Landings of Sidney

Based on facility record review, staff interview and facility policy review, the facility failed to maintain a criminal background check log which included all of the required elements for the log. This had the potential to affect all residents residing in the facility. The facility census was 63.

Findings include:

Review of facility Bureau of Criminal Investigation (BCI) log dated from January 2025 to October 2025 revealed the log including the following elements to be filled out: applicants name, date of hire, start date of work, date the BCI was submitted, date the report was requested, date the report was received, date report was provided, personal character standards met, final disposition and if the applicant was hirable.

On 10/22/25 at 12:41 P.M., an interview with Business Office Manager (BOM) #149 verified the facility did not fill out the BCI correctly by not including the information for the following required elements: applicants date of hire, applicants start date of work, date the BCI was submitted, date the report was requested, date the report was received, date report was provided, personal character standards met, final disposition and if the applicant was hirable.

Review of the facility policy titled, Background Check

Based on observation, medical record review and interview, the facility failed to ensure personal care was provided for one resident who was dependent on staff. This affected one resident (#48) of five sampled residents. The facility census was 63.

Findings Include:

Review of the medical record for Resident #48 revealed an initial admission date of 03/25/24 with the diagnoses including but not limited to cerebral arteriosclerosis, Alzheimer's disease, gastro-esophageal reflux disease, sensorineural hearing loss and hypercholesterolemia.

On 10/21/25 at 11:32 A.M. observation of the resident revealed the resident's nails were long and jagged and in need of grooming.

On 10/21/25 at 11:35 A.M., an interview with Licensed Practical Nurse (LPN) #105 verified the resident's nails were long and in need of grooming. The LPN revealed she actually had a list of resident who required nail trimming of fingers and toes and he was on the list.

Based on medical record review, interview and facility policy review, the facility failed to ensure medication was administered according to the directions prescribed by the physician. This affected one resident (#44) of five sampled residents. The facility census was 63.

Findings Include:

Review of the medical record for Resident #44 revealed an initial admission date of 12/06/24 with the diagnoses including but not limited to urinary tract infection, hypertension and insomnia.

Review of the resident's monthly physician orders for October 2025 identified an order dated 10/12/25 Macrobid (a medications used to treat infections) 100 milligrams (mg) by mouth twice daily for seven days for an infection.

Review of the progress note dated 10/12/25 at 10:20 A.M. revealed the resident received a hospice visit with a new order for Macrobid 100 mg by mouth twice daily for seven days. The resident's daughter was made aware of the new order.

Review of the progress note dated 10/15/25 at 11:42 A.M. revealed the urinalysis showed mix flora so a sensitivity was not completed. A new order was obtained to discontinue the remaining doses of the medication Macrobid.

Review of the resident's October 2025 Medication Administration Record (MAR) revealed the Macrobid 100 mg by mouth twice daily continued as a current order with the most recent dose of the medication being given on 10/22/25 at 8:00 A.M.

On 10/22/25 at 9:10 A.M., interview with the Executive Director (ED) verified the resident's Macrobid 100 mg by mouth was not discontinued as physician ordered.

Review of the facility policy titled, Medication Administration

Based on closed record review, facility investigation review, hospital record review, review of the facility incident/accident log, staff interview, review of email correspondence, and facility policy review, the facility failed to ensure appropriate fall interventions were in place to prevent falls and injury, failed to ensure a thorough investigation after a fall and failed to implement an individualized fall prevention interventions following a fall for one resident with a history of falls.

Actual harm occurred on 10/15/25 when Resident #67, who exhibited severe cognitive impairment and had a history of falls sustained a fall resulting in a right femur fracture and surgical repair. At the time of the fall the facility failed to provide evidence of individualized and comprehensive fall prevention/safety interventions being in place. This affected one (Resident #67) of five sampled residents for falls. The facility census was 63.

Findings Include:

Review of the closed medical record for Resident #67 revealed an initial admission date of 12/22/22 with the latest readmission of 08/20/23 with the diagnoses including but not limited to sensorineural hearing loss, hypertension, multiple fractures of bilateral ribs, deviated nasal septum, chronic fatigue, impacted cerumen, connective tissue and disc stenosis of intervertebral formation of cervical region, personal history of (healed) traumatic fractures. The resident was discharged to an acute care hospital on 10/16/25.

