Every finding on record at Alta Heights Post Acute

Based on review of the Resident Assessment Instrument Manual Version 1.20.1, medical record review, and interview, the facility failed to complete an accurate Minimum Data Set (MDS) assessment for 2 of 18 (Resident #62 and #74) residents reviewed for MDS discrepancies. The findings include: 1. Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.20.1, dated October 2025, revealed .J1800: Any Falls Since Admission/Entry or Reentry or Prior Assessment .1. Yes .Continue to J1900, Number of Falls Since .Prior Assessment .Code 2, two or more: if the resident had two or more .falls since admission/entry or reentry or prior assessment .L0200 .Check all that apply . Check L0200D, obvious or likely cavity or broken natural teeth: if any cavity or broken tooth is seen . 2. Review of the medical record revealed Resident #62 was admitted to the facility on [DATE], with diagnoses including Diabetes, Alzheimer's, Dementia, and Depression. Review of the quarterly MDS assessment dated [DATE] revealed Resident #62 scored a 3 on the Brief Interview for Mental Status (BIMS) assessment, which indicated she was severely cognitively impaired, and she had no falls since reentry. Review of the care plan dated 4/23/2026 revealed, .Resident is at risk for falls with or without injury related to cognitive impairment due to Alzheimer's and Dementia and history of syncope .Falls: Resident had an unwitnessed fall and is at risk for injury .recurring falls .Fall on 2/8, [2/8/2026] 2/9 [2/9/2026], 2/12 [2/12/2026], 2/23 [2/23/2026], 3/1[3/1/2026], 3/10 [3/10/2026], 3/25 [3/25/2026], 4/16 [4/16/2026] . During an interview on 4/29/2026 at 9:22 AM, the MDS Coordinator was asked if Resident #62 should have been coded for a fall after entry on the most recent MDS. The MDS Coordinator stated, It should have been coded for at 2 falls. It was coded incorrectly. During an interview on 4/29/2026 at 10:15 AM the Director of Nursing (DON) was asked if a Resident had a fall after entry to facility should they be coded for falls on the MDS. The DON stated, .I would think so . 3. Review of the medical record revealed Resident #74 was admitted to the facility on [DATE] and readmitted by 12/26/2024 with diagnoses including Nontraumatic Subarachnoid Hemorrhage, Dental Caries, Depression, Hemiplegia and Hemiparesis. Review of the annual MDS assessment dated [DATE], revealed Resident #74 scored an 8 on the BIMS assessment which indicated she was moderately cognitively impaired. She was coded as No for Obvious or likely cavity or broken natural teeth. During an observation and interview on 4/27/2026 at 3:25 PM, Resident #74 stated that the left side of her mouth on the top and bottom teeth hurt. The resident showed the surveyor her teeth which were broken teeth with visible caries. During an interview on 4/29/2026 at 9:16 AM, the MDS Coordinator was asked if Resident #74 should have been coded YES for Obvious or likely cavity or broken natural teeth (due to having dental caries and broken teeth). The MDS Coordinator stated, Yes, it was miscoded.

Based on policy review, observation, and interview, the facility failed to provide and maintain a safe and sanitary environment for 11 of 48 occupied rooms (Resident #5, #9, #29, #36, #40, #44, #51, #65, #20 and #67's room, #68 and #27's room, and #72, and #73's room) when there was a broken/missing piece on the window blind, a sharp screw exposed on the closet door, there were holes in the wall, missing hooks from the privacy curtain, the air conditioner's front panel and filter was off, a cable cord box was not attached to the wall, there were bulging and missing pieces from the over tables, there were missing laminate pieces from the dresser and nightstands, plaster was peeling from the wall, uncovered corner pieces on the wall, a broken bed with no mattress stored in a resident's room, and when there were strong malodorous odors in residents' rooms. The findings include: 1. Review of the facility's policy titled, Maintenance Service, dated December 2024, revealed .Maintenance service shall be provided to all areas of the building, grounds, and equipment . 2. Observation in Resident #5's room on 2/24/2025 at 11:23 AM and 2/25/2025 at 8:48 AM, revealed the wall plaster peeling from the wall, and the laminate off the right side and bottom of the nightstand. 3. Observation in Resident #9's room on 2/25/2025 at 8:21 AM and 2/26/25 at 4:09 PM, revealed a broken/missing piece on the window blind, and a sharp screw exposed on the closet door due to the knob being off. 4. Residents #20 and #67 were roommates. Observation in Resident #20's room on 2/24/2025 at 11:31 AM and 2/25/2025 at 8:49 AM, revealed peeled plaster on the wall, a night stand with missing laminate strips on the left and right sides and the drawers, the over the bed table had a piece on the side that had come apart, and a holes in the wall. Observation in Resident # 67's room on 2/24/2025 at 11:32 AM, revealed crumbled plaster on the resident's wall. 5. Residents #27 and #68 were roommates. Observation in Resident #27's room on 2/24/2025 at 10:48 AM and at 4:13 PM, and 2/25/2025 at 8:30 AM, revealed the air conditioner had no front cover, the filter to the air conditioner was off, both side panels of the dresser had separated from the frame/coming off on both sides, the dresser was not upright/leaned back toward the wall, and the cable cord box was coming off /broken from the lower wall. Observation in Resident #68's room on 2/24/2025 at 10:49 AM and 2/26/2025 at 4:30 PM, revealed the top of the over the bed table had bulged/lifted from the frame and the wall had holes. 6. Observation in Resident #29's room on 2/24/2025 at 11:16 AM and 2/25/2025 at 1:52 PM, revealed a dresser with missing laminate strips on the front sides and drawers. 7. Observation in Resident #36's room on 2/24/2025 at 4:05 PM, 2/25/2025 at 8:24 AM, and 2/26/2025 at 4:24 PM, revealed holes in the wall and 5 hooks missing from the privacy curtain. 8. Observation in Resident #40's room on 2/24/2025 at 11:46 AM and 2/25/2025 at 8:55 AM, revealed and nightstand and dresser with missing laminate strips. 9. Observation on 2/24/2025 at 10:45 AM, revealed Resident #44 was lying in bed with a sheet over his peri-area and no other clothes visible. There was trash, and soiled clothing items on the floor and multiple items cluttered on the overbed table, in chair, in wheelchair and throughout the room. The odor was malodorous and difficult to inhale. 10. Observation in Resident #51 on 2/24/2025 at 11:46 PM, revealed the nightstand had missing laminate strips on the left side. 11. Observation and interview on 2/24/2025 at 10:54 AM, revealed a bed frame with no mattress and metal rails were present on the A side of Resident #65's room. The bed frame was low to the floor. Resident #65 stated his bathroom was broken and he has been going across the hall to use the bathroom. 12. Observation on 2/25/2025 at 10:00 AM, revealed a strong odor present in Resident #72 and Resident #73's room. The odor smelled somewhat like decaying flesh. 13. During an interview and observation in Resident #5's room on 2/26/2025 at 4:53 PM, the Maintenance Supervisor confirmed Resident #5's dresser needed to be replaced and the resident's wall needed to be repaired. During an interview and observation in Resident #9's room on 2/26/2025 at 4:09 PM, the Maintenance Supervisor confirmed the blind and the closet doorknob needed to be replaced. During an interview and observation in Resident #20's room on 2/26/2025 at 5:01 PM, the Maintenance Supervisor confirmed the resident's corner wall needed a corner guard, the nightstand needed to be replaced, the walls needed to be repaired and painted, and the resident needed a new over bed table. During an interview and observation in Resident #27's on 2/26/2025 at 4:30 PM, the Maintenance Supervisor confirmed Resident # 27's air conditioner front panel, and the filter should not have been left off, the dresser needed to be replaced, and the cable cord box needed to be attached to the lower wall. During an interview and observation in Resident #29's room on 2/26/2025 at 4:59 PM, the Maintenance Supervisor confirmed Resident #29's dresser needed to be replaced with a new one. During an interview and observation in Resident #36's on 2/26/2025 at 4:24 PM, the Maintenance Supervisor confirmed the missing hooks on the privacy curtain needed to be replaced and there should be no holes in wall. During an interview on 2/24/2025 at 12:30, CNA L was asked what the staff did related to Resident 44's room. CNA L confirmed that resident had continued to keep the room in this condition despite daily room cleaning and nothing further had been done. During an interview and observation in Resident #65's room on 2/27/2025 at 11:20, revealed the Maintenance Director was asked what was wrong with the bathroom in Resident #65's room. The Maintenance Director stated the showers in the resident rooms were no longer being used. The shower was broken, and the toilet seat was loose. The Maintenance Director confirmed the lift motor was not working on the bed. During an interview on 2/27/2025 at 4:58 PM, the Administrator was asked whether he had been made aware of the bedframe being store on Resident #65's room. He stated, he was not aware of the broken bed being in the room and stated, .it is not an ideal situation and 100% there should have been a mattress on the bed . During an interview and observation in Resident #67's room on 2/26/2025 at 5:07 PM, the Maintenance Supervisor confirmed the resident's wall needed to be repaired. During an interview and observation in Resident #68's room on 2/26/2025 at 4:30 PM, the Maintenance Supervisor confirmed Resident #68's over the bed table needed to be replaced, and there should not be holes in the wall During an interview on 2/27/2025 at 11:45 AM, Housekeeper AA was asked if she had been made aware of specific provisions to prevent the wound related odors. The housekeeper stated, there has been no special provisions in place, and she has done everything that she could to try to help the smell. During an interview on 2/27/2025 at 12:00 PM, the Environmental Supervisor was asked whether she had been made aware of the odor present in Resident #72 and Resident #73. She stated the specialty cleaner that she ordered to help with the smell had not been delivered. During an interview on 2/27/2025 at 12:15 PM, the DON was asked what had been done regarding the smell in Resident #72 and Resident #73's room. The DON stated Resident #73 did not express that the smell was a problem. During an interview on 2/27/2025 at 2:30 PM, LPN W was asked what the smell was in Resident #72 and Resident #73's room. LPN W stated Resident #72 had skin cancer and has copious amounts of drainage from his wound which has been the cause of the odor. During an interview on 2/27/2025 at 5:00 PM, the Administrator was asked if he had been made aware of the odors present in Resident #72 and Resident #73's rooms and he stated they typically speak with the roommate to see whether there are any concerns related to the offensive smells. During an interview in the conference room on 02/27/2025 at 5:04 PM, the Administrator confirmed holes in the walls, over the bed tables, dressers and night stands with bulging and missing pieces, hooks missing hooks from privacy curtains, peeling plaster from walls, and an air conditioner with no front panel did not constitute a homelike environment for the residents. 46047

