Every finding on record at Als Mount Vernon Inc

Based on medical record review, and staff interview the facility failed to permit Resident #21 to return to the facility after a hospitalization. This affected one (Resident #21) of three residents reviewed for discharge. The facility census was 20.Findings include:Review of the medical record for Resident #21 revealed an admission date of 01/09/2026. Diagnoses included nontraumatic intracerebral hemorrhage, atherosclerotic heart disease, hypertension, nicotine dependence, nonrheumatic aortic valve stenosis, prediabetes, malignant neoplasm of prostate, diverticulosis of intestine without perforation or bleeding, vitamin D deficiency, dysphagia, cognitive communication deficit, muscle weakness, abnormalities of gait and mobility, lack of coordination, hearing loss, and amnesia.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #21 had a Brief Interview of Mental Status (BIMS) score of two, indicating severe cognitive impairment. Review of Resident #21's record revealed the facility issued a Notice of Medicare Non Coverage (NOMNC) via telephone on 02/09/26 at 9:15 A.M. speaking to the responsible party/Power of Attorney for Resident #21 with the information that Medicare coverage would end on 02/11/26 and financial liability would begin on 02/12/26. The party responsible was also informed of the right to appeal. The notice was provided by the facility's social service. Review of the medical record for Resident #21 revealed the resident was transferred to the hospital on [DATE] for an elevated heart rate and was admitted for observation and treatment. The transfer documentation dated 02/10/26, did not include information that the resident and/or resident representative were provided a written notice of transfer or discharge at the time of transfer to the hospital. The transfer form dated 02/10/26 confirmed the resident was transferred to the hospital at approximately 9:10 A.M.; however, the documentation only reflected clinical and communication information provided to the hospital and did not include evidence of a written notice of transfer or discharge being provided to the resident or representative.Review of the resident record revealed the resident was discharged from the facility and off of the census in the electronic medical record on 02/10/26.Review of the Beneficiary and Family Centered Care-Quality Improvement Organizations (BFCC-QIO) Determination letter dated 02/11/26 revealed Resident #21 lost the appeal for the (NOMNC) and the resident no longer met the Meidcare coverage requirements for skilled nursing facility services. The notice documented the resident or representative were notified by telephone on 02/11/26 at 12:48 P.M. of the determination and that beginning 02/12/26 the resident would be responsible for the cost of all services continued at the facility except for those that were covered (where applicable) by Medicare part B. The notice documented if the resident or representative disagreed with the decision they may request that the determination be reconsidered to uphold the facility's end of Medicare covered services. The request must be made by telephone or in writing no later than sixty (60) calendar days for the date of the notice. Resident #21's medical record had no documentation the resident and or resident representative were offered to return/stay at the facility and provided a cost of the services they would incur as the Medicare coverage would end after 02/11/26 and they would be responsible for the payment of services.Interview with the Administrator on 03/17/2026 at 2:00 P.M. confirmed the facility did not provide a bed hold notice to Resident #21 or the resident representative, did not offer the option to hold the bed when the resident discharged to the hospital, and did not hold the bed during the hospitalization. The Administrator confirmed no bed was available for Resident #21 to admit to when the resident was ready to return from the hospital on [DATE], as another resident had been admitted to the bed Resident #21 had previously been in.Interview with the Administrator on 03/17/26 at 2:26 P.M. confirmed the facility received the denial for the appeal of Medicare coverage for Resident #21 on 02/11/26.

Based on medical record review, staff interviews, and review of facility policies, the facility failed to ensure a bed hold notice was provided and failed to inform the resident and/or resident representative of bed hold rights at the time of hospital transfer. This affected one (Resident #21) of three residents reviewed for discharge. The facility census was 20.Findings include:Review of the medical record for Resident #21 revealed an admission date of 01/09/2026. Diagnoses included nontraumatic intracerebral hemorrhage, atherosclerotic heart disease, hypertension, nicotine dependence, nonrheumatic aortic valve stenosis, prediabetes, malignant neoplasm of prostate, diverticulosis of intestine without perforation or bleeding, vitamin D deficiency, dysphagia, cognitive communication deficit, muscle weakness, abnormalities of gait and mobility, lack of coordination, hearing loss, and amnesia.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #21 had a Brief Interview of Mental Status (BIMS) score of two, indicating severe cognitive impairment. Review of the medical record for Resident #21 revealed the resident was transferred to the hospital on [DATE] and was admitted for treatment, with readmission to the facility on [DATE]. The medical record further revealed the resident was transferred again to the hospital on [DATE] and was admitted for observation and treatment.Review of the discharge/transfer record dated 01/16/2026 at 2:03 P.M. revealed it did not include documentation that the resident and/ or resident representative were provided a bed hold notice at the time of transfer. The medical record did not include a progress note related to the discharge which occurred on 01/16/26.Review of the Notice of Medicare Non Coverage for Resident #21 revealed on 02/09/26 at 9:15 A.M. the responsible party/Power of Attorney for Resident #21 was provided the notice via telephone with the information that Medicare coverage would end on 02/11/26 and financial liability would begin on 02/12/26. The responsible party was also informed of the right to appeal. The notice was provided by the facility's social service. Review of Resident #21's medical record, including transfer documentation dated 02/10/2026, did not identify documentation indicating the resident and/or resident representative were provided a written notice of transfer or discharge at the time of transfer to the hospital. The transfer form dated 02/10/26 confirmed the resident was transferred to the hospital at approximately 9:10 A.M.; however, the documentation only reflected clinical and communication information provided to the hospital and did not include evidence of a written notice of transfer or discharge being provided to the resident or representative. Further review of the progress notes dated 02/10/2026 to 02/12/2026 did not identify documentation that a written discharge notice was issued to the resident or resident representative after the facility determined the resident would not be permitted to return following hospitalization. Review of the Beneficiary and Family Centered Care-Quality Improvement Organizations (BFCC-QIO) Determination letter dated 02/11/26 revealed Resident #21 lost the appeal and the Resident no longer met the Meidcare coverage requirements for skilled nursing facility services. The notice documented the resident or representative were notified by telephone on 02/11/26 at 12:48 P.M. of the determination and that beginning 02/12/26 the the resident would be responsible for the cost of all services continued at the facility except for those that are covered (where applicable) by Medicare part B. The notice documented if the resident or representative disagreed with the decision they may request that the determination be reconsidered to uphold the facility's end of Medicare covered services. The request must be made by telephone or in writing no later than sixty (60) calendar days for the date of the notice. Resident #21's medical record had no documentation that bed hold rights were explained to Resident #21 or the resident representative, had no documentation a bed hold notice was provided to the resident or resident representative at the time of the transfer on 01/16/26 or 02/10/26, and contained no signed bed hold notice from Resident #21 or the resident's representative. The record additionally did not contain any documentation of the resident or representative being provided documentation of a transfer/discharge notice. Interview with the Administrator on 03/17/2026 at 11:10 A.M. revealed the facility's practice was not to provide bed hold notices for residents who were not Medicaid eligible. The Administrator stated, if a resident doesn't have Medicaid, we don't do bed holds,. The Administrator confirmed Resident #21 and the resident representative did not receive a bed hold notice.Interview with Regional Business Office Manager (RBOM) #130 on 03/17/2026 at 12:42 P.M. confirmed the facility only provided bed hold notices to residents with Medicaid and did not provide them to residents with Medicare or who were private pay.Interview with the Director of Nursing (DON) on 03/17/2026 at 1:35 P.M. revealed the DON was not knowledgeable regarding when bed hold notices should be issued and could not clarify the process followed for Resident #21's hospital transfer.Interview with the Administrator on 03/17/2026 at 2:00 P.M. and again at 2:26 P.M. confirmed the facility did not provide a bed hold notice to Resident #21 or the resident representative, did not offer the option to hold the bed, and did not hold the bed during the hospitalization. The Administrator confirmed no bed was available for the Resident #21 to admit to when the resident was ready to return from the hospital on [DATE], thus he was not able to return to the facility.Review of the facility policy titled Bed Hold Notice/Policy, undated, revealed the facility was required to provide written information to the resident and/or resident representative prior to and at the time of transfer for hospitalization, including the duration of the bed hold policy, reserve bed payment information, and conditions for return to the facility. The policy required documentation of a signed and dated acknowledgment and indicated the information was to be provided to all residents regardless of payment source. This deficiency represents non-compliance investigated under Complaint Number 2799184.

