Every finding on record at Autumn Lake Healthcare at Ballenger Creek

Based on observations, record review, and interviews, it was determined that the facility failed to ensure that a resident who required assistance with self-care was groomed in a manner that preserved the resident's dignity. This was evident in 1 (Resident #34) of 1 resident reviewed for dignity. The findings include:The Minimum Data Set (MDS) is a federally mandated assessment tool used by nursing home staff to gather information on each Resident's strengths and needs. The information collected informs resident care planning decisions. A care plan is a guide that addresses each Resident's unique needs. It is used to plan, assess, and evaluate the effectiveness of the Resident's care. Staff use care plans to provide resident-centered care, including support, services, and resources to address Residents' needs. An observation on 6/24/26 at 10:43 AM noted Resident #34 seated in a wheelchair by the bedside. The Resident had a significant amount of facial hair on the chin and upper lip. The Resident expressed a desire to have it shaved. A subsequent observation on 6/25/26 at 11:41 AM showed that Resident #34 still had facial hair on the chin and upper lip. A record review on 6/25/26 at 11:47 AM included an admission MDS assessment for Resident #34. The MDS noted that Resident #34 had severely impaired cognition and required staff assistance with self-care, including personal hygiene. A review of Resident #34's care plan noted that the Resident required assistance/is dependent for ADL care in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, toileting. The review did not indicate that Resident #34 preferred to wear facial hair. During an interview on 6/25/26 at 11:48 AM, staff #10, a nursing assistant, reported that Resident #34 required staff assistance with personal hygiene, including shaving. When asked about Resident #34's facial hair, staff #10 responded, I will take care of it later. In an interview on 6/25/26 at 11:57 AM, staff #2, the unit manager (UM) for the nursing hall where Resident #34 resided, stated that she expected Resident #34's facial hair to have been shaved if Resident #34 preferred it. The UM said she would have it shaved immediately after the surveyor's intervention.

Based on interviews, observations and record reviews, it was determined that the facility failed to ensure resident room temperature was maintained based on the resident's comfort level and preference. This was evident for 1 (Resident #129) of 4 residents reviewed for environment. The findings include:Resident #129 was a newly admitted resident of the facility. During an interview with the resident on 6/24/26 at 1:14 PM, s/he stated, the room is too cold, and nobody has an idea what to do. The resident also reported that s/he requested a friend to bring in a thick blanket and was observed using it on top of the facility provided blanket. However, the resident indicated that it was not enough and that s/he was still cold. The resident's room had an air vent cover with fixed louvers and there was no thermostat or control unit found in the resident's room with the ability to change the room temperature.The maintenance director (Staff #31) was interviewed on 6/30/26 at 11:02 AM. During the interview, Staff #31 reported that room temperatures were controlled by a thermostat. However, there was only 1 thermostat for every 4 rooms. Staff #31 was further questioned about his process when a resident wants to change his/her room temperature. Staff #31 explained that he tries to get a median temperature setting for the 4 rooms and if 1 room still needs to be adjusted, the vent covers have adjustable louvers to lessen the air flow and would offer extra blankets to help warm the resident according to their preference and comfort level.An observation of Resident #129's room was then conducted with Staff #31. Staff #31 confirmed that the resident's vent cover did not have adjustable louvers and reported that he would find a replacement. While in the room, the resident again reported to the surveyor and staff that having 2 blankets was not enough to warm him/her up. Staff #31 indicated that he was not aware of the resident's concern about the room temperature and that the facility had an electronic system to report and track maintenance concerns, however facility staff preferred to report concerns by writing it in the maintenance binder.The maintenance binder located in front of the nurse's station was reviewed with Staff #31 on 6/30/26 at 11:10 AM. The review revealed a form titled Work order request with columns for date and time, requested by, request with room number, and completed by. An entry dated 6/23/26 indicated a concern in Resident #129's room that read, s/he reports his/her room is really cold, could we look at adjusting the vent blades. This entry had a signature under the completed by column and Staff #31 reported that it was his assistant's signature (Staff #32). There was no documentation to indicate what was completed by Staff #32 other than his signature. Staff #31 reported that he did not know what was done either and indicated that he would ask Staff #32.An interview with Staff #32, in the presence of Staff #31 was conducted on 6/30/26 at 11:15 AM. During the interview, Staff #32 reported that the thermostat was adjusted (moved up) and that an internal damper was closed to lessen the air flow to Resident #129's room. However, there was no documentation to indicate these actions , only his signature. Further review of the binder revealed another entry for the resident's room dated 6/30/26 that read, air vent blowing cold air - wants covered. This entry had also been signed by Staff #32 as completed and when asked what he had completed he reported that he did not need to do anything because he had already addressed the issue in the past. The surveyor then asked if he had at least explained to the resident today the actions he had done since he signed the request as completed. Staff #32 then stated, oh my god, fu*k this. Then threw his keys on the counter and walked away. Staff #31 stated, He's absolutely wrong with the way he reacted.On 6/30/26 at 11:22 AM, the concern was discussed with Staff #31 that Staff #32 was pre-signing work order request as completed with no documentation, report, and/or evidence that the concern had been addressed. Staff #31 verbalized understanding and acknowledged the concern.