Based on policy review, observation, and interview the facility failed to ensure practices to prevent the potential spread of infection were maintained when 3 of 3 nurses (Licensed Practical Nurse (LPN O, LPN W, LPN X) failed to clean reusable equipment before and after use and failed to use protective barriers, and when 1 of 3 nurses (LPN X) failed to wear Personal Protective Equipment (PPE) in enhanced barrier precaution rooms. The findings include: 1. Review of the facility's policy titled Enhanced Barrier Precautions, dated 2001, revealed Enhanced barrier precautions (EBPs) are utilized to reduce the transmission of multi-drug resistant organisms (MDROs) to residents .EBPs are indicated .for resident with wounds and/or indwelling medical devices regardless of MDRO colonization .Indwelling medical devices include .feeding tubes . Review of the facility's policy titled, Handwashing/Hand Hygiene, dated October 2023, revealed .This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections .Hand hygiene is indicated .after contact with blood, body fluids, or contaminated surfaces .after touching a resident .after touching the resident's environment .immediately after glove removal . Review of the facility's policy titled Instillation of Eye Drops, dated February 2025, .Should both eyes require instillation, perform hand hygiene before treating each eye .Clean your equipment and return it to its designated storage area (i.e., bedside stand, bathroom, etc.) 2. A random observation in the 100 Hall on 2/24/2025 at 10:23 AM, revealed Licensed Practical Nurse (LPN DD) exited a resident's room with gloved hands, removed gloves and placed gloves in the trash on a treatment cart, failed to perform hand hygiene, and opened the top drawer of the treatment cart, and removed an item out of the drawer. During an interview on 2/27/2025 at 5:40 PM, the Infection Control Preventionist confirmed staff should not exit a resident's room with gloved hands and staff should perform hand hygiene after removing their gloves. 3. Review of the medical record revealed Resident #27 was admitted to the facility on [DATE], with diagnoses including Cerebral Infarction, Cardiomyopathy, Dysphagia, Dementia, and Insomnia. Review of the annual Minimum Data Set (MDS) dated [DATE], revealed Resident #27's cognitive section was not documented. The quarterly MDS dated [DATE] had a Brief Interview for Mental Status (BIMS) score of 6, which indicated severe cognitive impairment. Observations on 2/27/2025 at 7:36 AM, in Resident #27's room revealed LPN O, carried medications into the resident's room and sat the medicines on the over bed table without a protective barrier. LPN O then put one drop of Brimonidine Solution eye drop in the resident's left eye and immediately put one drop in the right eye. This did not follow the policy for administering eye drops. LPN O failed to perform hand hygiene between administering medicine in left and right eye. Then when LPN O administered the Refresh tears one drop to right eye and immediately one drop to the left without hand hygiene between. LPN O went back to the medication cart and retrieved the blood pressure (BP) machine placed it in her pocket and reentered the resident's room. Once LPN O took the resident's BP she placed the machine in her pocket and returned to medication cart. LPN O placed the BP machine on top of the cart until she had completed the computer work. Then placed the BP machine and eye drop bottles back into the cart drawers without disinfecting. 4. Review of the medical record revealed Resident #64 was admitted to the facility on [DATE], with diagnoses including Cerebral Infarction, Anxiety, Bipolar Disorder, Depression, Psychosis, and Dysphagia. Review of the quarterly MDS dated [DATE], revealed Resident #64 had a BIMS score of 13, which indicated moderate cognitive impairment. Observations on 2/27/2025 at 8:08 AM, in Resident #64's room revealed LPN O pulled scissors from her pocket and cut open the package for the medicated patch which had been laid on the bed, replaced scissors back into her pocket. LPN O failed to disinfect the scissors after use in Resident #64's room. 5. Review of the medical record revealed Resident #73 was admitted to the facility on [DATE], with diagnoses including Pneumonia, Esophageal Cancer, Acute Kidney Disease, Chronic Ischemic Heart Failure, and Sepsis. Review of the admission MDS dated [DATE] revealed Resident #73 had a BIMS score of 11, which indicated moderate cognitive impairment. Observations on 2/27/2025 at 8:55 AM, in Resident #73's room, revealed LPN X entered to administer Percutaneous Endoscopic Gastrostomy (PEG) medications. LPN X failed to use a barrier on the over bed table when laid the medication down and failed to wear PPE in the enhanced barrier precautions room while administering medications. 6. Review of the medical record revealed Resident #129 was admitted to the facility on [DATE], with diagnoses including Tourette's Disorder, Diabetes, Chronic Kidney Disease, Systemic Inflammatory Response Syndrome (SIRS) and Anxiety. There was no MDS completed at this time due to the resident was a new admission. Observations on 2/27/2025 at 12:04 PM, in Resident #129's room, revealed LPN W entered the room, sat the med cup, water cups and syringe on over bed table without a protective barrier and failed to wear PPE in the enhanced barrier precaution room. 7. During an interview on 2/27/2025 at 3:28 PM, LPN O was asked should you have disinfected the eye drop bottles after setting them on the over bed table without a barrier and the BP machine after placing it in your pocket. LPN O stated, Yes. During an interview on 2/27/2025 at 5:17 PM, the Director of Nursing (DON) was asked should PPEs be worn in enhanced barrier rooms during medication administration. The DON stated, Absolutely. During an interview on 2/27/2025 at 5:40 PM, the Infection Control Preventionist confirmed staff should not exit a resident's room with gloved hands and staff should perform hand hygiene after removing their gloves. 46047 47127

Based on the facility policy review, observations and interviews, the facility failed to properly label, date and store food items in the kitchen and failed to properly store, label and date personal resident food items in the 300 Hall nourishment room. The findings included: 1. Review of the facility policy titled Food Receiving and Storage dated November 2022, revealed .All food stored in the refrigerator or freezer are covered, labeled and dated ['use by' date] .All foods belonging to residents are labeled with the resident's name, the item and the 'use by' date .beverages are dated when opened and discarded after twenty-four (24) hours .partially eaten food is not kept in the refrigerator . Review of the facility policy titled Foods Brought by Family/Visitors dated February 2014, revealed .Intact fresh fruit may be stored without lid .Perishable foods must be stored in re-sealable containers with tightly fitting lids in the refrigerator. Containers will be labeled with the resident's name, the item and the 'use by' date . 2. Observation during the initial kitchen walk-through on 2/24/2025 at 9:30 AM, revealed an opened container of chicken salad and an opened container of pimento cheese, neither were labeled with an open date or use by date. During an interview on 2/24/2025 at 9:45 AM, [NAME] C was asked what date the chicken salad and the pimento cheese had been opened? The [NAME] C stated, there was not a date on either item. During an interview on 2/24/2025 at 10:00 AM, the Dietary Manager was asked about the open date on the chicken salad and pimento cheese. The Dietary Manager agreed there was no date on either item and both should have been dated. 3. Observation in the kitchen on 2/25/2025 at 8:15 AM, revealed 4 uncovered pieces of raw bacon lying on the countertop. 4. Observation of 300 Hall Nourishment Room on 2/27/2025 at 4:00 PM, revealed 1 unlabeled and undated bag of grapes and 1 opened and undated bag of oranges in the refrigerator. An undated and opened container of juice was also present in the refrigerator. During an interview on 2/27/2025 at 4:42 PM, the Admission Nurse was asked how long juice was allowed to remain open in the refrigerator. She responded, The juice can stay in the refrigerator until the manufacture's expiration date. The Admission Nurse was also asked whether all items in the refrigerator should have the resident's names on them. She responded that all items should be labeled.

Based on facility policy review, medical record review, facility investigation, and interview, the facility failed to provide adequate supervision and assistance to prevent an elopement from the facility for 1 of 3 residents (Resident #80) reviewed for wandering. The facility failed to provide adequate supervision and assistive devices when Resident #1 eloped from the facility on 10/29/2024 at 9:40 AM, resulting in a fall with minor injuries. The Findings Include: 1. Review of the facility policy titled, Elopement and Wandering Patients, revised 2/5/2024, .This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk .Residents shall be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay by the interdisciplinary care plan team . 2. Review of medical record revealed Resident #80 was admitted to the facility on [DATE], with diagnoses including Traumatic hemorrhage of left cerebrum (a collection of blood in the brain that occurs after a head injury) without loss of consciousness, subsequent encounter, Traumatic subdural hemorrhage (at type of bleeding near your brain that can happen after a head injury) without loss of consciousness, subsequent encounter, Malignant neoplasm (lung cancer) of upper lobe, right bronchus or lung, Alcohol use, Chronic Obstructive Pulmonary Disease (a chronic lung condition that makes it difficult to breathe), Chronic Atrial Fibrillation (an irregular heartbeat), Tobacco use, anxiety disorder, aphasia (a disorder that affects how you communicate), other Chronic Pain, Essential (Primary) Hypertension (High Blood Pressure), Depression, and Muscle Weakness (Generalized). Review of the physician orders dated 10/21/2024, for Resident #80 revealed, MD orders for Buspirone 7.5 mg (milligram) twice a day for Anxiety, Lexapro 20 mg once a day for depression, Hydralazine 23 mg every 8 hours for high blood pressure, Losartan 25 mg one time a day for high blood pressure, Metoprolol 25 mg twice a day for high blood pressure, Nicotine Patch one time daily, Trazodone 100 mg tablet one at bedtime for depression, Clonazepam 1 mg tablet three times a day for anxiety, gabapentin 300 mg capsule three times a day for chronic pain, Behavior Monitoring three times a day, and Psychotropic medication monitoring two times a day. Review of the Fall Risk assessment dated [DATE] for Resident #80 revealed falls history of a single fall in the past 90 days with a fall risk total score of 8 with a risk scale of 0-10 = Low. Review of the Elopement Risk assessment dated [DATE], revealed Resident #80 could ambulate independently, was at risk for leaving the facility to satisfy addiction which indicated Resident #80 was at high risk for elopement. Review of the admission baseline care plan dated 10/22/2024, revealed, a problem for at risk for elopement. A goal of resident will maintain a safe environment with no interventions noted on the care plan. Review of nurse progress note dated on 10/22/2024 at 11:53 AM, revealed, . Resident [Resident #80] found to have wandered in another female patient room. Resident easily directed out of room, but asking what room her sister is in. Resident informed her sister is not at this facility and resident proceeds to ask .tell me what happened to her. Informed her that her sister has never been at this facility that this is not the hospital she is at a skilled nursing facility. Resident [Resident #80] proceeds to get angry and yell at this nurse telling her she doesn't know what she is talking about and started towards her room mumbling under her breath . signed by LPN OO. Review of the nurse progress note dated 10/23/2024 at 6:09 AM, revealed . Resident [Resident #80] wandering halls during the evening shouting obscenities and taunting staff and other residents. Walked into her restroom and urinated in the middle of the floor in front of me. Pt stated she's been here 6 months and been treated poorly the whole time, educated pt that she only just arrived. Redirection unsuccessful, making roommate and staff uncomfortable with her [NAME]. Very confused. Restless and agitated until receiving pharmacy delivery and was given her medications then slept most of the night . signed by RN PP. Review of Physical Therapy Progress Report dated 10/23/2024 through 10/28/2024 for Resident #80 revealed, .Functional Skills Assessment .Walk 10 feet = Partial/Moderate Assist .Walk 50 feet with 2 turns = Partial/Moderate Assessment .Walk 150 feet = Partial/Moderate Assist .Mobility function Score .(Range 0-12, 12 Highest function) = 8 .by Physical Therapist (PT) QQ on 10/28/2024 at 9:12 AM. Review of the nurse progress notes for Resident #80 dated 10/26/2024 at 10:30 AM, 10/26/2024 at 3:20 PM, 10/26/2024 at 4:03 PM, revealed documentation of wandering behaviors. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 5, which indicated Resident #80 was severely cognitive impaired. Continued review revealed Resident #80 exhibited wandering behaviors that placed the resident at significant risk of getting to a potentially dangerous place (outside of the facility), and significantly intruded on the privacy or activities of others had occurred 1 to 3 days of the assessment look back period. Review of the Care Plan updated 10/29/2024, for Resident #80 revealed, . At Risk For Falls related to the following potential causative factors: unsteadiness of gait and balance when on feet; generalized muscle weakness; altered mental status with a very poor safety awareness; adverse effects from psychotropic medications . [Resident #80] will demonstrate the ability to ambulate/transfer without fall related injuries over the next 90 day review period . 10/29 FALL WITH INJURY . Confusion, alteration in thought process related to [Resident #80] had a low BIMS score and a Slums test .recent had a falling incident which resident sustained a traumatic hemorrhage of the left cerebrum .[Resident #80] has exhibited Wandering and exit seeking Behavior .resident is very difficult to be redirected and will become agitated and verbally inappropriate .update 10/29/24 resident wandered out of the facility . Review of the [Named] Medical Center Emergency Provider Report dated 10/29/2024 at 11:57 AM, for [Resident #80] revealed, .History of Present Illness: History was obtained from the patient and EMS [Emergency Medical Services]. [Resident #80] is a 65 -year-old female presenting to the ED by EMS secondary to fall. EMS reports that she fell on a sidewalk and went into the courthouse to ask them for help. They noted a laceration to her left great toe and an abrasion to her right arm. Initially she did not want to be transported but they realized the patient was acting confused at times. She was alert oriented X 3 but some things that she was saying was not making sense. She told them that she was assaulted 6-8 weeks ago. On arrival here the patient has no complaints but tells me that she was assaulted 6-8 weeks ago and was in the hospital for several weeks. She reports when she left she was sent to a place in Louisville that is for people with OCD [Obsessive-Compulsive Disorder]. EMS did note that her blood pressure was 80 systolic upon their arrival .Review of Systems .Abrasion [a scrape on your skin] noted to posterior [back of] right arm with no active bleeding, small superficial laceration [a cut close to the surface of the body] noted to left great [big] toe .Summary of visit: [AGE] year-old female presenting to the ED secondary to confusion and fall. I did review the patient prior discharge summary. It reported she had a traumatic intracranial hemorrhage with expressive aphasia. She also has a history of substance abuse and alcohol abuse. We will obtain lab work to include a repeat head CT . 46252