Based on the facility Legionella Environmental Assessment, the Legionella plan and monitoring process, and interview, the facility failed to accurately complete the assessment and follow the plan for monitoring to minimize the risk of Legionella in the water system. This had the potential to affect all 19 residents. The facility census was 19. Findings include: Review of the Legionella Environmental Assessment Form (no date) revealed the facility did not have a whirlpool spa, hot, or hydrotherapy spa on the facility premises. The form also revealed the facility had a water safety plan but did not indicate if the facility ever tested for Legionella in water samples. The source of water used by the facility was municipal water but there was no documentation of how the municipal water was disinfected or if the treatment of the water had changed within the last year. The assessment also revealed there were thermostatic mixing valves used but no documentation where they were located. It was documented that the hot water temperatures were measured by the facility at the points of use, but the lowest hot water temperature was not documented. Review of the facility Legionella monitoring process revealed the hot water temperatures would be checked weekly on each hall and the hot water heaters would also be checked weekly. Review of the water temperature logs revealed water temperatures on each hall were checked in 2024, on 05/07/25 and again on 01/23/26. Water heater temperatures were documented as being checked monthly but there was not day or year documented on the form. An interview on 01/29/26 at 8:04 A.M. with Maintenance Director #102 revealed he had started working at the facility two weeks ago. Maintenance Director #102 verified that the Legionella binder had documentation from 2024 through 2026 and he had provided the surveyor with all the documentation he had available. Maintenance Director #102 verified the facility had a whirlpool tub and the Legionella Environmental Assessment Form was incorrect and incomplete. He also verified there was no documentation of the water temperatures being checked weekly as stated in the monitoring process.

Based on review of the Facility Assessment, personnel record review, and interview, the facility failed to provide dementia training to staff upon hire. This had the potential to affect all residents residing in the facility. The facility census was 19. Findings include: Review of the facility's Facility assessment dated [DATE] included under staff training, education and competencies that training would be provided on hire and annually on caring for residents with dementia, Alzheimer's and cognitive impairments as well as implementing non-pharmacological interventions.Review of the personnel record for Certified Nursing Assistant (CNA) #125 revealed a hire date of 12/11/25 with no documentation of dementia training.Review of the personnel record for CNA #120 revealed a hire date of 12/31/25 with no documentation of dementia training.Review of the personnel record for Social Services Designee (SSD) #141 revealed a hire date of 02/25/25 with no documentation of dementia training.Review of the personnel record for Maintenance Director (MD) #102 revealed a hire date of 01/13/26 with no documentation of dementia training.Interview on 01/28/26 at 3:50 P.M. with Human Resource Director (HR) #142 revealed that dementia training is done annually when it populates into the internet training modules.Interview on 01/29/26 at 9:24 A.M. with Director of Nursing (DON) #100 revealed DON #100 identified ten residents (#4, #5, #6, #8, #9, #10, #12, #15, #16, and #21) who had a diagnosis of dementia that resided in the facility.Interview on 01/29/26 at 2:00 P.M. with HR #142 identified 11 staff (Registered Nurse (RN) #115, CNA #120, CNA #125, Licensed Practical Nurse (LPN) #126, CNA #116, Activities Director #105, Activities Aide #130, SSD #141, Dietary Aide #121 and MD #102 as being hired within the last year.

Based on review of the Facility Assessment, personnel record review, and interview, the facility failed to provide behavioral health training upon hire. This had the potential to affect all residents residing in the facility. The facility census was 19. Findings include: Review of the facility's Facility assessment dated [DATE] included under staff training, education and competencies that training would be provided on hire and annually on caring for residents with mental and psychosocial disorders, as well as caring for residents with a history of trauma and/or post-traumatic stress disorder and implementing non-pharmacological interventions.Review of the personnel record for Certified Nursing Assistant (CNA) #125 revealed a hire date of 12/11/25 with no documentation of behavioral training.Review of the personnel record for CNA #120 revealed a hire date of 12/31/25 with no documentation of behavioral training.Review of the personnel record for Social Services Designee (SSD) #141 revealed a hire date of 02/25/25 with no documentation of behavioral training.Review of personnel record for Maintenance Director (MD) #102 revealed a hire date of 01/13/26 with no documentation of behavioral training.Interview on 01/28/26 at 3:50 P.M. with Human Resource Director (HR) #142 revealed that behavior training is done annually when it populates into the internet training modules.Interview on 01/29/26 at 9:24 A.M. with Director of Nursing (DON) #100 revealed DON #100 identified six residents (#5, #6, #10, #11, #13, and #17) who have behaviors that currently reside in the facility.Interview on 01/29/26 at 2:00 P.M. with HR #142 identified 11 staff (Registered Nurse (RN) #115, CNA #120, CNA #125, Licensed Practical Nurse (LPN) #126, CNA #116, Activities Director #105, Activities Aide #130, SSD #141, Dietary Aide #121 and MD #102 as being hired within the last year.

Based on record review, staff interview, and facility policy review, the facility failed to ensure as needed (PRN) medication orders for psychotropic medications were limited to 14 days or that the facility physician justified in the medical record continued use of such medications. This affected one resident (#12) of six residents reviewed for unnecessary medications. The facility identified three residents (#2, #10 and #12) as receiving PRN psychotropic medications. The facility census was 19.Findings include: Review of the medical record for Resident #12 revealed an admission date of 09/07/23 with diagnoses including diabetes mellitus, anxiety, and major depressive disorder.Review of the current physician ' s orders revealed that Resident #12 was prescribed 0.5 milligrams (mg) of Lorazepam (an antianxiety medication) by mouth every four hours as needed (PRN) for agitation and anxiety on 12/24/25 with no stop date.Review of the MDS 3.0 quarterly assessment dated [DATE] revealed Resident #12 had a Brief Interview for Mental Status (BIMS) score of 02, indicating the resident was severely cognitively impaired. Review of the medication administration record (MAR) for January 2026 to date revealed Resident #12 did not receive any PRN doses of Lorazepam.Review of both the electronic and hard chart revealed no other evidence the Resident #12's attending physician documented rationale for continued use of the PRN Lorazepam beyond 14 days as required.Interview on 01/29/26 at 10:07 A.M. with the Director of Nursing (DON) verified that no rationale was documented in Resident #12's medical record for the continued use of the PRN Lorazepam. The DON verified that Resident #12's physician discontinued the PRN Lorazepam as of this date (01/29/26).Review of the undated facility policy titled, Psychotropic Management Policy revealed any as needed (PRN) use of a psychotropic was limited to 14 days and required that the prescriber evaluate the resident for appropriateness prior to renewal.

Based on medical record review and interview, the facility failed to code resident Minimum Data Set (MDS) assessments accurately. This affected two residents (#12 and #21) of 18 sampled residents reviewed for accuracy of MDS assessments. The facility census was 19.Findings include: 1. Review of the medical record for Resident #12 revealed an admission date of 09/07/23 with diagnoses including diabetes mellitus, anxiety, and major depressive disorder. Review of the physician's orders revealed Resident #12 was admitted to hospice services on 06/23/25 and remained on hospice services. Review of the MDS 3.0 quarterly assessment dated [DATE] revealed Resident #12 had a Brief Interview for Mental Status (BIMS) score of 02, indicating the resident was severely cognitively impaired. Resident #12 was recorded as not receiving hospice services during the look back period. Interview on 01/28/26 at 3:50 P.M. with Corporate MDS Nurse #201 revealed Resident #12 should have been marked as being on hospice on the quarterly MDS assessment dated [DATE]. 2. Review of the medical record revealed Resident #21 was admitted on [DATE] with diagnoses that included Alzheimer's disease, mood disorder, hypertension, osteoporosis, and depression. Continued review of the medical record revealed Resident #21 signed a Hospice Agreement on 09/22/25 while residing at an assisted living facility. Review of the Clinical admission assessment dated [DATE] revealed Resident #21 was admitted with hospice services. Review of Resident #21's baseline care plan dated 01/08/26 revealed Resident #21 received hospice services. Review of Resident #21's physician orders revealed an order dated 01/08/26 which noted Resident #21 received hospice services. Review of the admission MDS assessment dated [DATE] revealed Resident #21 had a severe cognitive impairment. Further review of the MDS revealed in section J, item J1400 noted Resident #21 did not have a condition or chronic disease that may result in a life expectancy of less than six months. An interview on 01/28/26 at 3:55 P.M. Corporate MDS Nurse #201 verified Resident #21 received hospice services and section J1400 of the admission MDS was marked incorrectly.