Based on record reviews and staff interviews, it was determined that the facility failed to complete comprehensive Minimum Data Set (MDS) assessments within the regulatory timeframes to maintain current, accurate assessment records. This was evident for 3 (Residents #24, #37, and #34) of 3 residents reviewed for Resident assessment. The findings include:The MDS is a federally mandated assessment tool that nursing home staff use to gather information about each Resident's strengths and needs. The information collected informs Resident care planning decisions. The admission MDS is a comprehensive assessment for new Residents and, under certain circumstances, returning Residents. It must be completed by the end of day 14, with the date of admission to the facility as day 1. The last day of the observation period is the Assessment Reference Date (ARD). It marks the end of the observation period and serves as a common reference point for all team members involved in the assessment. 1) Record review on 6/29/26 at 9:51 AM showed that Resident #24 was admitted to the facility on [DATE].A continued review included Resident #24's admission MDS assessment dated [DATE], which was due to be completed by the facility on 6/21/26. However, further review showed that the Resident's admission MDS was signed as complete in sections V0200B2 and Z0500B on 6/23/26, 16 days after Resident #24's admission to the facility, making it 2 days late. During an interview on 6/30/26 at 8:46 AM, staff #4, an MDS Coordinator, confirmed that Resident #24's admission MDS assessment was completed late. 2) A review on 6/29/26 at 9:55 AM of Resident #37's admission MDS assessment with ARD 6/14/26 revealed that Resident #37 was admitted to the facility on [DATE]. A continued review of the MDS assessment showed that it was due to be completed on 6/21/26. However, further review showed that it was signed as complete in sections Z0500B and V0200B2 on 6/24/26, 17 days after Resident #37's admission to the facility and 3 days late. During a follow-up interview on 6/30/26 at approximately 9:00 AM, Staff #4 confirmed that Resident #37's admission MDS was completed late. 3) A record review conducted on 6/24/26 at 12:05 PM for Resident #34 included an admission MDS assessment dated [DATE]. The review showed that the Resident was admitted to the facility on [DATE]. Therefore, the admission MDS assessment was due on 6/14/26. However, a subsequent review showed that Resident #34's admission assessment was signed as complete in sections Z0500B and V0200B2 on 6/16/26, 16 days after the Resident's admission to the facility, making it 2 days late. During an interview on 6/30/26 at approximately 9:05 AM, staff #4 checked the completion date of Resident #34's admission MDS and reported that it was completed late.