Based on the facility policy review, medical record review, observation and interview the facility failed to provide privacy for 1 of 28 (Resident #28) sampled residents reviewed. The findings include: 1. Review of the facility policy titled, Resident Rights, dated 8/2009, revealed .Employees shall treat all residents with kindness, respect, and dignity .These rights include the resident's right to .Privacy and confidentiality .Visit and be visited by others from outside the facility .Our facility will make every effort to assist each resident in exercising his/her rights to assure that the resident is always treated with respect, kindness, and dignity . 2. Review of the medical record revealed Resident #28 admitted to the facility on [DATE], with diagnoses which included Hypertensive Heart Disease, Anemia, Hyperlipidemia, and Atherosclerotic Heart Disease.? Review of the Quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #28 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognitive abilities.?? During an observation and interview on 2/25/2025 at 2:35 PM, Certified Nursing Assistant (CNA) BB and CNA CC entered Resident #28's room without knocking or asking to come into her room while the surveyor was performing an interview. After the two CNAs entered the room and saw the Surveyor, CNA BB asked if they could come in after already entering the closed door. Resident #28 had just been asked by the surveyor if she was treated with respect and dignity at the facility. After the 2 CNAs entered the room without knocking Resident #28 stated, .Well they didn't that time . and rolled her eyes. During an interview on 2/27/25 at 5:07 PM, the Administrator was asked what he would expect the CNAs to do before entering a resident room. He stated, CNAs should knock before entering a room.

Based on policy review, interview, and observation, the facility failed to provide reasonable accommodations of needs for water temperature when bathing for 3 of 14 sampled residents (Resident #24, #28, and #64) interviewed for activities of daily living. The findings include: 1. Review of the facility policy titled, Resident Rights, dated 8/2009, revealed .Employees shall treat all residents with kindness, respect, and dignity .Federal and state laws guarantee certain basic rights to all residents of the facility . Review of the Rules of the Tennessee Health Facilities Commission dated July 2022, revealed .Water distribution systems shall be arranged to provide hot water at each hot water outlet at all times. Hot water at shower, bathing and hand washing facilities shall be between 105 [degrees] F [Fahrenheit] and 115 F . 2. Review of the medical record revealed Resident #24 admitted to the facility on [DATE], with diagnoses which included Atherosclerotic Heart Disease, Cardiomyopathy, and Diabetes Mellitus type 2. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #24 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated moderate impairment. During an observation and interview on 2/24/2025 at 12:20 PM revealed Resident #24's bathroom water was turned to hot and running. Resident #24 was asked why the bathroom water was running and she stated, .they [referring to the CNAs] trying to get the water hot . Observation in Resident #24's bathroom on 2/25/2025 at 8:37 AM revealed a hot water temperature of 78 degrees. 3. Review of the medical record revealed Resident #28 admitted to the facility on [DATE], with diagnoses which included Hypertensive Heart Disease, Anemia, Hyperlipidemia, and Atherosclerotic Heart Disease. Review of the Quarterly MDS dated [DATE], revealed Resident #28 had a BIMS score of 15, which indicated intact cognitive abilities. During an interview on 2/24/25 at 12:32 PM, Resident #28 stated, .I get a bed bath 2 or 3 times a week .the water is cold .the CNAs [Certified Nursing Assistants] will let it run forever trying to get it hot . During an interview on 2/24/2025 at 12:47 AM, Certified Nursing Assistant (CNA) P was asked why the hot water was running in 2 rooms. CNA P stated, .I am trying to get the hot water warm enough to give a couple of bed baths .it is like this every day .it takes forever and sometimes it never gets hot enough . 4. Review of the medical record revealed Resident #64 was admitted on [DATE], with diagnoses which included Cerebral Infarction, Depression, Hemiplegia affecting left nondominant side, and Essential Hypertension. Review of the Annual MDS dated [DATE], revealed Resident #64 had a BIMS score of 15, which indicated intact cognitive abilities. During an interview on 2/24/2025 at 11:53 AM, Resident #64 stated, .I get a bed bath once per day .no hot water, wash us down in cold water . Observation in Resident #64's bathroom on 2/25/2025 at 8:17 AM revealed a hot water temperature of 97 degrees. 5. During an interview on 2/25/2025 at 9:00 AM, the Maintenance Director was asked why the hot water on the 100 and 200 hall was not up to temperature and why CNAs are having to turn on the water in the bathrooms prior to breakfast so it will be warm enough to perform a bed bath. The Maintenance Director stated, .we have insta hots a hot water on demand system on the 100 and 200 hall .until a high demand is needed the water can't heat up .they need to turn on the water in three bathrooms before the water will heat to the right temperature . During an interview on 2/27/2025 at 8:00 am, the Social Service Director stated, .we have had residents complain about the water being cold and that is why they don't want to take a shower .I know the Maintenance director knew about it . During an interview on 2/27/2025 at 5:19 PM, the Administrator was asked about the hot water system on the 100/200 hall and if staff and residents should be waiting on hot water every day. The Administrator stated, .they should not have to wait on hot water .you have to get the water going on the hall before you can get the hot water . The Administrator was asked if staff should have to turn the hot water on in three bathrooms before the hall has hot water and what would the residents do if they wanted to wash their hands in the bathroom. The Administrator stated, .I am not saying we should have to do that .

Based on policy review, medical record review, observation, and interview, the facility failed to provide care and services related to activities of daily living (ADLs) for 1 of 3 (Resident #29) sampled residents for ADLs. The findings include: 1. Review of the facility's policy titled, Activities of Daily Living (ADL), Supporting, dated 2001, revealed .Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs) .Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene .Care and services to prevent and/or minimize functional decline will include appropriate pain management, as well as treatment for depression and symptoms of depression .Interventions to improve or minimize a resident's functional abilities will be .will be monitored, evaluated and revised as appropriate . Review of the facility policy titled, Resident Rights, dated 2001, revealed .Employees shall treat all residents with kindness, respect, and dignity . 2. Review of the medical record revealed Resident #29 was admitted to the facility on [DATE], with diagnoses including Diabetes, Hypertension, and Vitamin D Deficiency, and Cognitive Communication Deficit. Review of a quarterly Minimum Data Set assessment dated [DATE], revealed Resident #29 had no behaviors, a Brief Interview for Mental Status score of 11, which indicated Resident #29 had moderately impaired cognition. Further review revealed the resident required clean up assistance from staff for toileting hygiene and personal hygiene and was occasionally incontinent of urine and always incontinent of bowel. Review of the care plan dated 2/21/2025, revealed .at risk for ADL/mobility decline and requires assistance related to disease progression .Provide the resident with AM [morning] and PM [evening] care [oral and grooming] daily and assist the resident as needed for completion of task .Toileting hygiene and incontinent care daily and as needed . Observation on 2/24/2025 at 11:16 AM and 12:13 PM, revealed Resident #29 in bed, appeared to be sleep, in a sleep shirt and brief. Observation on 2/24/2025 at 4:21 PM, revealed Resident #29 was in bed laying on her left side wearing an incontinent brief soiled with urine. During an interview on 2/24/2025 at 4:29 PM, CNA P was asked about Resident #29. CNA P stated, . not getting up stated she told me to get the hell out of her room . everyday resident very seldom up .3 to 4 days per week will not let you do anything .have not reported to nurse today . Observation on 2/25/2025 at 1:52 PM, revealed Resident #29 in room sitting on side of bed. Resident #29 had facial hair over her lip. Resident #29 was asked does she want the facial hair off or does she want to keep the facial hair. Resident #29 stated, Want it off. Resident #29 confirmed she needs the assistance from staff for removal of her facial hair. During an interview on 2/27/2025 at 8:59 AM, the Director of Nurses confirmed residents who want their facial hair removed should have help from staff to get it removed. The DON was asked if a resident continues to refuse incontinent care what should staff do. The DON confirmed the C NA should notify the charge nurse, document the refusal, and staff should use a different approach. The DON confirmed if redirection and explaining the consequences of the refusal does not work, staff should try to find out why the resident refuses. During an observation and interview 2/27/2025 at 9:11 AM, revealed Resident #29 continued to have a mustache. Resident #29 confirmed she would like the mustache removed and confirmed staff had not offered to remove her facial hair. The DON confirmed the staff are expected to recognize the need to remove the resident's facial hair and offer to remove.

Based on facility policy review, medical record review, and interview the facility failed to revise comprehensive care plans for 2 of 28 (Resident #3 and #64) sample residents reviewed. The Findings include: 1. Review of the facility policy titled, Care Plans, Comprehensive Person-Centered, dated 3/2022 revealed, .A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change . 2. Review of the medical record revealed Resident #3 was admitted to the facility on [DATE], with diagnosis which included Chronic Obstructive Pulmonary Disease, Anemia, Hypothyroidism, Anxiety Disorder, and Hyperkalemia. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #3 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated moderate cognitive impairment. Review of the care plan dated 2/8/2025 revealed Resident #3 was not care planned for Do Not Resuscitate (DNR) status. During an interview on 2/26/2025 at 8:47 AM the Director of Nursing (DON) was asked to Review Resident #3's POST (Physician Order for Scope of Treatment)?form and confirmed the code status was DNR. The DON was asked to review Resident #3's physician orders and care plan. The DON stated, .I don't see an order for DNR, and she doesn't have a care plan for DNR . Review of the Order Summary Report revealed an order for DNR added on 2/26/2025 at 11:37 AM after the interview with the DON. 3. Review of the medical record revealed Resident #64 was admitted to the facility on [DATE], with diagnosis which included Cerebral Infarction and Hemiplegia affecting left nondominant side, Review of the Care Plan Report dated 10/2/2023 - Present revealed a problem for self-care deficit and requires assistance with ADLs (Activities of Daily Living) with no interventions related to the use of the immobilizer brace or person-centered transfer interventions with her recent fracture to the left leg. Review of the Radiology Report dated 2/7/2025 revealed, .FEMUR MIN .2 VIEWS, LEFT Results: Acute nondisplaced supracondylar distal femoral fracture . During an interview on 2/24/25 at 11:54 AM, Resident #64 stated, .I broke my leg three Mondays ago, the Certified Nursing Assistant [CNA] was transferring me. I have a brace on my left leg now to help it heal . During an interview on 2/26/2025 at 3:20 PM, the Rehab Director stated, .[Named Resident #64] has always been difficult to transfer requiring substantial assistance of 1 person to stand and pivot with the resident .we are suppose [supposed] to evaluate a resident and make recommendations, provide education with transfers .we have not evaluated her since 7/2024 . During an interview on 2/27/2025 at 11:15 AM, the DON confirmed the care plan does not reflect her recent fracture and how the resident should be transferred or repositioned.