Review of the service plan dated 02/17/23 revealed the resident had a history of fall. Interventions included become familiar with their daily routine and attempt to anticipate and meet their needs daily, inform resident about safety reminders and to notify staff immediately if they have a fall or near fall, remind to rise and change positions slowly, remind to use assistive device, (however the resident's assistive devices were not listed) and resident to wear gripper socks or rubber soled shoes/slippers while up.

Review of the facility's incident/accident log revealed the resident has sustained a fall on 03/21/25 at 8:00 P.M., when the resident was using her wheelchair as a walker. The facility implemented the intervention to remind the resident not to use the wheelchair as a walker (despite the residents' severe cognitive deficit).

Review of the facility's incident/accident log revealed the resident sustained a fall on 03/25/25 at 9:15 A.M. when the resident was found in her apartment on the floor. The facility implemented the intervention to remind the resident to use her walker when out of bed (despite the resident's severe cognitive deficit).

Review of the resident's fall risk assessment dated 07/08/25 revealed a score of 20 indicating the resident was at high risk for falls.

Review of the facility's incident/accident log revealed the resident sustained a fall on 07/18/25 at 1:30 P.M. when the resident was found in her apartment on the floor. The facility implemented the intervention to admit the resident to hospice services.

Review of the resident's bi-annual assessment dated 08/19/25 indicated the resident lived on the facility's memory care unit. The assessment indicated the resident had a cognitive deficit and was only oriented to person and place. The assessment indicated the resident was a one person assist with mobility, ambulation and transfers with the use of a wheelchair or walker. The assessment indicated the resident had a history of falls but had not fallen in the past three months. The resident was triggered to care plan for falls however, no interventions were initiated. The assessment indicated the resident did not have a history of pain.

Review of the progress note dated 10/15/25 at 4:11 A.M., authored by Licensed Practical Nurse (LPN) #152 revealed the nurse and caregivers walked into the resident's room and the resident was found on the floor in the doorway of the bathroom lying on her right side. The resident reported that her right side/hip area hurt. The nurse completed a full head to toe assessment and the resident complained of pain to the hip area. The entry indicated the nurse placed pressure on her right hip, pelvic and leg area and the resident stated, I feel no pain or discomfort. The resident was assisted off the floor and into bed by the nurse and caregivers using a gait belt. The entry contained no documented evidence that the resident's primary care physician was notified of the fall and complaints of right hip pain.

Review of the fall investigation typed out on a piece of paper, not dated revealed on 10/14/25 at 11:45 P.M. the resident was found on the floor in front of her bathroom door lying on her right side. Upon assessment by the nurse the resident had reported her right hip hurt. The resident was assisted by two staff members off the floor and ambulated to the bathroom. The resident was then ambulated back to her bed where a notable limp was observed but was not screaming with movement. The resident's daughter was contacted and made the decision to leave her at the facility due to concerned it was more a fearful movement. Further review of the fall investigation revealed the fall investigation was a summary of the resident's progress notes. The investigation had no staff statements, root cause of fall or implementation of fall prevention intervention to prevent further falls.

Review of the progress note dated 10/15/25 at 6:55 P.M. revealed the nurse was notified of the final X-ray results indicating the resident had an acute fracture of the right proximal femur. The resident's family and hospice company were notified of the final results. The nurse then educated the staff on keeping the resident's leg as immobile as possible, using proper body mechanics when rolling the resident and the resident was to remain in bed until orders from the physician were received despite the fact the resident had a suspected fracture since the fall which occurred on 10/14/25 at 11:45 A.M.

Review of the progress note dated 10/15/25 at 6:55 P.M. revealed the resident's family requested the resident to be sent to the local emergency department (ED) for an evaluation and an orthopedics consultation.

Review of the progress note dated 10/16/25 at 4:12 P.M. revealed the resident had surgery and per the family was doing well.