Based on record reviews and interviews, it was determined that the facility failed to complete a Significant Change in Status Minimum Data Set (MDS) assessment within 14 days for a resident who experienced a major decline in health status that impacted more than one area of the Resident's health. This was evident for 1 (Resident #3) of 5 residents reviewed for unnecessary medications. The findings include: The Minimum Data Set (MDS) is a federally mandated assessment tool used by nursing home staff to gather information about each Resident's strengths and needs. The information collected on the MDS informs Resident care planning decisions. MDS assessments must be accurate to ensure that each Resident receives the care they need. Activities of daily living (ADLs) is a term used to collectively describe the fundamental skills required to care for oneself independently, such as eating, bathing, and mobility. A significant change means a major decline or improvement in the Resident's status that will not normally resolve without further intervention by staff or by implementing standard disease-related clinical interventions, that has an impact on more than one area of the Resident's health status and requires interdisciplinary review or revision of the care plan, or both. The nursing home should complete a Significant Change in Status MDS assessment within 14 days of a major decline or improvement in a resident's status. A review of Resident #3's medical record on 6/25/26 at 3:25 PM included an MDS assessment dated [DATE], which noted that Resident #3 had a diagnosis of Dementia, severely impaired cognition, and required setup or cleanup assistance from staff with eating, and partial/moderate assistance with oral hygiene, upper-body dressing, and wheeling in a wheelchair for 50 feet. A continued review showed that in March 2026, Resident #3 was hospitalized for a left thigh fracture repair. Upon the Resident's return to the facility, an MDS assessment for Resident #3 was completed with an ARD of 3/23/26. The MDS recorded that Resident #3 required partial/moderate assistance from staff with eating and was fully dependent on staff for oral hygiene, upper-body dressing, and wheel self for 50 feet. The review showed a decline in Resident #3's ability to eat, perform oral hygiene, upper-body dressing, and propel himself/herself once set up in a wheelchair. The review also included a nutrition evaluation note dated 3/24/26, which recorded significant weight loss over 1, 3, 6 months. However, the review failed to show that a significant Change in Status MDS assessment was completed for Resident #3 to reflect the decline in ADLs and significant weight loss. An interview with staff #24, a registered dietitian, on 6/29/26 at 8:18 AM confirmed that Resident #3 was observed to have significant weight loss upon returning from the hospital in March and April 2026. In an interview with staff #4, an MDS nurse, on 6/30/26, at 8:46 AM, she reported that she would complete a Significant Change in Status MDS assessment for a decline in more than one area of a resident's ADLs, significant weight loss, or a fracture. Staff #4 reviewed Resident #3's medical record and confirmed that his/her decline would warrant a Significant Change in Status MDS assessment. Staff #4 added that her corporate MDS person would also be notified of the final decision regarding completion of a Significant Change in Status MDS. However, the interview did not show that the corporate MDS person was notified of Resident #3's decline.

Based on interviews and record reviews, it was determined that the facility failed to ensure that a resident's representative participated in the care plan process. This was evident for one (Resident #34) of 3 residents reviewed for care planning. The findings include:The Minimum Data Set (MDS) is an assessment of the Resident that provides the facility information necessary to develop a care plan, provide the appropriate care and services to the Resident, and modify the care plan based on the Resident's status.Care plans are developed to guide residents' care in the facility. They must be created within 7 days of completing a resident's comprehensive MDS admission assessment and revised at least quarterly (or more often as needed). The facility is required to have care plans developed and revised by an interdisciplinary team, including the attending physician, a registered nurse, a nursing aide, a representative from dietary services, the Resident, and the Resident's representative (as practicable).Participation in care planning by a resident and a resident representative can take many forms, such as holding care planning conferences (meetings) when the resident representative (RP) is available to participate, conference calls, or videoconferencing.In an interview on 6/24/26 at 10:48 AM, Resident #34 was asked about his/her care plan meeting and stated that he/she did not recall any such meeting. A medical record review showed that Resident #34 was admitted to the facility in June 2026. The review noted that Resident #34 had been assessed by two attending providers, who determined that the Resident lacked adequate decision-making capacity due to a diagnosis of Dementia (Dementia is not a specific disease but a general term for impaired ability to remember, think, or make decisions that interfere with everyday activities).A continued review included an admission MDS assessment for Resident #34, which documented that Resident #34 had severely impaired cognition. The review also included a baseline care plan record dated 6/1/26 for Resident #34, which listed the Resident's son as the Resident's RP. Further review included care plan meeting notes dated 6/9/26 for Resident #34, indicating that the Rehab manager, Unit manager, dietitian, social services, activities director, and the Resident were present. However, a message was left for Resident #34's RP during the meeting. The review lacked supporting evidence that the facility had attempted to involve Resident #34's RP in the Resident's care plan meeting prior to the meeting.The care planning meeting notes also indicated that, during the meeting, Advance Directive offered to complete, resident declined. However, an earlier review of records showed that Resident #34 had been evaluated by two attending providers and deemed incapable of making health care decisions due to a diagnosis of Dementia. Therefore, the Resident's RP needed to be present at the meeting for any decision-making to occur.During an interview on 6/29/26 at 1:09 PM, staff #18, a social services designee, reported that if a resident lacked decision-making capacity, the facility would continue calling the Resident's RP until the RP was available to attend the care plan meeting. However, staff #18 reported that the call to Resident #34's RP regarding the 6/9/26 care plan meeting was made during the meeting, and a voicemail was left.In a follow-up interview on 6/29/26 at 3:22 PM, staff #19, the Social Services director, explained her expectations and indicated that, if a resident lacked decision-making capacity, the Resident's RP should be invited in advance of care plan meetings.