Based on policy review, medical record review, and interview the facility failed to ensure a resident's medication regimen was free of unnecessary medications when the facility failed to ensure monitoring related to the use of an anticoagulant (blood thinner) for 1 of 5 residents (Resident #39) sampled for unnecessary meds. The findings include: 1. Review of the facility's policy titled, Anticoagulation - Clinical Protocol, dated 2/2014, revealed .The staff and physician will identify and address potential complications .The staff and physician will monitor for possible complications . 2. Review of the medical record revealed Resident # 39 was admitted to the facility on [DATE], with diagnoses including Hypertension, History of Thrombosis and Embolism, and Paralytic Gait. Review of the significant change Minimum Date Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 14, which indicated Resident #39 had intact cognition, received antidepressant, antipsychotic, anticonvulsant, diuretic, and anticoagulant medications. Review of the Physicians Order dated 11/6/2024, revealed Eliquis [an anticoagulant-blood thinner] Tab 2.5 MG [milligrams] Give 1 tablet orally two times a day for hx [history] of embolism. Review of a Medication Administration Record dated 12/2024, 1/2025, and 2/2025 revealed Resident #39 had no monitoring for bleeding. During an interview on 2/27/2025 at 7:47 PM, the Director of Nursing (DON) confirmed Resident #39 had an order for Eliquis, however the facility failed to monitor Resident #39 for bleeding and bruising related to the use of Eliquis and monitoring should have been completed.

Based on policy review, medical record review, observation, and interview, the facility failed to ensure a medication administration error rate of less than 5% (percent) when 2 of 5 nurses (Licensed Practical Nurse (LPN) W and X) failed to properly administer medications for 2 of 5 sampled residents (Resident #73 and #129) observed during medication administration. This resulted in a medication administration error rate of 12.5 % [percent] when 3 errors occurred out of 24 opportunities. The findings include: 1. Review of the facility's policy titled Administering Medications through an Enteral Tube, dated November 2018, revealed .Do not crush or split medications for administration through an enteral tube unless provider has given order to crush medications .dilute crushed (powered) medication with at least 30 ml [milliliter] purified water (or prescribed amount) .Administer medication by gravity flow .If administering more than one medication, flush with 15 mL warm purified water (or prescribed amount) between medications . 2. Review of the medical record revealed Resident #73 was admitted on [DATE], with diagnoses including Esophagus Cancer, Respiratory Failure, Acute Kidney Failure, Dysphagia, and Sepsis. Review of the Physician Order dated 1/10/2025, revealed Levothyroxine Sodium Oral Tablet 75 MCG .Give 1 Tablet via PEG [Percutaneous Endoscopic Gastrostomy]-Tube at bedtime related to HYPOTHYROIDISM . Review of the Physician Order dated 2/3/2025 revealed Potassium Chloride ER [extended release] 10 MEQ [Milliequivalent] by mouth one time a day for hypokalemia . Review of the Medication Administration Record [MAR] dated 2/1/2025 to 2/28/2015 confirmed the Potassium pill was administered by mouth not by PEG [Percutaneous Endoscopic Gastrostomy] tube from 2/4/2025 through 2/28/2025. Review of the https://www.mayocinic.org website revealed Potassium supplement (oral route, parenteral route)- For patients taking the extended-release capsule for of this medicine: Do not crush or chew the capsule. Swallow the capsule whole with a full (8-ounce) glass of water . Review of the Medication Administration Record [MAR] dated 2-1-2025 -2-28-2015 confirmed the Levothyroxine Sodium Oral Tablet 75 MCG .Give 1 tablet via PEG -Tube at bedtime related to HYPOTHYROIDISM . Review of the Medication Administration Record [MAR] dated 2-1-2025 -2-28-2015 confirmed the Levothyroxine Sodium Oral Tablet 75 MCG was given at 8 PM each night. Observation and interview on 2/27/2022 at 8:55 AM, outside Resident #73's room at the medication cart revealed (Licensed Practical Nurse LPN X ) took out 5 medications that included a Potassium ER 10 Milliequivalents (Meq) 1 tablet and a Levothyroxine 75 mcg [micrograms] 1 tablet and crushed all 5 pills. LPN X spilled the crushed Levothyroxine on top of the medication cart. LPN X then stated, I will have to get the Unit Manager to get me another Levothyroxine out for me to give. I'm going to give the rest of these first. LPN X went into administer the medications by PEG. She administered the Potassium last, and it clogged the PEG tube. She disconnected the syringe and went to bathroom to run water through it to unclog. LPN X then completed the administration. Once LPN X was back to the medication cart she stated, In hindsight, I should have given the Potassium by mouth . During an interview on 2/27/2025 at 11:15 AM, LPN X was asked should she have crushed the Potassium ER tablet. LPN X stated, It is ordered by mouth . The first med error resulted when LPN X crushed the Levothyroxine with the morning meds, it was ordered to give by mouth at bedtime. The second med error resulted when LPN X crushed the Potassium Chloride Extended Release that should not be crushed for PEG tube administration. The Potassium Chloride ER was ordered to give by mouth. 3. Review of the medical record revealed Resident #129 was admitted to the facility on [DATE], with diagnoses including Tourette's Disorder, Diabetes, Chronic Kidney Disease Stage 3, Dysphagia, and Systemic Inflammatory Response Syndrome (SIRS). Review of the MAR dated 2/1/2025 - 2/28/2025 revealed Carbidopa- Levodopa Oral Tablet 25-100 MG [Milligrams] .Give 1 tablet by mouth three times a day for Parkinson's with meals . Observation on 2/27/2025 at 12:04 PM, outside Resident #129's room, at the medication cart revealed LPN W took out the Carbidopa- Levodopa Oral Tablet and crushed the tablet, put the crushed tablet in a medication cup. LPN X entered Resident #129's room, donned gloves, flushed PEG tube with 30 ml water, then poured 30 ml of water into the syringe and poured the crushed medication into the syringe without diluting with water. LPN W did not dilute the crushed medication prior to placing powder into syringe for administration and the order was to give by mouth. This resulted in the 3rd medication error. 4. During an interview on 2/28/2025 at 5:17 PM, the Director of Nursing (DON) was asked should a Potassium ER tablet be crushed and administered by a PEG tube. The DON stated, No. DON was asked should crushed medication be administered without diluting in a PEG tube. The DON stated No.

Based on policy review, observation, and interview the facility failed to ensure medications were properly stored when 1 of 1 Licensed Practical Nurse (LPN DD) left 1 of 7 med storage areas unlocked and unattended, when medications were left on an over the bed table in 1 of 48 occupied rooms, and when 2 of 3 nurses Licensed Practical Nurse (LPN O and LPN X) left meds unattended and out of sight during medication administration. The findings include: 1. Review of the facility's policy titled, Storage of Medications, dated Revised November 2020, revealed .The facilities store all drugs and biologicals in a safe, secure, and orderly manner .Drugs and biologicals used in the facility are stored in locked compartments .The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner .Unlocked medication carts are not left unattended . 2. A random observation and interview in the 100 Hall on 2/24/2025 at 10:23 AM, revealed an unlocked unattended treatment cart. Licensed Practical Nurse (LPN DD) exited a resident's room, went to the unlocked treatment cart and opened the top drawer. LPN DD was asked about the treatment cart being left unlocked and unattended. LPN DD stated, It was not locked .I should have locked it. 3. Observation on 2/25/2025 at 9:04 AM, revealed (named) lidocaine (medication used to relieve pain) spray on the over the bed table next to Resident #39's bed and on the over the bed table that was positioned over Resident #39's bed. Observations on 2/27/2025 at 7:36 AM, room, revealed LPN O entered Resident #27's room, sat the medications on the over bed table and turned and left the room to go out to the medication cart to get gloves and left the 5 pills in a medication cup, 2 eye drops by the resident's bed out of sight and unattended. LPN O returned and administered the pills and administered the first eye drops. LPN O left the 2 eye medications out of sight again while she went to the bathroom to wash her hands. During an interview on 2/27/2025 at 8:39 AM, the Director of Nursing (DON) confirmed medications should be stored in a way that is inaccessible to others. Observation in Resident #73's room on 2/27/2025 at 8:55 AM, revealed Licensed Practical Nurse (LPN X) left medications unattended and out of sight during medication pass when she walked away from the meds and entered the bathroom to get water. During an observation and interview on 2/27/2025 at 8:56 AM, revealed a can of (named) lidocaine spray was on Resident #39's over the bed table. The DON confirmed the (named) lidocaine spray should not be stored on the resident over the bed table, it should be stored, locked and away from others who could get to it. During an interview on 02/27/2025 at 11:51 AM, LPN X was asked should you have left the medications unattended and out of sight. LPN X stated, I shouldn't . During an interview on 2/27/2025 at 3:28 PM, LPN O was asked should you have left the medications out of sight and unattended in Resident #27's room. LPN O stated, I should have taken my meds with me. 46047

Based on policy review, medical record review, facility investigation, observation, and interview, the facility failed to ensure an allegation of abuse was reported for 1 of 6 (Resident #27) sampled residents reviewed for allegations of abuse and neglect. The findings include: 1. Review of the facility's undated policy titled, Abuse, Neglect, Exploitation, and Misappropriation Prevention Program, revealed Residents have the right to be free from abuse, neglect and misappropriation of resident property and exploitation. This includes but not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraints not required to treat the resident's symptoms .investigate and report any allegations within timeframes required by federal requirements . 2. Review of the medical record revealed Resident #27 was admitted to the facility on [DATE], with diagnoses including Cerebral Infarction, Muscle Weakness, Difficulty Walking, Hemiplegia and Hemiparesis, Optic Atrophy Left Eye, Dementia, Attention and Concentration Deficit, Memory Deficit, and Fracture (broken bone) of Upper Humerus (upper arm). Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #27 had a Brief Interview for Mental Status score of 6, indicating severe cognitive impairment, and required supervision for Activities of daily living (ADLs). Review of a facility's Clinical Note dated 8/17/2024, revealed At approximately 715pm [7:15 pm] resident [#27's] family said that resident told them that someone took him by the arm and 'spun me around' .He was upset about temperature in room issue with roommate. Resident was sitting in front of air conditioner unit and seemed to be guarding it . Review of a facility's Clinical Note dated 8/17/2024, revealed Reported incident to DON [Director of Nursing] for follow up. Resident's sister made aware that DON notified. Review of a facility's Clinical Note dated 8/18/2024, revealed Sister came to nursing station and said she had spoken to DON. She said that resident complained to her about shoulder pain. When this nurse questioned resident about pain later he denied pain. Asked to look at resident's shoulder and resident would not allow. Review of the facility's Grievance Record dated 8/19/2024, confirmed Resident #27 told his daughter that someone took him by arm and moved him around in his wheelchair in a rough way on 8/17/2024 as a result of Resident #27's obsession with controlling the thermostat in the room. The allegation of abuse was not reported on 8/17/2024 when Resident #27 reported it to his daughter. Review of Resident #27's interview and statement dated 8/19/2024, revealed Did someone take your hand and turn your around in our wheelchair .No response .Can you tell me who it was that took your hand .I don't know her name .Can you tell me if she worked day shift or night shift .Day time .was she turning you around in our w/c .No response .Was she trying to reposition you in the W/C .no response .Would you be able to recognize her i you saw her .Yes .I told resident I would bring in several staff to let him identify who it was. After bringing in 2 staff members, he did not identify them, he then recognized the third staff member, [Named CNA EE] and pointed to her saying it was her . Review of the written statement from CNA EE dated 8/18/2024, revealed I answered the room light of .Resident #16 [On 8/17/2024] complained about the heat and asked to have the AC turned on. I went to turn the AC on and then went back to passing trays, not even 2 minutes later, did Resident #16 have the room light on again, stating Resident #27 cut off the AC. I went to turn on the AC again at which point Resident #27 started to yell and point his finger telling me to get out of his room, it's possible that his hand hit my body during this time .signed by CNA EE. During an interview on 2/25/2025 10:05 AM, Sister #2 of Resident #27 confirmed that Resident #27 had called her sister (Sister #1) and she heard loud noise in Resident #27's room and she called her and they both went to visit Resident #27 at shift change on Saturday 8/17/2024. Sister #2 confirmed that Resident #27 told them that someone had grabbed his arm and twirled him around in his wheelchair. Sister #2 confirmed that she asked night shift about it and no one knew anything about it but Resident #27 just kept asking for them to take him home and complaining that his arm was hurting and was numb. Sister #2 confirmed that she told Charge Nurse and the next day they found out it was a CNA [First Name CNA EE]. Sister #2 confirmed that the x-ray showed that the right arm was fractured. Sister #2 confirmed that the Administrator was out of town over the weekend but the charge nurse called the Director of Nursing and told her what had happened. Sister #2 confirmed that she was the one who called NP HH on Saturday when she was told by Resident #27 and told her what Resident #27 had told her and Sister #1. During an interview on 2/25/2025 at 10:38AM, the Administrator confirmed the CNA was CNA EE and was terminated due to other unrelated issues. The Administrator confirmed a timeline of events was in the facility's investigation that showed when the incident occurred. The Administrator confirmed that family reported the incident to staff on Saturday 8/17/2024 and that staff was educated on properly repositioning of residents as an intervention to the incident and the injury was not an allegation of abuse or an injury of unknown and was not reported to state agencies. The facility failed to report allegations of abuse on 8/17/2024 when Resident #27 reported that a staff member spun him around by his arm in his wheelchair that resulted of a fractured right arm.