Review of the resident's hospital summary from 10/15/25 to 10/17/25 revealed the resident arrived at the (ED) via emergency medical services (EMS) for a right femur fracture. The facility reported to the ED the resident sustained a fall on 10/14/25 with imaging completed at the facility revealing a right femur fracture. The resident presented to the ED with her right lower extremity slightly shorter but without rotation. Further review revealed the resident underwent surgical intervention for the right femur fracture on 10/15/25. Further review revealed on 10/17/25 at 2:40 P.M. a rapid response was called when the resident was pale looking, unresponsive with no spontaneous respirations and no jugular or femoral pulse. The resident's pupils were fixed and dilated. The resident was pronounced dead at 2:45 P.M.

Review of the email correspondence from the Executive Director (ED) dated 10/27/25 at 12:07 P.M. revealed the resident had a total of four falls prior to the fall on 10/14/25. The ED revealed the resident has call light teaching, low bed with blue mat, frequent checks and bell due to non-use of call light, however review of the resident's medical record revealed no evidence the stated fall interventions had been implemented for the resident and the ED provided no documented evidence the fall interventions were in place.

Review of the facility policy titled, Falls

Based on observation, record review and interview, the facility failed to maintain appropriate infection control practices with medication administration. This affected one resident (#44) of three residents observed for medication administration. The facility census was 63.

Findings Include:

Review of the medical record for Resident #44 revealed an initial admission date of 12/06/24 with the diagnoses including but not limited to urinary tract infection, hypertension and insomnia.

Review of the service plan dated 06/13/25 revealed the resident was unable to self-administer medications. Intervention included medications will be administered by licensed or certified team members per physician orders.

Review of the resident's mini mental state exam dated 10/16/25 revealed a score of 24 indicating the resident had a borderline condition of dementia and/or cognitive impairment.

Review of the resident's monthly physician orders for October 2025 identified an order dated 02/17/25 Depakote Sodium 125 milligrams (mg) by mouth three times a day.

On 10/21/25 at 11:24 A.M., observation of Licensed Practical Nurse (LPN) #105 prepare and administer Resident #44's noon medication revealed the LPN pulled a pack of prepackaged medication out of the medication cart containing Depakote 125 mg and Carbidopa-Levodopa 25-100 mg tablets. Further observation revealed the LPN dropped the white tablet identified as Depakote 125 mg on a white piece of paper laying on the top of the medication cart. The LPN picked the Depakote 125 mg tablet up with her bare hands and placed in a clear plastic cup. The LPN administered the medication to Resident #44.

On 10/21/25 at 11:28 A.M., an interview with LPN #105 verified she picked the Depakote 125 mg tablet up with bare hand and administered to the resident.

Based on observation, interview and facility policy review, the facility failed to maintain a clean and sanitary kitchen. Also, the facility failed to appropriately store and date food in the facility kitchen and kitchenette on the 400/600 hallway in a manner that protects it against contamination and spoilage. This had the potential to affect all residents residing in the facility. The facility census was 63.

Findings Include:

1. On 10/21/25 at 9:31 A.M., observation of the facility microwave revealed dried food to the handle to open the door and dried food to the inside walls.

On 10/21/25 at 9:33 A.M., an interview with the Dietary Service Manager (DSM) #102 verified the microwave had dried food to the handle and the inside walls. The DSM #102 revealed the microwave should be cleaned nightly.

2. On 10/21/25 at 9:38 A.M., observation of the reach in freezer revealed six serving bowls of ice cream not covered or dated, two bowls of chocolate ice cream dated 10/11/25. Further observation revealed one bag of chicken nuggets opened and not dated, one bag of hash browns opened and not dated, one bag of french fries opened and not dated and four bags of chicken nuggets not dated. DSM #102 verified the inappropriate storage of the opened bags of hash browns, french fries, chicken nuggets and ice cream. The DSM #102 also verified the lack of dates on the opened food.

3. On 10/21/25 at 10:31 A.M., observation of the 400/600 hallway kitchenette revealed a white household reach in refrigerator. The freezer had multiple a dried brown sticky substance on the bottom with multiple loose undated popsicles. The reach in refrigerator had a dried sticky substance on the back wall of the inside of the refrigerator.

On 10/21/25 at 1:30 P.M., an interview with the Executive Director (ED) verified the popsicles were not dated and the refrigerator was dirty.

Review of the facility policy titled, Food and Dietary Supplies Storage

Based on facility fire drill record review, staff interview and facility policy review, the facility failed to This had the potential to affect all residents residing in the facility. The facility census was 63.