Based on observation, record review and interview it was determined that the facility failed to ensure that staff only documented completing tasks that were actually completed. This was found to be evident for one (Resident #117) out of four residents reviewed for pressure ulcer care. The findings include:On 6/24/26 at 2:13 PM surveyor observed Resident #117 seated in their room. The bed had an air mattress which was observed to be set at 180 lbs., and static was set to the on position.Static mode on an air mattress means the mattress maintains a constant even pressure without inflating or deflating. When static is not on the air mattress will cycle the inflation and deflation of air cells providing pressure relief.After the observation at 2:13 PM, review of the medical record revealed there was an order, in effect since 6/5/26, for: LAL (low air loss) alternating pressure mattress: Check function Q [every] shift, set to resident's weight; Static button off unless providing care.The resident's weight on 6/23/26 was documented as 81.8 lbs. On 6/24/26 at 3:08 PM review of the Treatment Administration Record (TAR) for June 2026 failed to reveal documentation to indicate the nurse had completed the check of the air mattress for the day shift, as evidenced by a blank space in the section to document.On 6/24/26 at 3:59 PM further review of the June TAR revealed Nurse #23 had signed off that this order was completed during the day shift on 6/24/26.On 6/24/26 at 4:16 PM surveyor asked Nurse #23 if she had checked the resident's air mattress today and Nurse #23 responded: No, I didn't. Surveyor and Nurse #23 then reviewed the electronic health record and noted the resident's weight was 81.8 lbs. Surveyor then reviewed the TAR with Nurse #23 who confirmed her initials on the documentation that indicated the mattress was checked and that the static button was off. Surveyor and Nurse #23 then entered Resident #117's room. Resident was in bed at this time. Nurse #23 confirmed that the air mattress was set at 180 lbs. and the Static was set to on.On 6/25/26 at 3:20 PM surveyor reviewed the concern with the Unit Nurse Manager (UM#6) regarding the air mattress setting and that the nurse had signed off that it was checked.On 6/30/26 at 2:45 PM surveyor reviewed with the Director of Nursing the concern that staff had documented that they had checked the air mattress setting when they had not.

Based on interview, observations, and record review, it was determined that the facility failed to ensure that residents who required assistance with Activities of Daily Living (ADLs) received supervision with oral intake and showers. This was evident for 2 (Resident #88, #28) of 5 residents reviewed for ADL care.The findings include: 1) Activities of Daily Living (ADLs) are the essential everyday self-care tasks required to live safely and independently, such as bathing, dressing, and feeding. Resident #88 has complex medical diagnoses which include, in part, squamous cell carcinoma and malignant neoplasm of the tongue and pharynx (cancer of the throat and tongue), dysphagia (difficulty swallowing), and Parkinson's disease, a neurological disorder that affects the brain's control over movement and can make feeding oneself difficult. Motor symptoms, including resting hand tremors, muscle rigidity (stiffness), and bradykinesia (slowness of movement), can make it difficult to lift utensils, chew, and swallow safely. Additionally, the resident has malnutrition and adult failure to thrive. Malnutrition combined with adult failure to thrive is a serious condition in which an adult's body and mind progressively weaken due to inadequate nutrition, resulting in severe weight loss and extreme exhaustion. On 6/24/26 at 12:18 PM, during the initial screening process of the survey, the surveyor interviewed Resident #88, who reported that they had recently finished their 60th radiation treatment for throat cancer, have difficulty swallowing, and have lost their sense of taste. They requested that the surveyor inquire about getting them assistance with eating. They added that they have Parkinson's disease, which causes their hands to shake, and demonstrated how their hand trembles when attempting to raise it to their mouth. The surveyor observed trembling of the resident's hands during the demonstration. The surveyor asked whether anyone assisted them with eating, and they replied, No. On 6/24/26 at 1:49 PM, the surveyor returned to Resident #88's room and observed the resident in bed with their bedside table positioned over the bed. No staff were present. A Magic Cup (a frozen nutritional supplement) and a dish of fruit resembling applesauce were left at the bedside without a spoon. Finger swipes observed in the fruit indicated the resident had attempted to eat it with their fingers. When the surveyor asked if they would like a spoon, the resident replied, That would be nice. The surveyor asked