Based on facility policy review, record review, and interview the facility failed to ensure care plans were reviewed by the Interdiciplinary Team to include the residents responsible party for 1 (Resident #1) resident of 1 sampled resident for review. The findings include: Review of the facility policy titled, Comprehensive Careplan, dated 11/30/2021, revision date 3/25/2021, effective date 3/25/2022, revealed, .the comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly Minimum Data Set (MDS) assessment . Review of the medical record revealed Resident #1 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Interdisciplinary Team Care Plan Review notes for Resident #1 revealed, .3/24/21 .attempted to call (named, family member) but here (there) was no answer .7/1/2021 .family did not participate due to not responding when facility contacted them .3/17/2022 .care plan meeting with (named, family member) . During a telephone interview on 5/3/2022 at 1:00 PM, family member #1 stated she reported her concerns in a care plan meeting in March 2022. She stated that was the first care plan meeting that she had been offered since Resident #1 was admitted . She had been told the facility had attempted to call her for care plan meetings and had not been able to reach her. She stated there were three phone numbers provided to reach her and she did not believe the facility could not reach her for months to discuss a care plan. During an interview on 5/3/2022 at 1:43 PM, the Social Worker stated she had not been at the facility for the March care plan meeting for Resident #1. She stated care plan meetings should be conducted on admission, quarterly, at discharge and when needed for changes in a resident's status. During continued interview she confirmed there were only three care plan meeting notes for Resident #1 dated 3/24/2021, 7/1/2021, and 3/17/2022. During an interview on 5/3/2022 at 2:00 PM, Licensed Practical Nurse (LPN) #1 stated she was present at the care plan meeting for Resident #1 in March. She confirmed that she made notes for nursing, dietary and social services because the position was not filled yet. During an interview on 5/3/2022 at 4:30 PM, the DON confirmed there were only three care plan meeting notes for Resident #1 dated 3/24/2021, 7/1/2021, and 3/17/2022. She stated according to the facility policy there should have been more care plan meetings.

Based on facility policy review, and interview the facility failed to ensure meal trays were delivered to residents in a timely manner resulting in late meal intake. The late delivery of meal trays had the potential to affect all residents in the facility. The findings include: Review of the facility's policy titled, Dietary: Dining Services, revised 10/15/2021,revealed, .Mealtimes and menus should be posted for the resident and family .Meals must be delivered to the residents in a timely fashion . Review of the medical record revealed Resident #1 was admitted to the facility on [DATE], with diagnoses which included [CONDITION(S)], Dysphagia, Oropharyngeal Phase, and Unspecified Diastolic (Congestive) Heart Failure. Review of the medical record revealed Resident #2 was admitted to the facility on [DATE], with diagnoses which included Acute Respiratory Failure with [CONDITION(S)], Panic Disorder, and Dysphagia. Review of the medical record revealed Resident #3 was admitted to the facility on [DATE], with diagnoses which included Chronic Obstructive Pulmonary Disease ([CONDITION(S)]), Pain, Unspecified, and Essential (Primary) Hypertension. Review of the Admission MDS assessment dated [DATE], revealed Resident #3 had a BIMS score of 15, which indicated high cognitive functioning. Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] with diagnoses which included [CONDITION(S)], Muscle Weakness, and [CONDITION(S)]. Review of the Annual MDS assessment dated [DATE], revealed Resident #5 had a BIMS score of 15, which indicated high cognitive functioning. During observation and interview on 5/2/2022 at 8:50 AM, Resident #1 stated his meals were sometimes late getting to him and he had reported it to his daughter. During an interview on 5/2/2022 at 12:10 PM, Resident #3 stated in April there had been many times when meals were served late. The meals were served between 2:30 PM and 3:15 PM on the first Saturday of April. During an interview on 5/2/2022 at 3:50 PM, the Dietary Supervisor stated the meals had been late coming out of the kitchen. There had been a serious shortage of dietary staff. She was not sure how late the meals had been, she believed the weekends were worse for being late. During an interview on 5/3/2022 at 9:30 AM, Licensed Practical Nurse (LPN) #2 stated in April the meal carts came to the floor unusually late at times. She did not recall exactly how late some of the meals had been. During an interview on 5/3/2022 at 10:31 AM, Dietary Aide #1 stated there had not been enough dietary staff to work every day. He works in all positions in the kitchen and sometimes the CNAs would come in to help. There were times when the meal trays were not served on the hall until sometime after the normal hours of the meal. They did the best they could do with the staff they had to work with. During an interview on 5/3/2022 at 11:30 AM, Resident #5 stated on 4/2/2022 the lunch meal was served around 2:30 PM, this is not unusual for the weekend. Breakfast meals are not as late as the lunch and supper meals. She has been served supper as late as 7:00 PM. During a telephone interview on 5/3/2022 at 12:06 PM, the Ombudsman stated she had been in the facility on 4/21/2022 at 7:00 PM. She stated the evening meal carts started coming to the floor at 7:00 PM to be served. During a telephone interview on 5/3/2022 at 1:00 PM, family member #1 stated on 4/2/2022 she visited Resident #1 in the facility, and he told her he was hungry. She asked a tech on the hall if he could get something to eat. The tech told her that lunch was late and about to be served on the hall. At 3:00 PM, Resident #1 was given a tray for the lunch meal. During an interview on 5/3/2022 at 5:00 PM, the Administrator confirmed there was a shortage of Dietary Staff in April. She stated she would not expect the lunch meal to be served as late as 2:30 PM-3:00 PM.

Based on facility policy review, review of facility investigation notes, and interviews the facility failed to report allegations of abuse as required for 1 (Resident #1) resident of 1 sampled resident reviewed for allegations of abuse. The findings include: Review of the facility's policy titled, Abuse Prohibition Plan, with a revision date of 6/10/2022, revealed, .resident will not be subjected to mistreatment, neglect .facility will attempt to identify and will investigate any reported violation or allegation of abuse .Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being .includes verbal abuse .Neglect means failure of the facility, its employees .to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress .investigation will begin immediately . Review of the medical record revealed Resident #1 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #1 had a BIMS score of 11, which indicated moderate cognitive functioning. During an interview on 3/28/2022 at 1:05 PM, Resident #1 stated Licensed Practical Nurse (LPN) #2 came into her room Saturday (3/19/2022) night and the cup of medication he brought to her was not what she had been getting, and she didn't want to take it. She stated LPN #2 set the cup of pills down on her table and left from the room. She stated on Sunday (3/20/2022) morning, LPN #2 brought more medication to her that she did not recognize, and she took the cup to the Risk Manager who told LPN #2 the medication was wrong. LPN #2 became mad, and he started yelling. Resident #1 stated I started yelling right back at him and told him he couldn't talk to me that way. She stated on 3/21/2022, the Director of Nursing (DON) and another nurse came into her room to talk to her about her medication. She told them that she thought LPN #2 might have been taking her medication because he appeared high over the weekend and gave her the wrong medicine. She stated the DON told her she would handle it. During an interview on 3/28/2022 at 4:30 PM, the Risk Manager stated on 3/20/2022, Resident #1 brought her a medicine cup with pills that she said were left in her room by LPN #2. She took the resident to talk to LPN #2 about the medication. LPN #2 became agitated when the resident questioned him about the medications. He attempted to explain what the medications were, and he and the resident started to yell at each other. She told both of them to calm down and reminded LPN #2 to remain professional. She reported the incident to the DON immediately after making sure the resident was okay and back to her room. During an interview on 3/30/2022 at 6:57 PM, the Administrator confirmed that the facility was required to report allegations of abuse within two hours and conduct an investigation. During an interview on 3/30/2022 at 7:05 PM, the DON confirmed the facility was required to report allegations of abuse within two hours and conduct an investigation.

Based on facility policy review, review of facility investigation notes, and interviews the facility failed to thoroughly investigate allegations of abuse for 1 (Resident #1) resident of 6 sampled residents reviewed for abuse. The findings include: Review of the facility's policy titled, Abuse Prohibition Plan, with a revision date of 6/10/2022, revealed, .resident will not be subjected to mistreatment, neglect .facility will attempt to identify and will investigate any reported violation or allegation of abuse .Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being .includes verbal abuse .Neglect means failure of the facility, its employees .to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress .investigation will begin immediately . Review of the medical record revealed Resident #1 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #1 had a BIMS score of 11, which indicated moderate cognitive functioning. Review of the investigation notes provided by the Administrator dated 3/21/2022, revealed 8 residents were interviewed. No specific questions were identified. During an interview on 3/28/2022 at 1:05 PM, Resident #1 stated Licensed Practical Nurse (LPN #2) came into her room Saturday (3/19/2022) and the cup of medication he brought to her was not what she had been getting, and she didn't want to take it. She stated LPN #2 set the cup of pills down on her table and left from the room. She stated on Sunday (3/20/2022) morning, LPN #2 brought some more medication to her that she did not recognize, and she took the cup to the Risk Manager who told LPN #2 the medication was wrong. LPN #2 became mad, and he started yelling. Resident #1 stated I started yelling right back at him and told him he couldn't talk to me that way. She stated on 3/21/2022, the Director of Nursing (DON) and another nurse came into her room to talk to her about her medication. She told them that she thought LPN #2 might have been taking her medication because he appeared high over the weekend and gave her the wrong medicine. She stated the DON told her she would handle it. During an interview on 3/28/2022 at 4:30 PM, the Risk Manager stated on 3/20/2022, Resident #1 brought her a medicine cup with pills that she said were left in her room by LPN #2. She took the resident to talk to LPN #2 about the medication. LPN #2 became agitated when the resident questioned him about the medications. He attempted to explain what the medications were, and he and the resident started to yell at each other. She told both of them to calm down and reminded LPN #2 to remain professional. She reported the incident to the DON immediately after making sure the resident was okay and back to her room. During an interview on 3/30/2022 at 12:20 PM, LPN #3, the Staff Development Coordinator stated that she had not been asked to keep LPN #2 off the schedule pending an investigation of any allegations by the residents in the facility. During an interview on 3/30/2022 at 6:57 PM, the Administrator confirmed that the facility was required to report allegations of abuse within two hours and conduct an investigation. She stated the employee would be suspended pending the investigation. She stated LPN #2 was not suspended because he only works on the weekend and would not be in the facility during the investigation. During an interview on 3/30/2022 at 7:05 PM, the DON confirmed the facility was required to report allegations of abuse within two hours and conduct an investigation. She stated if an employee is suspected of abuse, they would be suspended pending an investigation. She stated on 3/20/2022 the Risk Manager reported that LPN #2 and Resident #1 had an argument and she asked LPN #2 to calm down and made sure Resident #1 was okay. The DON stated she spoke to LPN #2, and he told her that Resident #1 was in his personal space and he became frustrated. The DON stated she told him to make sure he maintained professionalism when he spoke to a resident.