Based on observation, record review, interviews, and facility policy review, the facility failed to ensure activities were held where Resident #2 could attend and failed to ensure meaningful activities were provided for Resident #4. This affected two residents (#2 and #4) out of five residents reviewed for activities. The facility census was 19.Findings include: 1. Review of the medical record revealed Resident #2 was admitted on [DATE] with diagnoses that included osteomyelitis of the vertebra, type 2 diabetes, and chronic kidney disease. The activities initial review dated 10/27/25 revealed Resident #2 liked playing her gaming system, gardening, reading, word searches, coloring, watching television, and previously enjoyed attending church every Sunday. Resident #2 was currently bedbound and would be doing activities in her room. The activity participation review revealed Resident #2 was willing to go to group activities when she was feeling better. Review of the modification of the 5-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 was cognitively intact and used a manual wheelchair. The plan of care dated 10/28/25 and revised on 01/28/26 revealed Resident #2 was at risk for alteration in activity participation. Interventions included to identify activities of interest, reassess as indicated, encourage resident to experience and learn new activities, and provide one-on-one as needed. No new interventions were added with the revision on 01/28/26. Review of the group activity participation log from 12/31/25 through 01/27/26 revealed Resident #2 participated in only one social activity on 01/07/26. The self-directed activity participation log from 12/31/25 through 01/27/26 revealed Resident #2's activities included watching television and reading. An interview on 01/27/26 at 9:12 A.M. Resident #2 revealed she enjoyed playing bingo. The resident stated the activities were sometimes held at one of the assisted living facilities located on the same campus. Resident #2 stated she was able to walk with a walker now, but it was too far to walk to the assisted living facility. Review of the activities calendar for January revealed four of the 13 scheduled bingo activities were scheduled to be at the assisted living facility. Two of the 13 scheduled bingo activities revealed there were appointments that Activity Director #105 had to transport residents to. The transportation log revealed on 01/27/26 at 8:15 A.M. Activity Director had a scheduled transportation. The activities calendar revealed on 01/27/26 at 9:30 A.M. a craft was scheduled at the assisted living facility, and at 1:30 P.M. bingo was scheduled at the assisted living facility. Continued review of the activities calendar revealed on 01/28/26 at 9:30 A.M., a craft was scheduled to be held at the assisted living facility. The transportation log revealed Activities Director #105 had a scheduled transportation at 11:30 A.M. The activity calendar revealed on 01/28/26 at 1:30 P.M. resident council was to be held at the assisted living facility. The activity calendar also revealed an ice cream social was scheduled at 3:00 P.M. The transportation log revealed 10 days of scheduled appointments that required Activities Director #105 to transport residents. An interview on 01/29/26 at 1:38 P.M. Activities Director #105 verified that activities were held at the skilled and assisted living facilities and residents, but some of the residents did not like going to another building for the activities. Activities Director #105 verified one of her duties required her to transport residents to appointments. If a resident was scheduled for an appointment, the activity would be canceled or held when she returned to the facility. Activities Director #105 verified in the last 30-days there was only documentation of Resident #2 participating in a group activity one time on 01/07/26. Review of the activities policy dated 8/2023 revealed comprehensive activity evaluations were completed upon admission, routinely, and as needed with a change in condition that affects activity participation. Activities are offered based on the individual preferences and needs of each resident. Activity participation is documented in the medical record. 2. Review of the medical record revealed Resident #4 was admitted on [DATE] with diagnoses that included hemiplegia, multiple sclerosis, dementia, aphasia, and depression. Review of the significant change MDS assessment dated [DATE] revealed Resident #4 had a severe cognitive impairment. The activity group activity participation log from 12/31/25 through 01/27/26 revealed Resident #4 participated in an activity on 01/13/26.The self-directed activity participation log from 12/31/25 through 01/27/26 revealed Resident #4 activities included television and a visitor. Multiple observations on 01/28/26 between 8:57 A.M. and 1:30 P.M. revealed Resident #4 was sitting in the common area and there were no structured activities. An observation on 01/29/26 at 9:44 A.M. revealed Resident #4 was sitting in the common area. The movie Sleeping Beauty was on the television at a low volume. No activity members were present in the common area. An interview on 01/29/26 at 1:38 P.M. with Activities Director #105 verified there was not a staff member present for the movie on 01/29/26. Activities Director #105 verified in the last 30-days there was only documentation of Resident #4 participating in one group activity on 01/13/26. Review of the activities policy dated 8/2023 revealed activities are offered based on the individual preferences and needs of each resident. Activity participation is documented in the medical record.

Based on observation, interview, record review, and facility policy review, the facility failed to serve pureed foods at a smooth consistency for safe swallowing. This affected two residents (#4 and #17) who were ordered pureed diets prepared by the facility's kitchen. The facility census was 19. Findings include: 1. Review of the medical record for Resident #4 revealed an admission date of 05/14/24 with diagnoses including Huntington's Disease, depression, and dysphagia. Review of the physician's orders for January 2026 revealed that Resident #4 was prescribed a regular diet with pureed consistency and thin liquids.Review of the MDS 3.0 quarterly assessment dated [DATE] revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 05, indicating the resident was severely cognitively impaired. Resident #4 was dependent for activities of daily living (ADLs) and required assistance with eating.2. Review of the medical record for Resident #17 revealed an admission date of 12/20/23 with diagnoses including multiple sclerosis, depression, and dysphagia.Review of the MDS 3.0 quarterly assessment dated [DATE] revealed Resident #17 had not been assessed for a BIMS. Resident #17 was dependent for activities of daily living (ADLs) and required supervision and partial assistance with meals. Review of the physician's orders for January 2026 revealed that Resident #4 was prescribed a regular diet with pureed consistency and thin liquids.Observation of lunch service in the dining room on 01/29/26 at 11:36 A.M. revealed Resident #4 and Resident #17 received early trays. Observation of Resident #4's lunch revealed that the spaghetti with meat sauce appeared to have pieces of pasta in it. Observation of Resident #17's lunch revealed the pureed spaghetti and meat sauce also had pieces of pasta in it.Observation and interview on 01/29/26 at 11:37 A.M. with Dietary Manager #129 revealed there was pureed spaghetti and meat sauce in a pan on the steam table. DM #129 verified that the spaghetti and meat sauce appeared to have pieces of pasta in it and taste test verified that the spaghetti and meat sauce was not pureed to a smooth consistency. DM #129 stated that the cook who prepared the puree was nervous and would need to be retrained. Review of the undated facility diet protocol titled, Dysphagia 1/Puree Diet, revealed that pasta should be blenderized to a smooth homogenous consistency.

