Nursing Home News — Page 962

The facility failed to offer or administer Prevnar 20, a pneumonia vaccine specifically recommended for adults 65 and older.

Both residents had **severely impaired cognition** with Brief Interview of Mental Status (BIMS) scores of 7, indicating significant cognitive deficits.

The resident, identified as CR #1, was admitted with multiple serious conditions including heart failure, diabetes, morbid obesity, and atrial fibrillation.

Inspectors found the facility failed to ensure safe smoking practices when smoking residents possessed smoking materials and smoked without supervision.

Video surveillance documented that a CNA brought the resident's food tray to his room at 6:43 pm but left the facility at 7:05 pm.

During five separate observations between March 24-27, inspectors found the resident reclined in the Broda chair either at the nursing station or in her room.

## Medical Implications of the Transfer Accident The resident's medical history made this incident particularly dangerous.

When questioned about cleaning protocols, the nurse stated she sanitized the glucometer only at the beginning and end of her shift, not between residents.

The resident clearly communicated his wishes during the inspection, stating **he wanted to be resuscitated and wanted to be Full Code**.

Four residents specifically identified in the report experienced gaps in critical care that could have resulted in severe health consequences.

The resident, identified as R1 in the inspection report, subsequently died at the hospital after sustaining injuries from the fall.

QAPI programs serve as the backbone of nursing home operations, designed to continuously monitor and improve care quality.