Findings include:

Review of facility fire drills revealed the facility conducted a fire drill on the day shift on 10/29/24 at 2:30 P.M., 12/26/24 at 1:30 P.M., 02/28/25 at 10:00 A.M. and 04/29/25 at 1:15 P.M. Further review revealed no dayshift fire drill was conducted for the quarter of July, August and September 2025.

On 10/21/25 at 3:08 P.M., an interview with the Executive Director verified the facility failed to conduct a fire drill on the day shift for the quarter of July, August and September 2025.

Review of the facility policy titled, Fire Safety Training and Drills

Based on observation, staff interview and facility policy review, the facility failed to ensure hazardous chemicals were properly stored to prevent possible accidental exposures. This had the potential to affect 43 residents (#1, #2, #3, #7, #8, #9, #10, #12, #13, #16, #17, #18, #20, #21, #22, #23, #25, #26, #27, #28, #29, #30, #31, #33, #34, #35, #37, #40, #41, #42, #47, #49, #50, #51, #52, #53, #54, #55, #57, #60, #61, #63 and #66). The facility census was 63.

Findings include:

1. On 10/21/25 at 9:54 A.M., observations made during the initial tour of the facility noted a mechanical room door on the 100 hallway to be unsecured as the door was not locked and the room was unoccupied. There were multiple hazardous chemicals noted on a shelving unit and in boxes sitting on the floor located inside the room. Multiple cans of black hawk degreaser, multiple jugs of grease-strip plus, multiple jugs of bleach, and dawn dishwashing liquid was among the hazardous chemicals found.

On 10/21/25 at 9:56 A.M., an interview with Licensed Practical Nurse (LPN) #131 verified the maintenance room door was to remain locked to ensure hazardous chemicals remained secured.

2. On 10/21/25 at 10:09 A.M., observation made of the 100/300 hallway laundry room during the initial tour of the facility revealed multiple unsecured hazardous chemicals inside cabinets and sitting next to the washer and dryer. Two bottles of Clorox toilet bowl cleaner, a spray bottle of Ecolab 66 heavy duty alkaline bathroom cleaner and disinfectant, a bottle of Ecolab lemon eze bathroom cleaner, a can of hot shot ant, roach and spider spray, two spray bottles of Ecolab revitalize carpet and upholstery cleaner, a bottle of Ecolab stain-blaster makeup remover, two bottles of rapid multi surface disinfectant cleaner, a spray bottle with hand written Zep floor cleaner, dining room only, two blocks of Ecolab home style laundry detergent sitting unopened on a bucket of liquid laundry detergent was among the hazardous chemicals found.

On 10/21/25 at 10:23 A.M., an interview with LPN #131 verified the chemicals were not secured leaving residents with the potential for accidental exposure.

3. On 10/21/25 at 10:31 A.M., observation of the 400/600 hallway kitchenette during the initial tour of the facility revealed multiple unsecured hazardous chemicals in the cabinet under the sink. A spray bottle of scrubbing bubbles grime fighter cleaner, a bottle of Clorox toilet bowl cleaner, two cans of Lysol disinfectant spray, a bottle of 66 heavy duty bathroom cleaner and disinfectant, a Windex bottle with top of the bottle reading odorban, a bottle of great value stain remover, a bottle of Ecolab high performance neutral floor cleaner, an unmarked bottle of clear liquid, a bottle of revitalize carpet and upholstery cleaner, a spray bottle of Ecolab bi-enzymatic odor eliminator, five bottles of spray and go disinfectant cleaner and odor counteractant, a bottle of pure hard surface commercial line disinfectant, one container of Clorox scentiva disinfecting wipes, a spry bottle of rapid multi surface disinfectant spray, a bottle of lemon eze bathroom cleaner and a box of brillow pads were among the hazardous chemicals found.

On 10/21/25 at 1:30 P.M., an interview with the Executive Director (ED) verified the hazardous chemicals were not secured in the cabinet under the sink.

4. On 10/21/25 at 10:40 AM., observation of the 600 hallway laundry door revealed the handle was locked but the door was ajar allowing resident access to the area. Further observation revealed multiple chemicals as follows: Ecolab StainBlaster Makeup Remover by Ecolab, Lysol disinfecting spray, Ecolab Stain Blaster Enzyme Boost, Ecolab home-style solid laundry detergent unsecured.