Based on resident record review and staff interview, the facility failed to ensure resident medical records were complete. This affected five of five residents (#4, #7, #11, #12, and #20) reviewed for the administration of treatments, side effect monitoring, and behavior monitoring. The facility census was 19. Findings include: 1. Review of Resident #4's medical record revealed that she was admitted to the facility on [DATE] with diagnoses that included Huntington's disease, major depressive disorder, and dementia. Review of Resident #4's physician orders revealed that she had an order dated 03/06/25 to have her weight taken daily in the morning, an order on 03/01/25 to have skin preparation (prep) to her left knee during the day shift, an order on 03/03/25 to monitor for signs and symptoms of depression for each shift, an order on 03/03/25 to monitor for side effects of her sedative medication for each shift, and an order on 03/03/25 to monitor for side effects of her antidepressant medication on each shift. Review of Resident #4's treatment administration record revealed no documented evidence that the 03/07/25 morning nursing shift documented that the residents weight was obtained, that her skin prep was completed to her left knee, or that she was monitored for signs of depression, side effects of her sedative medication or side effects of her antidepressant medication. Interview with the Director of Nursing on 03/26/25 at 10:20 A.M. confirmed that there was no evidence in the medical record that the treatments for Resident #4 had been administered and/or signed off by the nurse on the morning of 03/07/25. 2. Review of Resident #7's medical record revealed that she was admitted to the facility on [DATE] with diagnoses that included dementia, type two diabetes mellitus, hypertension, chronic kidney disease, peripheral vascular disease, major depressive disorder and nail dystrophy. Review of Resident #7's physician orders revealed that effective 09/08/23 she was to have her behaviors monitored and documented on every shift, and effective 09/08/23 she was to be monitored for pain and non-pharmacological interventions were to be documented on each shift. Review of Resident #7's treatment administration record revealed no documented evidence that the 03/07/25 morning nursing shift documented that the residents behaviors were monitored or that she was monitored for pain and non-pharmacological interventions. Interview with the Director of Nursing on 03/26/25 at 10:20 A.M. confirmed that there was no evidence in the medical record that the treatments for Resident #7 had been administered and/or signed off by the nurse on the morning of 03/07/25. 3. Review of Resident #11's medical record revealed that she was admitted to the facility on [DATE] with diagnoses that included cerebral infarction, multiple sclerosis, dementia, depression, dysphagia, and the need for assistance with personal care. Review of Resident #11's physician orders revealed that effective 12/21/23 she was to be monitored for pain and non-pharmacological interventions were to be documented on each shift, effective 11/19/24, she was to have her head of bed elevated at 45 degrees or higher at all times on each shift, effective 01/06/25 she was to be monitored for side effects of her antidepressant medication on each shift, effective 02/10/25 she was to be monitored for signs and symptoms of a cough or fever for a respiratory screening on each shift, effective 02/14/25 she had orders to cleanse the area to her left great toe with wound cleanser and apply betadine twice daily, and effective 02/28/25 she was to be monitored for signs of depression on each shift. Review of Resident #11's treatment administration record revealed there was no documented evidence that the 03/07/25 morning nursing shift documented the residents area to her left great toe was cleansed and that betadine was applied, that her head of bed was elevated at 45 degrees or higher, that she was monitored for pain and non-pharmacological interventions were attempted, that she was monitored for side effects of her antidepressant medication, that she was monitored for signs of depression or that she was monitored for signs and symptoms of a cough or fever. Interview with the Director of Nursing on 03/26/25 at 10:20 A.M. confirmed that there was no evidence in the medical record that the treatments for Resident #11 had been administered and/or signed off by the nurse on the morning of 03/07/25. 4. Review of Resident #12's medical record revealed that he was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, dementia, need for assistance with personal care, congestive heart failure, cardiac pacemaker, inflammatory disorder of scrotum, obstructive sleep apnea, and depression. Review of Resident #12's physician orders revealed that he had orders effective 03/22/24 to monitor and document his behaviors on each shift, effective 03/22/24 he was to have his pain and non-pharmacological interventions documented on every shift, effective 02/28/25 he was to be monitored for side effects of his antidepressant medication on each shift, effective 02/28/25 he was to be monitored for signs of depression on each shift, and effective 02/28/25 he was to be monitored for side effects of a sedative on each shift. Review of Resident #12's treatment administration record revealed there was no documented evidence that the 03/07/25 morning nursing shift documented he had his behaviors monitored and/or documented, that he was monitored for pain and non-pharmacological interventions were attempted, that he was monitored for side effects of his antidepressant medication, that he was monitored for signs of depression, or that he was monitored for side effects of a sedative. Interview with the Director of Nursing on 03/26/25 at 10:20 A.M. confirmed that there was no evidence in the medical record that the treatments for Resident #12 had been administered and/or signed off by the nurse on the morning of 03/07/25. 5. Review of Resident #20's medical record revealed that she was admitted to the facility on [DATE] with diagnoses that included Huntington's disease, muscle weakness, depression, dysphagia, and need for assistance with personal care. Review of Resident #20's physician orders revealed that there was an order effective 05/14/24 she was to be monitored on every shift for pain and non-pharmacological interventions were to be documented on each shift, effective 05/14/24 her behaviors were to be monitored on every shift, effective 05/15/24 she was to be monitored for side effects of her antipsychotic medication on every shift, effective 05/15/24 she was to be monitored for side effects of her antidepressant medication on each shift, effective 05/28/24 she was to be monitored for side effects of her sedative on each shift, effective 01/22/25 she was to have her left dorsal foot cleansed and skin preparation (prep) was to be applied on every shift, effective 02/26/25 for her to have her right dorsal foot cleansed and silver alginate applied on every day shift, and effective 02/28/25 she was to be monitored for signs of depression on each shift. Review of Resident #20's treatment administration record revealed there was no documented evidence that the 03/07/25 morning nursing shift documented her right dorsal and left dorsal feet were cleansed and the treatments completed, that she was monitored for side effects of her sedative, antidepressant or her antipsychotic medication, or that she was monitored for pain or behaviors. Interview with the Director of Nursing on 03/26/25 at 10:20 A.M. confirmed that there was no evidence in the medical record that the treatments for Resident #20 had been administered and/or signed off by the nurse on the morning of 03/07/25.

Based on observation, medical record review, staff interviews, review of the facility assessment, and review of facility policy, the facility failed to provide adequate nursing supervision to assure safety for residents that were identified as a choking risk, while the residents were eating in the dining room. This had the potential to affect two residents who were identified as a choking risk (Resident #11 and Resident #20) out of four residents observed eating in the dining room without supervision. Findings include: Review of Resident #11's medical record revealed that she was admitted to the facility on [DATE] with diagnoses that included cerebral infarction, multiple sclerosis, need for assistance with personal care and dysphagia. Review of Resident #11's physician orders dated 11/19/24 revealed that she was prescribed a regular diet with pureed texture consistency. Review of Resident #11's care plan dated 12/20/23 revealed that she was at risk of alteration in her nutrition and hydration status related to using a mechanically altered diet and a loss of food and fluids from her mouth according to the Speech and Language Pathologist. Review of Resident #20's medical record revealed that she was admitted to the facility on [DATE] with diagnoses that included Huntington's disease, need for assistance with personal care and dysphagia. Review of Resident #20's physician orders dated 06/21/24 revealed that she was ordered to have a regular diet with pureed textures. Review of Resident #20's care plan dated 06/21/24 revealed that she was at risk for potential of alteration in nutrition and hydration related to dysphagia, mechanically altered diet, history of chewing difficulty and leaving residue in mouth. Observation on 03/26/25 from 7:45 A.M. to 7:50 A.M. revealed that there was no staff member in the dining room while Resident #7, Resident #11, Resident #12, and Resident #20 were eating food. During this time, Resident #20 coughed on three occasions and was observed with food dripping down her chin. Certified Nursing Aide #64 and Licensed Practical Nurse (LPN) #84 were observed passing meal trays in the hall, out of the line of sight from the dining room. Interview with LPN #84 on 03/26/25 at 6:44 A.M. revealed that it was her opinion that there was not enough nursing staff on day shift to take care of the resident's needs. Interview with LPN #84 on 03/26/25 at 7:50 A.M. confirmed that there was no nursing staff present in the dining room from 7:45 A.M. to 7:50 A.M. LPN #84 confirmed that to her knowledge, at least Resident #20 was a choking risk. She confirmed that a member of the nursing staff should be present in the dining room at all times. Interview with the Director of Nursing on 03/26/25 at 10:27 A.M. revealed that at least one nursing aide or nurse should be present in the dining room at all times while residents are consuming meals. Further interview confirmed that Resident #11 and Resident #20 were identified as at risk for choking. Review of the facility assessment revealed that there was no facility assessment available for review to determine the level of sufficient staff needed pertaining to the severity of conditions and limitations of the residents, and the services that the facility must provide. Interview with the Administrator on 03/26/25 at 12:41 P.M. confirmed that a completed facility assessment was not available for review. Review of an undated policy titled Dining Room Observation- Meal Time revealed that when it is meal time in the dining room, one staff member should be in the dining room while residents are eating their meal. If a staff member is unavailable when trays arrive, the room trays should be served first and then the dining room service should start. This deficiency represents non-compliance investigated under Complaint Number OH00163661.