Geriatric Nursing Assistant (GNA #3) to provide the resident with a spoon and asked whether the resident required assistance with eating. GNA #3 replied that they thought the resident used to but were not sure because they were new to that area of the building. The surveyor observed GNA #3 provide the resident with a spoon and leave the room without assisting or supervising the resident while eating. On 6/29/26 at 11:49 AM, the surveyor conducted a medical record review for Resident #88, which revealed the following: Care Plan:The resident requires assistance with ADL care, including assistance with eating, specifically stating, [Resident #88] to be supervised 1:1 during meals: promote out of bed eating, and provide resident with x1 assistance for eating. Medical Orders:1/3/26 - Patient to be supervised 1:1 during all meals: promote eating out of bed every shift.5/28/26 - Nutritional supplement two times daily (frozen nutritional treat at lunch and dinner) to aid nutritional status. On 6/29/26 at 12:06 PM, the surveyor reviewed the nursing assistant assignment tasks for Resident #88, which stated, Patient to be supervised 1:1 during all meals; promote out of bed eating. Review of documentation from 6/24/26 revealed that a GNA documented that the resident had been supervised while eating despite the surveyor's observation that the resident was eating without supervision and without a spoon. On 6/29/26 at 12:17 PM, the surveyor observed the resident in bed and asked whether they typically remained in bed to eat. The resident stated that staff leave them in the chair and do not return for hours; therefore, they requested to remain in bed. When asked whether staff help them eat, the resident stated, No, they just set up the tray and leave. The resident's roommate stated that they regularly witness that staff do not stay to help the resident. On 6/29/26 at 12:52 PM, the surveyor observed staff deliver a meal tray to Resident #88's room and leave shortly afterward. The surveyor entered the room and observed the meal tray set up for the resident; however, no staff member was present to provide the required 1:1 supervision. When asked whether staff had said they would return to assist, the resident stated, No, and the roommate added that the nurse had only provided tray setup. On 6/29/26 at 12:54 PM, the surveyor approached the staff member who had delivered the tray. The staff member identified themselves as the Unit Nurse Manager (Nurse #2). When asked about the resident, Nurse #2 explained that the resident was just finishing radiation therapy for neck and throat cancer. When asked about the level of assistance the resident required during meals and oral intake, Nurse #2 replied, They like to try to do it themselves at first and then we will cue, if needed. When asked whether they were aware of the physician's order requiring 1:1 supervision while the resident ate, Nurse #2 replied, No, I thought s/he was still cue (prompt) only. The surveyor informed Nurse #2 that the resident's orders required 1:1 supervision during meals for safety, and Nurse #2 stated that they would immediately get someone to supervise the resident. On 6/29/26 at 2:22 PM, the surveyor interviewed the Director of Nursing (DON), who confirmed that the resident was required to receive supervision while eating all meals. On 6/29/26 at 2:30 PM, the surveyor conducted a further review of the resident's medical record, which revealed a Speech Therapist evaluation dated 1/3/26 stating that the resident was at high risk for aspiration and must be closely monitored during all PO (oral) intake. The evaluation stated: Aspiration [accidentally breathing food, liquid, saliva, or stomach contents into the airway and lungs instead of swallowing them into the stomach] precautions and close 1:1 supervision by staff during all meals. Additionally, the evaluation instructed: Sit upright at 90 degree during and 30-45 minutes following intake, small bites/sips, slow rate, supervise patient during all PO [oral] intake. On 6/29/26 at 2:41 PM, the surveyor observed Resident #88 in their room eating oranges and chips without supervision. The DON was immediately notified by the surveyor. The DON stated that the family may have brought food into the facility and that they would contact the family to request that staff be notified whenever food is left for the resident so staff could provide the required supervision. On 6/29/26 at 2:43 PM, the surveyor interviewed the Unit Manager (Nurse #2) and asked how the GNAs know which residents require 1:1 supervision while eating. Nurse #2 stated that GNAs receive a daily assignment list identifying residents who require supervision. Nurse #2 showed the surveyor a document titled LTC-6 assignment sheet, which identifies each GNA's assignment and the residents requiring supervision. The surveyor confirmed with Nurse #2 that Resident #88 was included on the daily 1:1 supervision list and she was unable to provide rationale for why the resident was not receiving supervision while eating despite being included on the 1:1 supervision list. On 6/30/26 at 10:40 AM, the surveyor discussed concerns with the Nursing Home Administrator (NHA) regarding Resident #88 not receiving 1:1 supervision during all oral intake. The NHA confirmed that the DON had previously informed them of the surveyor's concerns and stated that the facility was addressing the issue. 