Based on facility record review, observation, and interview the facility failed to provide competent nursing staff for 5 (Residents #1, #2, #10, #11 and #12) residents of 7 sampled residents reviewed. The findings include: Review of the medical record revealed Resident #1 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #1 had a BIMS score of 11, which indicated moderate cognitive functioning. Review of the medical record revealed Resident #2 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission MDS assessment dated [DATE], revealed Resident #2 had a BIMS score of 15, which indicated high cognitive functioning. Review of the medical record revealed Resident #10 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission MDS assessment dated [DATE], revealed Resident #10 had a BIMS score of 11, which indicated moderate cognitive functioning. Review of the medical record revealed Resident #11 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Discharge MDS assessment dated [DATE], revealed Resident #11 had a BIMS score of 13, which indicated high cognitive functioning. Review of the medical record revealed Resident #12 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission MDS assessment dated [DATE], revealed Resident #12 had a BIMS score of 13, which indicated high cognitive functioning. During an interview on 3/28/2022 at 1:05 PM, Resident #1 stated Licensed Practical Nurse (LPN) #2 came into her room Saturday (3/19/2022) night and he was slurring and could hardly stand up. She asked him about getting a [MEDICATION(S)] and he told her she was out of the medication. The cup of medication he brought to her was not what she had been getting, and she didn't want to take it. She stated LPN #2 set the cup of pills down on her table and left from the room. She stated on Sunday (3/20/2022) morning, LPN #2 brought some more medication to her that she did not recognize, and she took the cup to the Risk Manager. She stated on 3/21/2022, the Director of Nursing (DON) and another nurse came into her room to talk to her about her medication. She told them that she thought LPN #2 might have been taking her medication because he appeared high over the weekend and gave her the wrong medicine. During an interview on 3/28/2022 at 2:00 PM, the Administrator stated Resident #1's family member notified her with concerns related to LPN #2 not giving the resident the right medications and behaving like he was high during the weekend of 3/18-3/20. During an interview on 3/28/2022 at 3:00 PM, Resident #2 stated LPN #2 brought medication to his room on Sunday (3/20/2022) morning about 2 AM. LPN #2 seemed tired, like he was trying to go to sleep while talking to him and unsteady when he walked into the room. During an interview on 3/28/2022 at 3:10 PM, the DON stated Resident #1 had spoken to her on 3/21/2022, about her concerns with LPN #2. Resident #1 complained of getting the wrong medications from LPN #2. During continued interview the DON stated she had received a call from the Assistant Director of Nursing (ADON) on 3/20/2022 with reports that RN #1 had called her during the night with concerns about the behavior of LPN #2. The ADON informed her that LPN #2 had been to the emergency room before work and did not get much sleep. During an interview on 3/28/2022 at 4:30 PM, the Risk Manager stated on the morning of 3/20/2022, Resident #1 brought her a medicine cup with pills that she said were left in her room by LPN #2. Continued interview revealed she stated LPN #2 appeared very unorganized and confused during the narcotic count that morning (3/20/2022). She stated the narcotics were not in the order they should be, and it made the count difficult to complete. During an interview on 3/28/2022 at 6:35 PM, LPN #1 stated on Resident #12 complained that something wasn't right with LPN #2 on 3/19/2022. The resident told her that LPN #2 brought him the wrong medicine and he was acting confused. She stated that Residents #1 and #2 had complained that LPN #2 brought them medicine that they did not recognize, and he had acted confused and unsteady. During an interview on 3/28/2022 at 6:45 PM, Certified Nursing Assistant (CNA) #1 stated on 3/19/2022 she saw LPN #2 standing at the med cart with his head bent down, staring at the top of the cart for several minutes. During an interview on 3/28/2022 at 7:08 PM, Registered Nurse (RN) #1 stated on 3/19/2022, LPN #2 had slurred speech and was stumbling while walking around. Three CNAs had reported to her that he was having erratic behavior. During an interview on 3/30/2022 at 10:35 AM, the Certified Occupational Therapy Assistant (COTA) stated on 3/21/2022 Resident #10 complained about LPN #2's behavior over the weekend which included dropping medication onto the floor and leaving the room. During continued interview the COTA stated he saw medication in the floor in Resident #10's room and notified the DON. During a telephone interview on 3/30/2022 at 5:05 PM, Resident #11 stated, [named, LPN] #2 just wasn't himself that night (3/19/2022). He appeared worn out. He looked really tired or sleepy. He was forgetful when I ask for things that night. He needed some rest and at times when he was talking, he struggled to stay awake. During a telephone interview on 3/31/2022 at 5:45 PM, Resident #12 stated that on 3/20/2022, LPN #2 came to his room at 1:00 AM, to give his medications from 3/19/2022. He stated LPN #2 was shaking and had foamy spit in the corners of his mouth when talking. Resident #2 stated he asked the nurse what was wrong, and LPN #2 told him he had been to the ER (emergency room ) and they were not sure if he had a stroke or a urinary tract infection ([CONDITION(S)]). He stated LPN #2 gave one of his IV antibiotics and not the second one. LPN #2 came back into his room and brought the other antibiotic and then left the room to get supplies. He left the medication on the bedside table and never came back in to administer it. Resident #12 stated the medication that he left on the table had a label with Resident #11's name on it. During an interview on 3/30/2022 at 5:49 PM, Resident #10 stated on the night of 3/19/2022, LPN #2 checked his blood sugar between 9 PM-10 PM and left the room to get his insulin and medications. He didn't return with the medications until after midnight. He stated when he asked what kind of medication he was getting, LPN #2 poured the pills on the bedside table to look at them. LPN #2 swept the pills off the table and picked them up out of the floor. He tried to set the cup back on the table and spilled them onto the floor a second time. LPN #2 did not come back with medication. During continued interview, the resident stated that he asked LPN #2 what was wrong with him, and LPN #2 told him that he was sick. During a telephone interview on 3/30/2022 at 6:41 PM, Physical Therapy Assistant (PTA) #1 stated on 3/21/2022, 3 residents complained to him about LPN #2's behavior over the weekend. The residents told him that LPN #2 was not acting normal, he did not look sober. Complaints of confusion related to their medication, spilling medication and getting the wrong medication. During a telephone interview on 3/30/2022 at 6:03 PM, CNA #2 stated on 3/19/2022, LPN #2 was acting weird, stumbling at times and he had spit foaming in the corners of his mouth. His eyes were red, and his speech was slurred. He acted intoxicated and she reported that to the Charge Nurse, Registered Nurse (RN) #1. During continued interview, CNA #2 appropriately answered the abuse questions for employees. During an interview on 6/30/2022 at 6:08 PM, CNA #3 stated on 3/19/2022, she spoke to LPN #2 when he came to the 200 Hall looking for a resident. The resident that he was looking for was not in the facility. She stated he looked confused and was unsteady when walking. She asked him if he was okay and he told her yes, he just had a [CONDITION(S)] and didn't feel well. She reported the encounter to Charge Nurse, RN#1. During an interview on 3/30/2022 at 6:15 PM, the ADON stated the Charge Nurse, RN #1 called her on 3/19/2022 with concerns about LPN's behavior. She stated RN #1 told her that he (LPN #2) had been acting like something wasn't right with him.

Based on facility policy review, record review, and interviews the facility failed to provide rationale for continued use of a [CONDITION(S)] medication PRN [as needed] after 14 days of use for 2 (Resident #4 and Resident #8) residents reviewed. The findings include: Review of the facility's policy titled, Use of [CONDITION(S)] Drugs, revised 6/8/2021, revealed, .PRN orders for [CONDITION(S)] drugs shall be used only when the medication is necessary to treat a diagnosed specific condition that is documented in the clinical record, and for a limited duration .14 days . Review of the medical record revealed Resident #4 was admitted to the facility on [DATE], with diagnoses which included [CONDITION(S)] ([CONDITION(S)]), Generalized Anxiety, and Chronic Pain Syndrome. Review of the Medication Administration Record (MAR) and Controlled Drug Receipt/Record/Disposition dated 3/2022, for Resident #4 revealed, .[MEDICATION(S)] [anxiety medication] 0.25 mg [milligram] tablet as needed two times daily for one hundred eighty days starting 11/15/2021 .generalized anxiety disorder . Review of the medical record revealed Resident #8 was admitted to the facility on [DATE], with diagnoses which included [CONDITION(S)], Heart Failure, and Repeated Falls. Review of the MAR and Controlled Drug Receipt/Record/Disposition dated 3/2022, for Resident #8 revealed, . [MEDICATION(S)] 0.25 mg tablet .as needed every eight hours for thirty days starting 3/18/2022 .generalized anxiety disorder . During an interview on 3/30/2022 at 4:09 PM, the Director of Nursing (DON) reviewed the orders for Resident #4 and Resident #8. She confirmed the orders PRN [CONDITION(S)] medications should be no longer than 14 days. During further interview she confirmed there was no documentation to justify the PRN use of the medication for more than 14 days. She stated she would expect the medication to be scheduled if needed for longer than 14 days.