Based on review of the facility assessment and staff interview, the facility failed to have documented evidence of a completed facility assessment for review. This had the potential to affect all 19 residents living in the facility. Findings include: Review of the facility assessment revealed that there was no facility assessment available for review to determine the level of sufficient staff needed pertaining to the severity of conditions and limitations of the residents, and the services that the facility must provide. Interview with the Administrator on 03/26/25 at 12:41 P.M. confirmed that a completed facility assessment was not available for review.

Based on record review and staff interview, the facility failed to ensure there was a registered nurse (RN) on duty for at least eight consecutive hours a day, seven days a week as required. This had the potential to affect all 19 residents currently residing in the facility. Findings include: Review of the staff schedule for June 2024 revealed there was no RN scheduled in the building on 06/01/24 (Saturday), 06/02/24 (Sunday), 06/05/24, 06/06/24, 06/07/24, 06/10/24, 06/11/24, 06/14/24, 06/15/24 (Saturday), 06/16/24 (Sunday), 06/17/24, 06/19/24, 06/20/24, 06/21/24, 06/24/24, 06/25/24, 06/28/24, 06/29/24 (Saturday) and 06/30/24 (Sunday). Interview on 06/19/24 2:45 P.M. with Licensed Practical Nurse (LPN) #402 confirmed the schedule does not have an RN listed for at least eight hours a day, seven days a week. LPN #402 stated The director of nursing (DON) is here the days the RN is not. I can fix the schedule to reflect that. When asked about the weekend RN coverage no explanation was given, and no evidence was provided there was an RN in the facility every Saturday and Sunday. Interview on 06/20/24 10:43 A.M. with RN #600 confirmed there is no RN on the schedule for eight hours a day, seven days a week.

Based on record review, interview, and facility policy review the facility failed to ensure residents and/or their representatives were invited to participate in initial and quarterly care plan meetings. This affected four residents (#10, #9, #13, and #15) of five residents reviewed for care plan meetings. The facility census was 19. Findings include: 1. Review of Resident #10's medical record revealed an admitted [DATE]. Medical diagnoses included chronic obstructive pulmonary disease, unsteadiness on feet, and muscle weakness. Resident #10 was hospitalized from 04/29/24 to 05/03/24. Review of Resident #10's Minimum Data Set (MDS) 3.0 significant change assessment, dated 05/14/24, revealed a brief interview for mental status (BIMS) score of 02, indicating severely impaired cognition. The resident was recorded to have an impairment on one side of his upper extremities. Resident #10 required set up assistance for eating and substantial/maximum assistance for other activities of daily living and mobility tasks. An additional review of the MDS 3.0 discharge return anticipated, dated 04/29/24, revealed the resident had one fall with a minor injury. Review of Resident #10's interdisciplinary progress notes revealed a note dated 05/06/24 which indicated the resident had pain, edema, and bruising to his right upper extremity. An additional note dated 05/06/24 indicated the facility Nurse Practitioner had ordered an x-ray examination of his right clavicle. The interdisciplinary progress notes revealed no mention of a care plan meeting being held, scheduled, or Resident #10's family being invited to such a meeting since the resident admitted to the facility on [DATE]. Review of an x-ray report, completed at the facility on 05/07/24, revealed Resident #10 had an acute fracture of the right mid clavicle, with moderate displacement and fracture overlap. Review of Resident #10's physician's orders revealed orders dated 05/07/24 for the resident to wear a sling to his right upper extremity and for the resident to be referred to an orthopedic specialist. Review of Resident #10's Interdisciplinary Plan of Care (IPOC) Summary form, dated 05/04/24, revealed the reason the IPOC meeting was held was Annual, Admission and Significant Change. The form indicated Resident #10 recently had a fall which resulted in injury with the family choosing to not see an orthopedic specialist. The summary of the meeting indicated Resident #10's child and Social Services Designee (SSD) #412 were the only two attendees. Resident #10's child's name was handwritten on the form which did not include a signature. A telephone interview conducted on 06/20/24 at 9:00 A.M. with a family member of Resident #10 revealed knowledge of Resident #10's fall and resulting clavicle fracture at the facility. The family member of Resident #10 denied ever being informed or refusing an orthopedic consult and indicated the family had previously transported the resident to all outside appointments via their personal vehicles. The family member of Resident #10 stated they had never been offered, nor attended, a care conference since the resident admitted to the facility approximately a year and a half ago. An interview conducted on 06/20/24 at 10:18 A.M. with SSD #412 revealed she coordinated the care plan meetings at the facility. SSD #412 stated only she and the daughter of Resident #10 were present for the care conference dated 05/04/24 and the date on the form indicated the date the care conference was held. The surveyor informed SSD #412 that the documentation on the form stated the family refused an orthopedic consult days before Resident #10's x-ray examination was ordered, completed, or revealed a fracture. SSD #412 verified the documentation was incorrect and stated that the correct date for the care plan meeting was 05/24/24. SSD #412 confirmed there was no documentation of scheduling or notices provided to coordinate a care plan meeting, and the IPOC Summary dated 05/04/24 contained no evidence that a nurse or other department representative was present at the care plan meeting. SSD #412 stated documentation should be completed in the resident's electronic medical record reflecting a care conference was scheduled, held and afterwards, a summary contained in the resident's electronic medical record. 47569 2. Review of Resident #9's medical record revealed admitted [DATE] with diagnoses including Huntington's Disease, chronic obstructive pulmonary disease (COPD), depression, and anxiety. Resident #9 required assistance from staff to complete activities of daily living (ADL) and had severely impaired cognition. Review of Resident #9's IPOC summary dated 02/01/23 revealed the IPOC summary was marked for an annual review and a quarterly review care conference. The only people in attendance for the care conference included Resident #9's power of attorney (POA) and the SSD designee #412. There were no completed IPOC summary review care conferences available to review from 03/01/23 to 06/24/24. Review of Resident #9's progress notes dated 02/01/23 to 02/20/23 revealed no documentation reflecting the IPOC care conference completed on 02/10/23. Further review of progress notes dated 03/01/23 to 06/24/24 revealed no documentation for any type of care conference, annual or quarterly, since the care conference completed on 02/10/23. Interview on 06/20/24 at 10:20 A.M. with SSD #412 confirmed there were no completed IPOC summary review care conferences since the IPOC summary care conference dated 02/10/23. SSD #412 further confirmed the only people in attendance for the care conference dated 02/10/23 was Resident #9's POA and SSD #412. SS #412 stated there should at least be a nurse, dietary representative, and therapy representative in attendance for a care conferences. SSD #412 confirmed there should be documentation in the progress notes to reflect the completion of care conferences. 3. Review of Resident #13's medical record revealed admitted [DATE] with diagnoses including traumatic brain injury (TBI), stroke, and hemiplegia to left side. Resident #13 required assistance from staff for ADL tasks and had moderately impaired cognition. Review of Resident #13's IPOC summary review care conference form dated 04/20/23 revealed the care conference marked as a quarterly IPOC summary review care conference. The attendees included Resident #13's family members, the Director of Nursing (DON), the Assistant Director of Nursing (ADON) #402, and SSD #412. There were no completed annual or quarterly IPOC summary review care conferences dated from 05/01/23 to 06/24/24 available to review. Review of Resident #13's progress notes dated 04/01/23 to 05/01/23 revealed no documentation to reflect the completion of the IPOC summary review care conference dated 04/20/23. Further review of Resident #13's progress notes dated 05/01/23 to 06/24/24 revealed no documentation was available for review to reflect an annual or quarterly IPOC summery review care conference completion. Interview on 06/20/24 at 10:20 A.M. with SSD #412 confirmed Resident #13 only had a quarterly care conference completed on 04/20/23, and there were no further care conferences completed from 05/01/23 to 06/24/24. SSD #412 stated Resident #13's family requested to only have annual care conferences instead of quarterly care conferences. SSD #412 confirmed there should be documentation in the progress notes to reflect the completion of care conferences. 4. Review of Resident #15's medical record revealed admitted [DATE] with diagnoses including high blood pressure, anxiety, and bipolar disorder. Resident #15 required minimal assistance from staff for ADL tasks and had intact cognition. Resident #15 was receiving therapy services in anticipation for discharge to previous living conditions. Review of Resident #15's IPOC summary review care conference form dated 06/13/24 revealed the care conference was marked as a discharge care conference. There was no previous IPOC summary review care conference forms to review or reflect the completion of an initial care conference completed for Resident #15. Review of Resident #15's progress notes dated 05/21/24 to 06/24/24 revealed no documentation available to review for completed IPOC review care conferences. Interview on 06/20/24 at 10:20 A.M. with SSD #412 confirmed Resident #15 did not have an initial IPOC summary review care conference completed upon admission to the facility. SSD #412 stated Resident #15 should have had an initial care conference completed within seven days of admission to the facility. SSD #412 confirmed there should be documentation in the progress notes to reflect the completion of care conferences. Review of the facility's policy titled, Nursing Home Resident's Rights revealed, Nursing home residents have the right to participate in planning your care and treatment or changes in your care and treatment.