2) The Minimum Data Set (MDS) is a federally mandated assessment tool used by nursing home staff to collect information on each Resident's strengths and needs. The information collected informs Resident care planning decisions. A care plan is a guide that addresses each Resident's unique needs. It is used to plan, assess, and evaluate the effectiveness of the Resident's care. Staff use care plans to provide resident-centered care, including support, services, and resources to address Residents' needs. During an initial tour of the facility, Resident #28 was observed sitting in a motorized wheelchair by the bedside, with white, flaky particles in his/her facial hair and on his/her clothing. An interview with Resident #28 at that time indicated that the Resident did not receive regular showers. A record review for Resident #28 on 6/25/26 at 1:57 PM included an MDS assessment dated [DATE], which indicated that Resident #28 had bilateral below-the-knee amputations, did not walk, and relied on staff for most of his/her self-care needs. A review of the shower schedule for the nursing unit where Resident #28 resided showed that the Resident was scheduled for bed baths on Wednesdays and Saturdays during the 11 PM-7 AM shift. A review of Resident #28's care plan for ADLs, initiated on 7/15/25 and revised on 5/9/26, indicated that the Resident's shower schedule, per preference, was Saturday at 4 AM. A follow-up review of the GNA (geriatric nursing assistant) shower documentation for Resident #28 from January 2026 to June 26, 2026, was completed. The review showed that, per preference, Resident #28's shower schedule was on Saturday, averaging 4 showers per month. The GNA documentation recorded 14 N (No – No showers), 7 Y (Yes – the Resident received showers), 4 blanks (no answer recorded), and 2 RR (Refusal – Resident refused showers). The review did not show that Resident #28 was consistently offered 1 shower every Saturday morning. In an interview on 6/25/26 at approximately 1:57 PM, staff #2, the unit manager (UM) for the unit where Resident #28 resided, was asked how staff determined which day to give Residents showers. UM reported that staff checked both the unit's paper shower schedule and the electronic health record (EHR). However, an earlier review of the EHR showed that Resident #28 was scheduled to receive showers on Saturday. In contrast, the paper shower schedule indicated that Resident #28 was to receive only bed baths (washing the Resident in bed). In a follow-up interview on 6/25/26 at 2:19 PM, the UM indicated that she would correct the discrepancy between the EHR and the paper shower schedule for Resident #28 to ensure that Resident #28 receives showers on Saturdays. During an interview on 6/30/26 at 10:54 AM, Resident #28 reported to the surveyor that the facility told him/her that he/she would start receiving showers beginning the Saturday after the surveyor's intervention.

Based on medical record review, observation and interview it was determined that the facility failed to ensure air mattresses were kept at the appropriate settings. This was found to be evident for two (Resident #117 and #1) out of four residents reviewed for pressure ulcer care. The findings include:1)Review of Resident #117's Minimum Data Set (MDS) assessment, with a reference date of 5/29/26, revealed the resident's weight was 89 lbs., the resident was at risk of pressure ulcers and that there was a pressure reducing device for the resident's bed. Review of the care plan revealed a plan to address the resident's risk for skin breakdown. On 6/5/26 the following intervention was added to this care plan: LAL [Low Air Loss] alternating pressure mattress: Check function Q shift, set to resident's weight. Static button off unless providing care.Static mode on an air mattress means the mattress maintains a constant even pressure without inflating or deflating. When static is not on the air mattress will cycle the inflation and deflation of air cells providing pressure relief.On 6/24/26 at 2:13 PM surveyor observed Resident #117 seated in their room. The bed had an air mattress which was observed to be set at 180 lbs., and static was set to the on position.After the observation at 2:13 PM, review of the medical record revealed there was an order, in effect since 6/5/26 for: LAL (low air loss) alternating pressure mattress: Check function Q [every] shift, set to resident's weight; Static button off unless providing