Based on facility policy review, record review, interviews, and observations the facility failed to ensure 5 (Residents #1, #2, #5, and #6) residents of 8 sampled residents were free of significant medication errors. The findings include: Review of the facility's policy titled, Medication Administration, revealed, .Medications will be administered .per the Physician's Signed Order .nurse will observe the 8 Rights of Medication Administration . Review of the medical record revealed Resident #1 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Patient Medication Profile for Resident #1 revealed, [MEDICATION(S)] [nerve pain medication] 75 mg [milligram] scheduled for twice daily and [MEDICATION(S)] 50 mg PRN [as needed] for pain. Review of the Medication Administration Record (MAR) and Controlled Drug Receipt/Record/Disposition Form for Resident #1 dated 3/2022, revealed [MEDICATION(S)] 75 mg was signed out on the control sheet on 3/22/2022, at 0013; the scheduled time for administration is 0800 and 2000. Continued review revealed [MEDICATION(S)] 50 mg signed out on the control sheet on 3/23/2022 and 3/24/2022. Review of the Clinical Notes for Resident #1 revealed, 3/23/2022 .1903 .Resident was given her prn [as needed] [MEDICATION(S)] [[MEDICATION(S)]] of 50 mg this AM instead of her scheduled 8 AM 75 mg of [MEDICATION(S)] .3/24/2022 .1000 .Resident received [MEDICATION(S)] 50 mg this morning med pass . Review of the medical record revealed Resident #2 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MAR and Controlled Drug Receipt/Record/Disposition dated 3/2022, for Resident #2 revealed multiple medication and documentation errors. [MEDICATION(S)] [nerve pain medication] Cap 400 mg scheduled for administration at 0500, 1300, and 2100 was signed out on 3/7 at 1600, 3/16 at 1800, and 3/22 at 1630 on the control sheet. On 3/11, 3/19, 3/26, and 3/27, no medication signed out for 1 of 3 scheduled doses. Review of the MAR revealed, [MEDICATION(S)] 400 mg capsule had been signed as administered three times daily on 3/19, 3/26, and 3/27/2022. Further review of the MAR revealed, no documentation on 3/18 at 2100, and 3/19 at 0500 and 2100. Review of the Patient Medication Profile for Resident #2 revealed, .2/26/2022 [MEDICATION(S)] 400 mg capsule .Take one (1) capsule by mouth three times a day. Review of the medical record revealed Resident #5 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission MDS assessment dated [DATE], revealed Resident #5 had a BIMS score of 13, which indicated high cognitive functioning. Review of the Patient Medication Profile for Resident #5 revealed, .[MEDICATION(S)] [opioid pain medication] 5 mg-acetaminophen 325 mg tablet .Every twelve hours for thirty days starting 3/28/2022 . Review of the MAR and Controlled Drug Receipt/Record/Disposition dated 3/2022, for Resident #5 revealed multiple medication and documentation errors. Review of the MAR revealed documentation of administration of [MEDICATION(S)] 5 mg-acetaminophen 325 mg 54 times between 3/1 and 3/28. There was missing documentation for 3/18 at 2000. Review of the control sheets revealed, [MEDICATION(S)]/apap 5/325 mg tablets signed out for administration 52 times including 1 time on 3/27 at 0300. No order found for PRN administration. There was no signature on 3/24 for 2100 administration. Review of the Clinical Notes Report for Resident #5 revealed no notifications of missed dosages, no documentation for additional dose and no indications of increased pain. Review of the medical record revealed Resident #6 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Patient Medication Profile for Resident #6 revealed, .2/16/2022 [MEDICATION(S)] [enteral feeding formula] 1.2 Cal [protein] 0.06 gram-1.2 kcal/ml [kilocalorie/milliliter] oral liquid @ 95 ml/hr [milliliter/hour] with H2O [water] @ 25 ml/hr continuous starting 2/16/2022. Observation and interview in room [ROOM NUMBER] at 9:15 AM, revealed Resident #6's feeding pump did not have a dual system hanging to include intermittent water flush. During an interview at 9:18 AM, Licensed Practical Nurse (LPN) #3 stated there should be a dual system hanging for formula and water. She stated during shift report the night shift nurse reported she could not find the correct bag to hang. During continued interview she stated 100 ml [milliliter] of water bolus had been given this morning at 7:30. She confirmed Resident #6 had orders for 25 ml water flush every hour and no other water had been administered by her manually.

Based on facility policy review, medical record review and interview, the facility failed to develop and implement a baseline care plan to address resident safety needs for 7 (#11, #25, #60, #66, #69, #75, and #276) of 24 residents who were identified on admission to be at risk for falls. The facility's noncompliance placed Resident #276 in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident) when the resident sustained [REDACTED].#11, #25, #60, #66, #69, and #75 in Immediate Jeopardy. The Administrator was informed of the Immediate Jeopardy (IJ) on 11/18/19 at 1:20 PM in her office. F-655, and F-689 were cited at a scope and severity of K. An extended survey was conducted from 11/18/19 to 11/19/19. The Immediate Jeopardy was effective from 9/23/19 through 11/18/19. A Removal Plan which removed the immediacy of the jeopardy was received on 11/19/19 at 9:00 PM and corrective actions were validated on site by the surveyors on 11/19/19. The facility's noncompliance at F-655 continues at a scope and severity of [NAME] for the monitoring of the effectiveness of the corrective actions. The findings include: Facility policy review, Baseline Care Plan, dated 11/2017, revealed .The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident .Be developed within 48 hours of a resident's admission .Interventions shall be initiated that address the resident's current needs including: safety concerns to prevent decline or injury, such as .fall . Medical record review revealed Resident #276 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review revealed the resident was readmitted on [DATE] with a new [DIAGNOSES REDACTED]. Medical record review of the 5-day Minimum (MDS) data set [DATE] revealed Resident #276 had a Brief Interview for Mental Status score of 3, indicating severe cognitive impairment. Further review revealed the resident required extensive assistance with bed mobility, transfer, dressing, toileting, personal hygiene and total dependence for bathing. Continued review revealed the resident was not steady and only able to stabilize with staff assistance; moving from seated to stand position, moving on and off toilet and surface to surface transfer. Further review revealed Resident #276 had a fall prior to admission with a [MEDICAL CONDITION] femur . Medical record review of Resident #276's Fall Risk Assessment, dated 9/10/19 revealed .Multiple falls in past 90 days .oriented to person only .Alzheimer's or other dementia .Total Score:12-Moderate risk for falls . Medical record review revealed a baseline care plan was not developed or implemented within 48 hours of admission for Resident #276. Further review revealed a fall care plan was not developed until after Resident #276 had fallen on 9/24/19 and sustained a fractured left femur. The Comprehensive Care Plan was developed at the same time. Review of Resident #276's fall investigation dated 9/24/19 revealed .fall unwitnessed .resident was walking to the restroom unassisted with oxygen tubing on .resident found sitting upright in front of restroom floor . Continued review of the investigation revealed the resident stated she got out of bed and was walking to the bathroom but forgot her nasal cannula was still on causing her to fall. Review of the Emergency Department record dated 9/24/19 revealed .She accidentally choked herself with her nasal cannula and fell on left side. Review of a Nurse's Note dated 9/24/19 at 10:07 AM revealed, .Left hip is positive for fracture. NP (Nurse Practitioner) notified .Order received to send to ER (emergency room ), POA (Power of Attorney) notified . Medical record review of a physician's orders [REDACTED].Send to ER for left [MEDICAL CONDITION] . Medical record review revealed Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #11's Fall Risk assessment dated [DATE] revealed the resident was at high risk for falls. Medical record review revealed no baseline care plan was developed for Resident #11 within 48 hours of admission to address immediate safety needs. Medical Record review revealed Resident #25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #25's Fall Risk assessment dated [DATE] revealed the resident was at moderate risk for falls. Medical record review revealed no baseline care plan was developed for Resident #25 within 48 hours of admission to address immediate safety needs. Medical record review revealed Resident #60 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #60's Fall Risk assessment dated [DATE] revealed the resident was at high risk for falls. Medical record review revealed no baseline care plan was developed for Resident #60 within 48 hours of admission to address immediate safety needs. Medical record review revealed Resident #66 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #66's Fall Risk assessment dated [DATE] revealed the resident was at moderate risk for falls. Medical record review revealed no baseline care plan was developed for Resident #66 within 48 hours of admission to address his immediate safety needs. Medical record review revealed Resident #69 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #69's Fall Risk assessment dated [DATE] revealed the resident was at high risk for falls. Medical record review revealed no baseline care plan was developed for Resident #69 within 48 hours of admission to address his immediate safety needs. Medical record review revealed Resident #75 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #75's Fall Risk assessment dated [DATE] revealed the resident was at moderate risk for falls. Medical record review revealed no baseline care plan was developed for Resident #75 within 48 hours of admission to address his immediate safety needs. Interview with the Administrator and the Interim Director of Nursing in the fine dining room on 11/19/19 at 7:05 PM confirmed Resident #'s 11, #25, #60, #66, #69, #75 and #276 did not have a baseline care plan. Continued interview confirmed all residents were to have a baseline care plan in place within 48 hours of admission. Further interview confirmed if a baseline care plan had been completed for Resident #276 monitoring and better interventions would have been implemented to prevent the fall. The surveyors verified the Removal Plan by: 1. The surveyors reviewed and verified Resident #276's updated care plan for the development and revision to provide adequate supervision and interventions to prevent accidents and injuries. 2. The surveyors reviewed and verified the facility's 100% audit of residents' care plans to ensure interventions for adequate supervision and interventions to prevent accidents and injuries were implemented. The surveyors reviewed the facility's 100% audit of resident current fall risk assessments. 3. The surveyors reviewed and verified the education and training on facility policy and procedure to develop a baseline care plan for the Interim Director of Nursing, the Assistant Director of Nursing, Staffing Coordinator, Minimum Data Set Coordinator and Medical Records Personnel. The surveyors reviewed and verified the facility's staff education for developing baseline care plans. The licensed staff was educated on 11/19/19 on baseline care plans and the CNAs were educated on 11/19/19 on communicating resident needs. New orientees will be educated on baseline and comprehensive care plans during orientation. The surveyors validated the facility's resource materials for determination of root cause analysis for falls/accidents and fall intervention tips were placed at each nurses' station. 4. The surveyors verified the facility's QAPI meeting held on 11/19/19 to discuss the Corrective Action Plan for the deficiencies and the Medical Director was in agreement with the plan. The audits on admission/readmission care plans and falls for implementation of a baseline and/or comprehensive care plan to include supervision and interventions to prevent accidents and injuries.