Based on observation, interview, and facility policy review the facility failed to maintain a clean home like environment in resident rooms. This deficient practice affected one resident (#17) out of 19 residents reviewed for environment. The facility census was 19. Findings include: Observation on 06/17/24 at 8:45 A.M. revealed Resident #17's outer doorframe was noted to have missing paint and dry wall covering. The area was observed on the wall surrounding the doorframe. The appearance of having had plastic covering taped around the doorframe and doorway was evident. The largest area was approximately four inches wide with paint and dry wall covering missing exposing the dry wall backing paper. Further observation inside Resident #17's room revealed the wall to the left side of the bed with multiple vertical large, long (approximately 12 inches long) gouges running the length of the bed. The gouges were deep enough for the dry wall material to be visible, approximately one-half inch deep, with torn dry wall covering hanging loosely on the wall. Resident #17's bed was against the wall with Resident #17's left side being towards the damaged wall. Interview on 06/24/24 at 9:35 A.M. with Maintenance Staff #416 confirmed the gouges being deep enough for the dry wall material to be visible, approximately one-half inch deep, with torn dry wall covering hanging loosely on the wall to the left side of the bed and the outer doorframe areas of missing dry wall and non-painted areas. Review of the facility's policy titled Resident Environmental Quality, dated 08/22, revealed, It is the policy of this facility to be designed, constructed, equipped, and maintained to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public.

Based on observation, staff interview, and record review the facility failed to accurately code the Minimum Data Set (MDS) 3.0 assessment for Residents #10 and #11. This affected two residents (#10 and #11) of 11 residents reviewed for accuracy of assessments. The facility census was 19. Findings include: 1. Review of Resident #10's medical record revealed an admitted [DATE]. Medical diagnoses included chronic obstructive pulmonary disease, unsteadiness on feet, and muscle weakness. Review of Resident #10's MDS 3.0 significant change assessment, dated 05/14/24, revealed a brief interview for mental status (BIMS) score of 02, indicating severely impaired cognition. The resident was recorded to have an impairment on one side of his upper extremities. Resident #10 required set up assistance for eating and substantial/maximum assistance for other activities of daily living (ADL) and mobility tasks. An additional review of the MDS 3.0 discharge return anticipated assessment, dated 04/29/24, revealed the resident had one fall with a minor injury, and no falls with a major injury. Review of Resident #10's progress notes revealed a note dated 04/29/24 at 12:25 A.M. indicating a thud was heard from the resident's room. When staff entered the room, the resident was observed on the floor underneath his bedside table. The resident reported he had been attempting to change clothes when he fell . The resident complained of pain to his right arm and head, with a knot noted near his right clavicle. Resident #10 was transferred and admitted to a local hospital. Review of a facility incident report, dated 04/29/24, revealed Resident #10 sustained a fall and was noted with a quarter sized knot near his right clavicle. The report indicated that Resident #10 was transferred and admitted to a local hospital. Review of hospital records for Resident #10, dated 04/29/24, revealed an x-ray examination of the right humerus was completed on 04/29/24 which showed no definitive fracture. The hospital records revealed no indication that a right clavicle x-ray examination had been completed while the resident was at the hospital. Review of Resident #10's vitals and pain assessment, dated 05/07/24, revealed the resident complained of pain rated at 7/10 on a 01-10 scale. The pain was described as aching and stiffness, worse with movement. Resident #10 was additionally observed to have edema (swelling) to his right upper extremity. Review of an x-ray report, completed at the facility on 05/07/24, revealed Resident #10 had an acute fracture of the right mid clavicle, with moderate displacement and fracture overlap. An interview conducted on 06/18/24 at 2:12 P.M. with the Director of Nursing (DON) revealed Resident #10 sustained a fall resulting in injury on 04/29/24 and was transported to the hospital, where he was admitted . The injury was a knot on his right clavicle, and the resident complained of arm pain. The DON stated she believed the hospital would have completed an x-ray examination of the clavicle, but the hospital only x-rayed the humerus (upper arm bone) which was not fractured. After the resident returned to the facility and was still having pain, the facility obtained an order to x-ray the clavicle. The DON confirmed the fracture to Resident #10's clavicle was a result of the fall sustained on 04/29/24. An interview conducted on 06/18/24 at 10:21 A.M. by phone with MDS Nurse #250 revealed she was unaware of Resident #10's fall on 04/29/24 resulted in a fractured clavicle. MDS Nurse #250 stated although the fracture was not noted at the time of the hospital transfer, she should have modified the MDS assessment once it was determined Resident #10 sustained a fracture, as that would be considered a major injury. MDS Nurse #250 stated the assessment was incorrect and stated she would complete a modification of Resident #10's MDS assessment to reflect one fall with major injury. Review of the Resident Assessment Instrument (RAI) Manual, revised October 2023, revealed an injury related to a fall included any documented injury that occurred as a result of, or was recognized within a short period of time after the fall and attributed to the fall. The RAI Manual identified a major injury included bone fractures and joint dislocations. 47569 2. Observation on 06/17/24 at 9:05 A.M. revealed Resident #11 sitting in a recliner chair receiving continuous two liters of oxygen therapy from an oxygen concentrator via a nasal canula tubing. Review of Resident #11's medical record revealed an admitted [DATE] with diagnoses including pneumonia, high blood pressure, heart failure, and rib fractures. Resident #11 required assistance from staff to complete ADL tasks and had moderately impaired cognition with a score of seven out of fifteen on Brief Interview of Mental Status (BIMS) score. Review of Resident #11's at risk for altered respiratory status care plan dated 05/14/24 revealed an intervention for the use of oxygen as ordered. Review of Resident #11's admission MDS 3.0 assessment, dated 05/07/24, revealed Section O - Special Treatments, Procedures, and Programs C1 Oxygen therapy was marked as being used on admission and while being a resident. Review of Resident #11's significant change MDS 3.0 assessment, dated 05/15/24, revealed Section O Special Treatments, Procedures, and Programs C1 Oxygen therapy was marked as not being used while being a resident. Interview on 06/24/24 at 10:25 A.M. with the MDS Registered Nurse (RN) #450 confirmed Resident #11's significant change MDS 3.0 assessment, dated 05/15/24, was coded incorrectly to reflect Resident #11 did not use oxygen therapy. Review of the RAI 3.0 User's Manual, dated October 2023, revealed the steps for assessment include, Review the resident's medical record to determine whether or not the resident received or performed any of the treatments, procedures, or programs within the assessment period defined for each column.