care. The resident's weight on 6/23/26 was documented as 81.8 lbs. Review of the Treatment Administration Record (TAR) for June 2026 revealed Nurse #23 had signed off that this order was completed during the day shift on 6/24/26.On 6/24/26 at 4:16 PM surveyor asked Nurse #23 if she had checked the resident's air mattress today and Nurse #23 responded: No, I didn't. When asked if she knew what the mattress was supposed to be set at the nurse responded that she did not know the resident's weight right now. Surveyor and Nurse #23 then reviewed the electronic health record and noted the resident's weight was 81.8 lbs. Surveyor then reviewed the TAR with Nurse #23 who confirmed her initials on the documentation that indicated the mattress was checked and that the static button was off. Surveyor and Nurse #23 then entered Resident #117's room. Resident was in bed at this time. Nurse #23 confirmed that the air mattress was set at 180 lbs. and the Static was set to on.On 6/25/26 at 3:20 PM surveyor reviewed the concern with the Unit Nurse Manager (UM#6) regarding the failure to ensure the air mattress was set at the correct setting.2) Review of Resident #1's medical record revealed the resident had acquired a deep tissue injury (DTI) to the heel on 5/4/26. The resident was followed by a wound specialist and treatment was instituted. Review of the 5/20/26 wound assessment report completed by the wound specialist revealed the DTI had resolved. Review of the 6/24/26 wound specialist note revealed the presence of a stage one pressure ulcer on the resident's heel; that the wound was acquired on 5/4/26 and had reopened. Review of the resident's care plan addressing impaired skin integrity revealed the following intervention, which was initiated 4/18/26: LAL alternating pressure mattress: Check function Q shift, set to resident's weight. Static button off unless providing care.On 6/24/26 at 2:59 PM surveyor observed Resident #1 lying in bed. The resident had an air mattress that was set at 320 lbs.On 6/25/26, the medical record revealed the resident's weight on 4/11/26 was 328.8 lbs. The resident's weight on 5/11/26 was 288.4 lbs. The resident had an order for monthly weights, but no weight was found in the vital sign section after 5/11/26.On 6/25/26 at 2:54 PM the resident's air mattress was observed to be set at just above 280. On 6/25/26 3:11 PM the Unit Nurse Manager (UM #6) reported, in regard to the air mattress setting, that staff is supposed to check the weight of the resident. Surveyor reviewed with the nurse manager that the air mattress was set at 320 yesterday and today it is at 280. Surveyor asked when the resident was most recently weighed. The unit manager checked the electronic health record and then stated: Looks like 5/11, no that can't be right, because I just got weights. I could swear I had somebody give me [his/her] weight recently. I need somebody to go get [his/her] weight. On 6/30/26 at 2:45 PM surveyor reviewed with the Director of Nursing the concern regarding the failure to ensure air mattresses were set at the correct setting.Cross Reference to F 692

Based on medical record review and interview it was determined that the facility failed to ensure weights were obtained as ordered and failed to ensure accurate assessment of a resident's body mass index. This was found to be evident for two (Resident #117 and #1) out of four resident reviewed for pressure ulcer care. The findings include: 1a)Review of Resident #117's medical record revealed a Nutrition Evaluation signed by the Registered Dietitian (RD #24) on 5/26/26. The resident's diagnosis included, but was not limited to, adult failure to thrive and dysphagia (difficulty swallowing). This evaluation revealed the resident's weight was 89 lbs. and height was 51 (no designated unit of measurement) and the BMI (body mass index) was documented as 23 or greater.A height of 51 inches means that the resident was 4 foot 3 inches tall.BMI is a measurement of body fat based on height and weight. According to https://www.nhlbi.nih.gov/calculate-your-bmi a healthy BMI is between 18.5 and 24.9.Review of Resident #117's Minimum Data Set (MDS) assessment, with a reference date of 5/29/26, revealed the resident's weight was 89 lbs., and that the resident's height was 51 inches. The MDS is a federally mandated assessment tool that helps nursing home staff members gather information on each resident's strengths and needs. Information collected drives resident care planning decisions. MDS assessments need to be accurate to ensure each resident receives the care they need.On 6/24/26 at 2:13 PM surveyor observed Resident #117 seated their room. Resident appeared to be of average height. An interview was conducted with the Registered Dietitian (RD #24) on 6/29/26 at 9:52 AM. When asked about the height assessment, RD #24 reported that nursing staff normally do that and if it is not obtained she will request