Based on facility policy review, medical record review, facility investigation and interviews, the facility failed to provide adequate supervision to prevent falls for 2 (#276, #39) of 24 residents who were assessed at risk for falls. The facility's noncompliance placed Resident #276 and #39 in Immediate Jeopardy (IJ) When Resident #276 sustained a femur fracture from a fall and resident #39 sustained skin tears to her head and forearm from a fall. The Administrator was informed of the Immediate Jeopardy (IJ) on 11/18/19 at 1:20 PM in her office. F-655, and F-689 were cited at a scope and severity of K. The facility was cited F-689 K which was Substandard Quality of Care. An extended survey was conducted from 11/18/19 to 11/19/19. The Immediate Jeopardy was effective from 9/23/19 through 11/18/19. A Removal Plan which removed the immediacy of the jeopardy was received on 11/19/19 at 9:00 PM and corrective actions were validated on site by the surveyors on 11/19/19. The facility's noncompliance at F-689 continues at a scope and severity of [NAME] for the monitoring of the effectiveness of the corrective actions. The facility is required to submit a plan of correction. The findings include: Facility policy review, Accidents and Supervision, dated 11/2017, revealed .The resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistive devices to prevent accidents. This includes: Identification of Hazards and Risk .All staff are to be involved in observing and identifying potential hazards in environment .Implementing interventions to reduce hazard(s) and risk(s) .as part of the plan of care .Monitoring is the process of evaluating the effectiveness of the care plan interventions . Medical record review revealed Resident #276 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review revealed the resident was readmitted on [DATE] with a new [DIAGNOSES REDACTED]. Medical record review of the 5-day MDS dated [DATE] revealed Resident #276 had a BIMS score of 3, indicating severe cognitive impairment; required extensive assistance with bed mobility, transfer, dressing, toileting and personal hygiene and total dependence for bathing. Continued review revealed the resident was not steady and only able to stabilize with staff assistance; moving from seated to standing position, moving on and off toilet and surface to surface transfer. Further review revealed Resident #276 had a fall with a right femur fracture prior to admission. Medical record review of Resident #276's Fall Risk assessment dated [DATE] revealed .Multiple falls in past 90 days .oriented to person only .Alzheimer's or other dementia .Total Score:12-Moderate risk for falls . Medical record review revealed Resident #276 did not have a baseline care plan. Further review revealed a fall care plan with interventions was not initiated until after the resident sustained [REDACTED]. Medical record review of Resident #276's Nurse's Note dated 9/24/19 at 6:59 AM revealed .summoned to resident room by loud noise and residents yell at 0300 (3:00 AM) .(Named Resident) was found sitting upright in front of the bathroom door . Medical record review of the Interdisciplinary Team Occurrence Investigation Worksheet for Resident #276, dated 9/24/19 revealed .c/o (complained of) leg pain . Further review revealed the MD (Medical Doctor) was notified of the incident. Review of Resident #276's fall investigation dated 9/24/19 revealed .fall unwitnessed .resident was walking to the restroom unassisted with oxygen tubing on .resident found sitting upright in front of restroom floor . Continued review of the investigation revealed the resident stated she got out of bed and was walking to the bathroom but forgot her nasal cannula was still on causing her to fall. Review of the Emergency Department record dated 9/24/19 revealed .She accidentally choked herself with her nasal cannula and fell on left side. Review of Resident #276's medical record revealed her care plan was not developed until 9/24/19, after the fall had occured. Further review revealed intervention added on 9/24/19 to .Change 02 tubing (oxygen tubing) to shorter tubing . Medical record review of Resident #276's physician's orders [REDACTED].BIL (bilateral) Hip x-ray . Review of Resident #276's Nurse's Note dated 9/24/19 at 10:07 AM revealed, .Left hip is positive for fracture. NP (Nurse Practitioner) notified .Order received to send to ER (emergency room ), POA (Power of Attorney) notified . Medical record review of Resident #276's Radiology Report dated 9/24/19 at 10:45 AM revealed, .left sub capital femoral neck fracture with mild impaction .Left [MEDICAL CONDITION] . Telephone interview with CNA #3 on 11/19/19 at 10:05 AM revealed, We were told to keep an eye on her because she was a high fall risk. Medical record review revealed Resident #39 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #39's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident had a Brief Interview of Mental Status (BIMS) score of 5 indicating the resident had severe cognitive impairment. Continued review revealed the resident required extensive assistance of 2 staff for transfers and toileting. Medical record review of Resident #39's Fall Risk Assessments dated 1/14/19, 1/17/19, 2/3/19, 2/12/19, 2/24/19, 4/15/19, 6/4/19 and 8/10/19 revealed the resident was a moderate fall risk. Medical record review of Resident #39's Nurse's Event Note dated 9/23/19 revealed .Resident was in bathroom sitting on toilet. Tech (Certified Nurse Aid (CNA)) left room for a brief moment and resident got up and attempted to pull pants up and walk to w/c (wheelchair). Was observed on floor with ST (skin tear) to R (right) eyebrow and a small ST to L (left) forearm by elbow. Instructed tech about not leaving residents who are fall risk alone in bathroom . Telephone interview with CNA #4 on 11/19/19 at 11:47 AM revealed she assisted Resident #39 to the bathroom on 9/23/19. She stated, I sat her on the toilet and walked out of the room to the hallway to the Kiosk (computer where staff charts). I heard her fall and went back into the room and she was lying on the floor by the bathroom door. I stepped outside the room to get assistance. The nurse came to her room to assess her, we got her clothes on her and she had a 'gash' on her head. I was told by the nurse after the fall that (Named Resident #39) was a fall risk and I was to never leave her by herself. Telephone interview with the Licensed Practical Nurse (LPN) #2 on 11/19/19 at 12:18 PM confirmed CNA #4 left Resident #39 alone in the bathroom on 9/23/19 and the resident had a fall resulting in skin tears to her right eyebrow and left forearm. Interview with Administrator and Interim Director of Nursing in the fine dining room on 11/19/19 at 7:05 PM confirmed we should never leave any resident who needs assistance in the bathroom by themselves. Continued interview confirmed leaving her (Resident #39) in the bathroom alone resulted in an injury. Further interview confirmed if a baseline care plan had been completed for Resident #276 monitoring and better interventions would have been implemented to prevent the fall. The surveyors verified the Removal Plan by: 1. The surveyors reviewed and verified Resident #39's and Resident #276's updated care plan for the development and revision to provide adequate supervision and interventions to prevent accidents and injuries. 2. The surveyors reviewed and verified the facility's 100% audit of resident's care plans to ensure interventions for adequate supervision and interventions to prevent accidents and injuries were implemented. The surveyors reviewed the facility's 100% audit of resident current fall risk assessments. 3. The surveyors reviewed and verified the education and training for the Interim Director of Nursing, the Assistant Director of Nursing, Staffing Coordinator, Minimum Data Set Coordinator and Medical Records Personnel. The surveyors reviewed and verified the facility's staff education for developing and implementing baseline care plans. The surveyors validated the facility's resource materials for determination of root cause analysis for falls/accidents and fall intervention tips were placed at each nurse's station. The surveyors reviewed and verified all on duty licensed nurses education on developing baseline and/or comprehensive care plans. The surveyors verified the facility's QAPI meeting held on 11/19/19.

Based on medical record review, facility policy review, observation, and interview, the facility failed to ensure the correct technique was used for transfer of one (#4) resident resulting in a Humerous Fracture and harm for resident #4, and failed to ensure safety measures were in place for two (#6, #12) of twenty residents reviewed. The findings included: Resident #4 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a Nurses Event Note dated March 17, 2011, revealed, "...Resident c/o (complained of) pain to (right) arm. (right) upper arm red (and) swollen. c/o pain with ROM (range of motion). Resident unsure what happen. NP (nurse practitioner) notified..." Medical record review of a physician's orders [REDACTED]. Medical record review of the x-ray report dated March 17, 2011, revealed, "...Right Shoulder...Impression: 1. Probable joint effusion. 2. Osteopenia. 3. No evidence of fracture..." Medical record review of a Nurses Progress Note dated March 18, 2011, revealed, "...called to resident's room per (technician). Resident complaining of (right) shoulder pain. Edema (swelling) noted to shoulder...no bruising noted some redness in arm noted. Call placed to (named nurse practitioner) (nurse practitioner) here to see resident. Stated 'I've already ordered an x-ray'..." Medical record review of a Nurses Progress Note dated March 21, 2011, revealed, "...cont (continues) to c/o worsening pain to (right) shoulder. Bruising/edema noted to have worsened (and) moved...into (right) elbow. Pt. (patient) crying...(new order) for x-ray to (right) elbow..." Medical record review of a physician's orders [REDACTED]. Medical record review of an x-ray report dated March 21, 2011, revealed, "...Right Elbow...Normal..." Review of a facility investigation summary dated March 21, 2011, revealed, "...On 3/16/2011 the resident was got up to go to a podiatrist appointment in the building. The techs used a two person lift which is indicated on the nurse aide communication sheet. The tech (CNA (certified nursing assistant) #4 and CNA no longer employed at the facility) put their hands under the arms (axillary area) and behind the knee during the transfer. The resident tolerated the transfer well and expressed no complaints of pain. The resident was placed in an electric wheelchair and we practiced turns, stop and starting the wheelchair. After the resident demonstrated proper control of the wheelchair...was able to move about freely. A little while later the resident started to complain of pain in the right shoulder...asked the tech to lay...down and we honored...(request) using the same technique as above. The next day the nurse noted some redness and some edema to the upper arm...called the NP and received new orders for x-ray of the arm. On 3/17/2011 the x-ray showed no fracture or dislocations of the arm. On 3/21/2011 the resident continued to complain of pain in the right arm and the redness had turned to some bruising and spread down the elbow. Another x-ray ordered showing no fractures or dislocations of the arm. On 3/22/2011 NP ordered x-ray of humerus. The x-ray showed a transverse slightly impacted fracture the neck of the right humerus...Will in-service all techs regarding transfers and proper hand placements, will have one to one in-service with the tech that transferred the resident..." Medical record review of an x-ray report dated March 22, 2011, revealed, "...Right Humerus...Transverse slightly impacted fracture neck of the right humerus..." Medical record review of a physician's orders [REDACTED]. Medical record review of an orthopaedic office note dated March 25, 2011, revealed, "...x-rays were...obtained and revealed a right humerus fracture. There is no known trauma...recommend nonoperative treatment with sling immobilization and pain control..." Observation on August 16, 2011, at 10:40 a.m., revealed the resident lying in the bed with a splint on the right hand. Interview on August 16, 2011, at 9:55 a.m., in the conference room, with the Assistant Director of Nursing, confirmed the techs were getting the resident up, lifted the resident under the arms and behind the knees. Interview on August 16, 2011, at 9:55 a.m., in the conference room, with the Director of Nursing, confirmed positioning of the resident was difficult and required further x-rays to confirm the fracture. Interview on August 16, 2011, at 10:15 a.m., in the conference room, with CNA #4, revealed CNA #4 and a CNA no longer employed by the facility, transferred resident #4 to the wheelchair with one CNA on each side of the resident by lifting the resident under the arms and under the legs. Interview on August 16, 2011, at 10:30 a.m., with Occupational Therapist #1, in the therapy department, confirmed it is not appropriate to transfer a resident by lifting the resident under the arms. Interview on August 16, 2011, at 10:40 a.m., with the Nurse Practitioner, at the nurse's station, confirmed the resident's bones are fragile. Interview on August 16, 2011, at 12:30 p.m., in the conference room, with Physical Therapist #1, confirmed there are alternatives to transferring a resident such as two people locking their hands behind the resident's back and putting their arms under the resident's legs (cradle). Interview on August 16, 2011, at 5:30 p.m., in the conference room, with the Assistant Director of Nursing, confirmed the resident's son was notified of the fracture and informed "we suspect it was done on a transfer technique." Resident #6 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a fall risk assessment dated [DATE], revealed the resident was at moderate risk for falls. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had a history of [REDACTED]. Medical record review of the physician's recapitulation orders dated August 1, 2011, through August 31, 2011, revealed, "...Body alarm at all times..." Observation on August 16, 2011, at 9:20 a.m., revealed the resident seated in a wheelchair, in the resident's room, without a body alarm in place. Observation and interview on August 16, 2011, at 9:22 a.m., with LPN (Licensed Practical Nurse) #2, revealed the resident seated in a wheelchair, in the resident's room, and confirmed a body alarm was not in place. Observation and interview on August 17, 2011, at 7:45 a.m., with LPN #3, revealed the resident lying on the bed and confirmed the body alarm was not attached to the resident. Resident #12 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE] revealed the resident was alert and oriented; required extensive assistance of one person with bathing, dressing, and toileting; required two person assistance with transfers; was occasionally incontinent of bowel and bladder. Medical record review of fall risk assessments revealed a fall risk score of 18 on admission and 21 on June 28, 2011, with a score of 11 - 19 being moderate risk, and a score of 20+ being high risk for falls. Medical record review of a nursing note dated June 28, 2011, revealed the resident was found on the floor between the two beds with no injury. Medical record review revealed Physical Therapy recommended a toileting schedule. Medical record review of a nursing note dated July 29, 2011, at 3:30 p.m., revealed the resident had been reaching for another chair and tipped the wheelchair over on top of self. Medical record review of a nursing note dated July 29, 2011, at 6:30 p.m., revealed the resident climbed out of bed to the floor. Continued medical record review revealed Physical Therapy recommended scheduled toileting. Continued medical record review revealed a Toileting Schedule with entries for July 29, 30, 31, August 1, 2, 2011, with a "V" in the spaces for 12 midnight, 2:00 a.m., 4:00 a.m., and 6:00 a.m., to indicate the resident voided in the toilet/urinal. The only scheduled toileting was carried out on the 10:00 p.m. to 6:00 a.m. shift. Medical record review of a nursing note dated July 30, 2011, revealed the resident was found lying on the floor on one side and the resident stated "...was trying to go to the bathroom..." Continued medical record review revealed the Physical Therapy recommendation after this fall had been to place a bed sensor and body alarm. Interview with the Assistant Director of Nursing (ADON) on August 17, 2011, at 12:30 p.m., in the 300 Hall nurses' station, confirmed the resident's bed was not in a low position nor were there safety mats on the floor. Continued interview revealed the ADON was unsure why the toileting schedule was done at night when the resident's falls occurred during the evening hours. Further interview with the ADON revealed if a resident fell while trying to go to the bathroom on a particular shift, then Restorative does scheduled toileting on that shift.