Based on observation, staff and resident interview, record review, and facility policy review, the facility failed to complete a physician-ordered orthopedic consult for Resident #10, and failed to ensure dressings were changed as ordered for Resident #5. This affected two residents (#10 and #5) of 11 residents reviewed for quality of care. The facility census was 19. Findings include: 1. Review of Resident #10's medical record revealed an admitted [DATE]. Medical diagnoses included chronic obstructive pulmonary disease, unsteadiness on feet, and muscle weakness. Resident #10 was hospitalized from 04/29/24 to 05/03/24. Review of Resident #10's Minimum Data Set (MDS) 3.0 significant change assessment, dated 05/14/24, revealed a brief interview for mental status (BIMS) score of 02, indicating severely impaired cognition. The resident was recorded to have an impairment on one side of his upper extremities. Resident #10 required set up assistance for eating and substantial/maximum assistance for other activities of daily living (ADL) tasks and mobility tasks. An additional review of the MDS 3.0 discharge return anticipated, dated 04/29/24, revealed the resident had one fall with a minor injury. Review of an x-ray report, completed at the facility on 05/07/24, revealed Resident #10 had an acute fracture of the right mid clavicle, with moderate displacement and fracture overlap. Review of Resident #10's physician's orders revealed orders dated 05/07/24 for the resident to wear a sling to his right upper extremity, and for the resident to be referred to an orthopedic specialist. Review of Resident #10's interdisciplinary progress notes revealed a note dated 05/06/24 which indicated the resident had pain, edema, and bruising to his right upper extremity. An additional note dated 05/06/24 indicated the facility Nurse Practitioner had ordered an x-ray examination of his right clavicle. Subsequent progress notes contained no evidence that Resident #10's referral to an orthopedic specialist had been completed or that a discussion had taken place with Resident #10's family regarding the orthopedic consultation. An observation and interview on 06/18/24 at 8:38 A.M. with Resident #10 revealed him seated on the edge of the bed. The resident denied pain when asked and denied any recent falls or hospitalization s, stating he could not remember. The resident was not wearing a sling and was observed to feed himself breakfast. An interview on 06/18/24 at 2:12 P.M. with the Director of Nursing (DON) revealed Resident #10 had a fall on 04/29/24 with a documented injury to his right clavicle, described as a quarter-sized knot. The DON stated the resident was transported to the hospital and admitted , and upon the return to the facility, the facility obtained an x-ray of the resident's clavicle as he was having ongoing pain. The resident's x-ray indicated a fracture to the right clavicle on 05/07/24, which the DON stated she attributed as being related to the fall on 04/29/24. The DON stated she thought the hospital would have x-rayed the resident's clavicle, but they only obtained x-ray imaging for the humerus (upper arm bone). The DON stated the facility Nurse Practitioner ordered an orthopedic consultation and a sling on 05/07/24 and verified there was no evidence in the medical record of the orthopedic consult being completed. The DON stated the resident's family possibly refused the orthopedic consult but verified there were also no refusals recorded in Resident #10's medical record but there should have been. An interview on 06/18/24 at 3:54 P.M. with Registered Nurse (RN) #413 revealed Resident #10 recently had a fracture identified to his right clavicle. Nursing staff had provided pain management, and over a few weeks the pain decreased, and the resident was gradually able to regain his range of motion. RN #413 stated he believed the family possibly did not want the resident to go to any outside providers. A telephone interview on 06/20/24 at 9:00 A.M. with a family member of Resident #10 revealed knowledge of the resident's recent fall at the facility on 04/29/24 and his return to the hospital. The family member indicated the fall on 04/29/24 resulted in a broken collarbone that the facility identified upon the resident's return from the hospital. The family member stated they were never notified of the resident being referred to an orthopedic specialist, and stated she would have been aware as they previously transported the resident to all outside appointments. Review of the facility policy titled Provision of Physician Ordered Services, dated 10/2023, revealed qualified nursing personnel will submit timely requests for physician ordered services (including consultations) to the appropriate entity. Documentation of consultations will be maintained in the resident's clinical record. 2. Review of Resident #5's medical record revealed an admitted [DATE]. Medical diagnoses included diabetes mellitus, a history of a myocardial infarction, and dementia with unspecified severity. Review of Resident #5's MDS 3.0 quarterly assessment, dated 04/17/24, revealed a BIMS score of 09, indicating moderately impaired cognition. Review of Resident #5's incident report revealed the resident sustained a fall on 06/15/24 when he was ambulating without his assistive device. The fall resulted in a skin tear to the resident's left outer forearm. The listed intervention included education on the use of proper footwear. Review of Resident #5's physician's orders revealed an order dated 06/18/24 to treat a recently obtained skin tear. The order called for staff to replace border foam to the resident's left outer forearm every three days, and check steri-strip placement. The order instructed staff to not remove steri-strips, as they will fall off on their own. The order was scheduled to be completed on day shift between 7:00 A.M. and 7:00 P.M. on the designated days. Review of Resident #5's June 2024 Treatment Administration Record (TAR) revealed the dressing was documented as being completed on 06/18/24 and 06/21/24. An observation on 06/24/24 at 8:06 A.M. revealed Resident #5 seated at the dining room table. He had eaten all of his breakfast and was observed coloring. The resident was observed with a dressing on his left elbow dated 06/18/24. An interview on 06/24/24 at 8:59 A.M. with the DON verified Resident #5's dressing was still dated 06/18/24 and was not completed as documented on 06/21/24. The DON stated the dressing needed to be changed. Review of the facility policy titled Wound Care, dated 08/2023, revealed treatments should be completed per physician's orders. Following the completion of the treatment, the nurse should document in the resident's electronic medical record.