On 10/21/25 at 10:45 A.M., an interview with Care Partner (CP) #158 verified the door was left open and the hazardous chemicals were not secure to prevent resident access.

Review of the facility policy titled, Housekeeping Safety

Based on closed record review, facility investigation review, hospital record review, review of the facility incident/accident log, interview and facility policy review, the facility failed to ensure timely and appropriate medical care following a fall with a fracture. This affected one resident (#67) of five sampled residents. The facility census was 63.

Findings Include:

Review of the closed medical record for Resident #67 revealed an initial admission date of 08/20/25 with the diagnoses including but not limited to sensorineural hearing loss, hypertension, multiple fractures of bilateral ribs, deviated nasal septum, chronic fatigue, impacted cerumen, connective tissue and disc stenosis of intervertebral formation of cervical region, personal history of (healed) traumatic fractures. The resident was discharged to an acute care hospital on 10/16/25 where the resident expired on 10/17/25.

Review of the resident's fall risk assessment dated 07/08/25 revealed a score of 20 indicating the resident was at high risk for falls.

Review of the service plan dated 02/17/23 revealed the resident had a history of fall. Interventions included become familiar with their daily routine and attempt to anticipate and meet their needs daily, inform resident about safety reminders and to notify staff immediately if they have a fall or near fall, remind to rise and change positions slowly, remind to use assistive device, however the resident's assistive devices were not listed and resident to wear gripper socks or rubber soled shoes/slippers while up.

Review of the progress note dated 10/15/25 at 12:15 A.M., authored by Licensed Practical Nurse (LPN) #152 revealed the nurse spoke with the family about resident's fall and informed them the resident's right side was hurting. The family requested to monitor the resident throughout the night and see how she was in the morning.

Review of the progress note dated 10/15/25 at 2:45 A.M., authored by LPN #152 revealed the nurse had contacted hospice to come in and assess the resident's hip area due to when the caregivers attempted to take the resident to the bathroom, she wouldn't get out of bed due to pain.

Review of the progress note dated 10/15/25 at 2:56 A.M., authored by LPN #152 revealed she had administered to the resident an as needed pain analgesic, Norco for pain from earlier fall.

Review of the progress note dated 10/15/25 at 3:04 A.M., authored by LPN #152 revealed the nurse notified the daughter that hospice was to come in and assess the resident due to the resident continuing to complain of pain from the fall.

Review of the progress note dated 10/15/25 at 4:11 A.M., authored by LPN #152 revealed the nurse and caregivers walked into the resident's room and the resident was found on the floor in the doorway of the bathroom laying on her right side. The resident reported that her right side/hip area hurt. The nurse completed a full head to toe assessment and the resident complained of pain to the hip area. The entry indicated the nurse placed pressure on her right hip, pelvic and leg area and the resident stated, I feel no pain or discomfort. The resident was assisted off the floor and into bed by the nurse and caregivers using a gait belt.

Review of the progress note dated 10/15/25 at 4:16 A.M., authored by LPN #152 revealed the hospice nurse arrived at the facility and ordered an x-ray of the right hip.

Review of the progress note dated 10/15/25 at 7:47 A.M., revealed the nurse was notified the resident was sitting on the toilet and became pale, clammy and her blood pressure (BP) was 72/48. The resident was weak and was assisted back to bed via wheelchair, despite the fact the resident had a pending x-ray order to rule out fractures from the fall on 10/14/25.

Review of the progress note dated 10/15/25 at 9:02 A.M., a new order was obtained for an x-ray of the right rib, hip, pelvis, femur and knee.

Review of the progress note dated 10/15/25 at 9:59 A.M., resident was complaining of right hip/leg pain. The resident was sweaty and pale with a low BP of 72/48. Further review revealed hospice was updated, however there was no documentation of the resident's family and/or primary care physician being updated on the resident's change in condition.

Review of the progress note dated 10/15/25 at 10:54 A.M., despite the resident complaining of right hip/leg pain and a pending x-ray the resident was out for lunch with other residents in the dining room.

Review of the progress note dated 10/15/25 at 12:50 P.M. revealed the resident was administered Ativan, however despite the documentation of the resident's continued complaints of pain the resident was not administered any as needed analgesic pain medication.

