needs, strengths and goals-Resident's customary routine-Summary information on and additional areas-Pertinent lab test results-Additional discharge planning informationThe medical record showed the resident had an order for oxygen between 8 to 10 liters per minute, ted hose to be worn, hospice evaluation, she had pertinent lab test results 2/6/23. -These areas (above) were not included in the discharge summary. III. InterviewsThe case manager (CM) was interviewed on 5/4/23 at 10:00 a.m. The CM said she opened the discharge summary for when a resident was discharging and informed the interdisciplinary team. She said the section she completed included the primary care physician information, diagnoses and home health information. She said the summary was to be completed on the resident's day of discharge. She said that the discharge summary and the medication list was provided to the family or the receiving facility. She said the health information manager was responsible to review the summary to ensure it was complete. Licensed practical nurse (LPN) #1 was interviewed on 5/4/23 at 11:00 a.m. LPN #1 said she completed the discharge summaries when residents were discharged from the facility. She said the section she completed was the vision, communication, dental, communication and continence. The health information manager (HIM) was interviewed on 5/4/23 at 11:45 a.m. The HIM said she was responsible for reviewing the resident discharge summaries. She said she had been auditing the discharge summaries and the therapy department, activities and the social service were the departments that were mostly non-compliant in completing their portions. She acknowledged the resident discharge summaries were not complete and missing pertinent information. She said she had brought it to quality assurance (QA) in December 2022. She said she would begin to complete audits once again, however, in order to make change, she said accountability for ensuring the summary was completed would need to be enforced. She said that was where the failure was, lack of accountability.

A revisit survey was completed on 1/30/23 for all previous deficiencies cited on 12/1/22. The facility is in compliance with all regulations surveyed.

A revisit survey was completed on 1/30/23 for all previous deficiencies cited on 12/1/22. The facility is in compliance with all regulations surveyed.

A document revisit was completed with all deficiencies being corrected. No other deficiencies were cited and no response is needed