Based on observation, record review, interview, and facility policy review the facility failed to ensure safety interventions were implemented and were appropriate for residents assessed to be at high risk for falls. This deficient practice affected two residents (#6 and #9) out of five residents reviewed for accidents. The facility census was 19. Findings include: Observation on 06/24/24 at 8:07 A.M. revealed Resident #9 sitting at the dining room table eating breakfast. Resident #9 was wearing light blue non-skid socks on his feet. The right foot sock was halfway on the foot with the toe of sock was folded under the foot and dragging on the floor. Resident #9's four wheeled walker was located behind the dining room chair approximately two feet out of Resident #9's reach. Resident #9 stood up from the table when State tested Nursing Assistant (STNA) #421 came over to the table to assist Resident #9. Resident #9 reached for the four wheeled walker, grabbed hold of the handles and then lost balance tipping the walker over to the left side, Resident #9 regained his balance and began to ambulate through the dining room. STNA #412 did not attempt to assist Resident #9 with bringing the four wheeled walker to within his reach, regaining his balance or attempting to readjust the right sock that was dragging on the floor. Review of Resident #9's medical record revealed admitted [DATE] with diagnoses including Huntington's Disease, chronic obstructive pulmonary disease (COPD), depression, anxiety, and history of falls. Resident #9 required assistance from staff to complete activities of daily living (ADL) and had severely impaired cognition. Resident #9 used a four wheeled walker for assistance with independent ambulation, and severely impaired balance and gait due to the diagnosis of Huntington's Disease. Review of Resident #9's recent fall investigations dated 09/04/23, 10/16/23, 12/23/23, 12/25/24, 01/11/24, and 06/06/24 revealed the falls occurred in the dining room during mealtime and involved Resident #9 attempting to sit in a chair or standing up from the table following the completion of the meal. Safety measures implemented for these falls include the following: 09/04/23 - Resident #9 encouraged to ask staff for help during transfers and sitting. 10/16/23 - Resident #9 educated to use walker when out of bed. 12/23/23 - Resident #9 to notify staff if stuck behind chair and needing assistance 12/25/23 - Staff educated to assist Resident #9 to the chair when coming into the dining room for meals. 01/11/24 - Staff educated to continue with current fall prevention interventions. 06/06/24 - Resident #9 educated to ask for help when transferring or sitting. Review of Resident #9's at risk for falls care plan dated 06/13/21 revealed other safety measures including providing staff assistance as needed, to wear non-skid footwear when ambulating, and implement fall prevention devices as ordered by the physician. Interview on 06/24/24 at 8:58 A.M. with STNA #438 confirmed Resident #9's right sock was folded under his foot and was dragging on the floor. STNA #438 stated Resident #9 should have shoes on instead of the non-skid socks. Interview on 06/24/24 at 9:20 A.M. with the Director of Nursing (DON) confirmed Resident #9's fall interventions were repetitive and ineffective safety measures due to Resident #9's impaired cognition. The DON stated it has been challenging to implement safety measures for Resident #9 due to diagnosis and impaired cognition. 47990 2. Review of Resident #6's medical record revealed an admitted [DATE]. Medical diagnoses included dementia without behavioral disturbances, anemia in chronic kidney disease, and diabetes. Review of Resident #6's MDS 3.0 quarterly assessment, dated 05/28/24, revealed Resident #6 was recorded to have a Brief Interview for Mental Status score of 00, indicating severely impaired cognition. The resident was recorded as requiring set-up assistance for eating and was dependent on staff for all other ADL and mobility tasks. Review of Resident #6's fall risk assessment, dated 06/01/24, revealed the resident scored a 9, indicating she was at risk for falls. Review of Resident #6's interdisciplinary progress notes revealed a note dated 06/01/24 which indicated Resident #6 fell out of bed. The resident was assessed for injury and transferred to the local hospital for evaluation in the emergency department. Resident #6 returned to the facility later that date after all x-rays and scans returned negative for injury. Resident #6's listed interventions included implementation of a perimeter mattress and a padded mat to the floor to the open side of the bed. Review of Resident #6's care plan, revised 06/02/24, revealed the resident was at risk for falls and potential injury related to weakness and dementia. Listed interventions included a bed with a perimeter mattress, a floor mat to the exit side of bed, and keeping commonly used articles within easy reach. An observation on 06/24/24 at 8:09 A.M. revealed Resident #6 in bed with the head of bed elevated. Her breakfast tray was in front of her. The padded mat was in a folded position leaning against the wall, approximately six feet from the resident's bed. An observation and interview on 06/24/24 at 8:14 A.M. with STNA #438 revealed Resident #6 remained in bed, awake and alert, feeding herself a sausage link. STNA #438 verified Resident #6's padded fall mat was not in place and should have been. STNA #438 replaced the fall mat during the interview. Review of the policy titled Managing Falls and Fall Risk, reviewed 08/2023, revealed based on previous evaluations and current data, staff will identify interventions related to the resident's risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. The staff, with the input of the attending physician/ nurse practitioner (NP) as needed, will implement a resident-centered fall prevention plan to reduce the specific risk factors of falls for each resident. Staff will monitor residents' response to interventions intended to reduce falling.

Based on observation, record review, interview, and review of the facility policy the facility failed to obtain a physician's order for the administration of oxygen therapy. This deficient practice affected one resident (#11) out of one resident reviewed for respiratory care. The facility census was 19. Findings include: Observation on 06/17/24 at 8:23 A.M. revealed Resident #11 sitting in a recliner chair receiving continuous two liters of oxygen therapy from an oxygen concentrator via a nasal canula tubing. Review of Resident #11's medical record revealed an admitted [DATE] with diagnoses including pneumonia, high blood pressure, heart failure, and rib fractures. Resident #11 required assistance from staff to complete activities of daily living (ADL) tasks and had moderately impaired cognition with a score of seven out of fifteen on Brief Interview of Mental Status (BIMS) score. Review of Resident #11's at risk for altered respiratory status care plan dated 05/14/24 revealed intervention for the use of oxygen as ordered. Review of Resident #11's hospice progress notes dated 05/09/24 revealed a physician order for oxygen two to five liters continuous via nasal cannula tubing. Review of Resident #11's physician orders dated 06/01/24 revealed no order transcribed for oxygen two to five liters continuous via nasal cannula tubing. Interview on 06/17/24 at 4:17 P.M. with Licensed Practical Nurse (LPN) #475 confirmed Resident #11 did not have physician's order for oxygen two to five liters continuous via nasal cannula tubing. LPN #475 stated Resident #11 has always been using oxygen since admission. Review of the facility's policy titled, Oxygen Administration dated 04/01/23 revealed, Oxygen is administered under orders of a physician.

Based on staff interview, record review, and facility policy review, the facility failed to ensure physician-ordered medication parameters were followed for Residents #4 and #5. This affected two (#4 and #5) of six residents reviewed for unnecessary medications. The facility census was 19. Findings include: 1. Review of Resident #4's medical record revealed an admitted [DATE]. Medical diagnoses included cerebrovascular accident (stroke), atrial fibrillation, coronary artery disease, and hypertension. Review of Resident #4's Minimum Data Set (MDS) 3.0 quarterly assessment, dated 06/03/24, revealed the resident had a Brief Interview for Mental Status score of six, indicating severely impaired cognition. Review of Resident #4's physician's orders revealed an order dated 05/13/24 for Carvedilol (an antihypertensive medication to lower blood pressure and/or heart rate) 3.125 milligram (mg) one tablet twice daily, with instructions to hold the medication for a systolic blood pressure less than 90 or for a resting heart rate less than 60. Resident #4 also had an order dated 05/13/24 for lisinopril (an antihypertensive medication to lower blood pressure) 5 mg once daily with instructions to hold the medication if the systolic blood pressure is less than 110. Review of Resident #4's May 2024 Medication Administration Record (MAR) revealed the resident was administered the dose of Carvedilol when his heart rate was recorded as being less than 60 beats per minute. These administrations occurred on 05/01/24, 05/02/24, 05/06/24, 05/11/24, 05/12/24, 05/16/24, 05/25/24, 05/28/24, 05/29/24, and 05/30/24. Additionally, Resident #4 was administered the dose of lisinopril when his systolic blood pressure was less than 110 on 05/01/24 and 05/30/24. Review of Resident #4's June 2024 MAR revealed the resident was administered the dose of Carvedilol when his heart rate was less than 60 beats per minute on 06/04/24, 06/08/24, 06/09/24, and 06/18/24. Resident #4 was administered his ordered dose of lisinopril on 05/13/24 when his systolic blood pressure was recorded as less than 110. 2. Review of Resident #5's medical record revealed an admitted [DATE]. Medical diagnoses included diabetes mellitus, a history of a myocardial infarction, and dementia with unspecified severity. Review of Resident #05's MDS 3.0 quarterly assessment, dated 04/17/24, revealed a BIMS score of nine, indicating moderately impaired cognition. Review of Resident #5's physician's orders revealed an order dated 11/02/23 for Midodrine (a medication used to raise blood pressure) 5 mg once daily, with instructions to hold the medication if the systolic blood pressure was greater than 120. Review of Resident #5's May 2024 and June 2024 MAR revealed no correlating blood pressure documented prior to medication administration. An interview conducted on 06/17/24 at 8:23 A.M. with Resident #5 revealed he had a recent fall and reported sometimes he felt dizzy. An interview conducted on 06/20/24 at 10:42 A.M. with Assistant Director of Nursing (ADON) #402 verified Resident #4's medications had been administered outside of parameters when the medication should have been held. ADON #402 additionally verified Resident #5 should have had correlating blood pressure documented prior to medication administration but did not. Review of the policy titled Medication Administration - General Guidelines, dated 07/01/21, revealed medications are administered as prescribed in accordance with good nursing principles and practices. Medications are administered in accordance with written orders of the prescriber.