Review of the progress note dated 10/15/25 at 1:56 P.M. revealed the family notified the nurse the resident needed to use the restroom. The resident was sitting in a wheelchair. The resident was assisted onto the toilet holding on to the grab bar to standing position. The resident was weak and required to assists to place onto the commode and once on the commode the resident became pale, eyes fixed, non-responsive and her BP was 198/143. The episode lasted five to ten minutes before staff was able to assist the resident off the toilet into the wheelchair. The staff assisted the resident into bed via Hoyer lift. Continuous oxygen was applied at four liters per nasal cannula due to oxygen saturation was at 81%. The resident was at bedside and hospice was notified of the incident.

Review of the progress note dated 10/15/25 at 2:16 P.M., a new order was obtained from hospice for Ativan 0.5 mg by mouth every two hours as needed and Morphine 5 mg by mouth every four hours as needed.

Review of the progress note dated 10/15/25 at 4:50 P.M. revealed the preliminary results showed a right femur fracture. The resident was to remain bedridden until final results were received. The family and hospice was informed of the results. The resident was administered Ativan and Norco due to continued complaints of right leg pain.

Review of the medical record revealed no documented evidence the resident's primary care physician was notified of the preliminary x-ray results of a right femur fracture.

Review of the progress note dated 10/15/25 at 6:55 P.M. revealed the nurse was notified of the final x-ray results indicating the resident had an acute fracture of the right proximal femur. The resident's family and hospice company was notified of the final results. The nurse then educated the staff on keeping the resident's leg as immobile as possible, using proper body mechanics when rolling the resident and the resident was to remain in bed until orders from the physician were received despite the fact the resident had a suspected fracture since the fall which occurred on 10/14/25 at 11:45 A.M.

Review of the progress note dated 10/15/25 at 6:55 P.M. revealed the resident's family requested the resident to be sent to the local emergency department (ED) for an evaluation and an orthopedics consult.

Review of the progress note dated 10/16/25 at 4:12 P.M. revealed the resident had survey and per the family was doing well.

Review of the resident's hospital summary from 10/15/25 to 10/17/25 revealed the resident arrived to the (ED) via emergency medical services (EMS) for a right femur fracture. The facility reported to the ED the resident sustained a fall on 10/14/25 with imaging completed at the facility revealing a right femur fracture. The resident presented to the ED with her right lower extremity slightly shorter but without rotation. Further review revealed the resident underwent surgical intervention for the right femur fracture on 10/15/25. Further review revealed on 10/17/25 at 2:40 P.M. a rapid response was called when the resident was pale looking, unresponsive with no spontaneous respirations and no jugular or femoral pulse. The resident's pupils were fixed and dilated. The resident was pronounced dead at 2:45 P.M.

On 10/22/25 at 2:14 P.M., an interview with the Executive Director (ED) verified the resident should not have been gotten out of bed with the pending x-ray to rule out a right hip/leg fracture. The ED also verified the nurse should have administered the as needed pain analgesic instead of the antianxiety.

On 10/22/25 at 2:24 P.M., an interview with LPN #152 revealed the resident fell on 10/14/25 at 11:45 P.M., despite the charting reflecting the resident fell on 10/15/25 at 4:11 A.M. The LPN revealed she assessed the resident twice and seen no deficits, only complaints of pain to her right hip. She said she contacted hospice and the hospice nurse told her to call the resident's primary care physician. The LPN revealed she told the hospice nurse she took orders from then since she was hospice. The LPN revealed she did obtain the x-ray order from hospice but there was a delay because she thought hospice scheduled the x-ray. She said the x-ray was not scheduled until day shift when LPN #105 scheduled the x-ray.

On 10/22/25 at 3:11 P.M., an interview with Resident Assistant (RA) #117 revealed she was cared for the resident on 10/15/25. The RA revealed the resident was more confused and complained of right hip pain. She revealed the resident walked with a walker however, following the fall the resident required two assists to get out of bed and toilet. She revealed she was unaware of the resident had a possible right hip/leg fracture and received no instructions from the nurse regarding the resident's care. The RA revealed she would not have gotten the resident out of bed if she knew the had a possible hip/leg fracture.

Review of the facility policy titled, Significant Change of Condition