it or look at the discharge summary and sometimes asks the resident themselves. When asked how tall Resident #117 was, RD #24 reported very short and indicated she did not want to provide an incorrect answer. Surveyor reviewed the concern that the assessment indicated the height was 51 inches but the resident did not appear to be that short. The RD indicated she would clarify the height measurement.On 6/29/26 at 10:48 AM RD#24 reported they just obtained the resident's height and got 65 inches, which puts the resident's BMI at 13.6. RD #24 went on to report the resident is very slender and that she didn't know where the 51 came from.b)Further review of the 5/26/26 Nutrition Evaluation revealed the nutritional interventions included, but were not limited to: Monitor weights as ordered.Review of the Medication Administration Record (MAR) revealed an order, in effect from 5/23/26 until it was discontinued on 6/24/26, to weigh the resident every Monday for 4 weeks. There was also an order in effect from 5/23/26 until it was discontinued on 6/24/26 to weigh every month, starting on the 1st for 3 days.The MAR had areas for nursing staff to document weights on 5/25; 6/1, 6/2, 6/3, 6/8, and 6/15. No weight values were found on the MAR for these dates. Review of the Vital signs section of the electronic health record revealed the following weight values:On 5/23/26: 89 lbs.On 6/19/26: 81.2 lbs.On 6/23/26: 81.8 lbs.No other weight values were found for this resident.Further review of the medical record revealed on 6/19/26 the RD #24 wrote a note addressing the resident's 7.8 lbs weight loss, which represents a significant loss of 8.7% in a month. This note revealed a recommendation to change the resident's supplement orders.On 6/26/26 at 3:46 PM surveyor reviewed the concern with the Unit Nurse Manager (UM #6) regarding the order for weekly weights but no weights were found for 5/25, 6/1, 6/8 or 6/15. UM #6 stated: I honestly can't tell you what happened, I'll have to follow up on that, [the resident] may have refused. Review of the May TAR revealed that on 5/25 nursing staff documented a 9 which means to see nurse's note, however review of the corresponding nursing note revealed the following notation: Weigh every day shift every Mon for 4 Weeks. No documentation was found as to why the weight was not obtained when due on 5/25/26.Review of the June TAR revealed blanks in the area to record the weights when due on June 1, 2, 8, 15. Staff documented 9 on 6/3/26, review of the corresponding nurse's note revealed that the resident declined. Staff documented a 9 on 6/16/26 (which was the day after the weight was due), review of the corresponding nursing note revealed Unable to due to resident resting quietly with eyes closed. No documentation was found to indicate why the weights were not obtained when due on the other dates.During the 6/29/26 at 9:52 AM interview with RD #24, she reported normally weights are initially ordered weekly for 4 weeks and then monthly, unless there is a change or if they want to monitor more frequently. After addressing the concern regarding the failure to obtain the ordered weekly weights the RD reported: at one point the resident did not want their weight obtained and then the RD indicated she would check the medical records. At 10:48 AM RD #24 presented with the progress notes that corresponded to the 5/25, 6/3 and 6/16 notations on the MAR. No additional documentation was provided to indicate the resident was refusing to be weighed on any date except 6/3/26.Further review of the medical record revealed a new order for weekly weights for 4 weeks was put in place on 6/24/26.On 6/30/26 at 2:45 PM surveyor reviewed with the Director of Nursing the concern regarding the failure to weigh the residents as ordered and failure to assess the resident's height correctly.2) On 6/25/26 a review of the vital sign section of the electronic health record revealed the following weights for Resident #1:On 4/11/26 weight was 328.8 lbs. On 4/13/26 weight was 327.9 lbs.On 4/29/26 weight was 324.2 lbs.On 5/2/26 weight was 292.6 lbs.On 5/3/26 weight was 292.6 lbs.On 5/11/26 weight was 288.4 lbs. Review of the progress note, written by RD #24 on 5/11/26 revealed: [Resident's name] is noted with a weight change based on weekly weight (5/11: 288.4). The note addressed possible medications that could be affecting this weight change and included: Will continue to monitor weights as ordered (weekly).On 6/25/26 no weight was found in the vital sign section after 5/11/26.Review of Resident #1's medical record revealed an order, dated 5/8/26 to weigh the resident every Monday for 2 weeks. Review of the May 2026 Medication Administration Record (MAR) revealed this order was included and there were areas for nursing staff to document a weight when due. Review of the MAR revealed a weight of 288.4 on 5/11/26 and also on 5/18/26. The 5/18/26 weight was documented by Nurse #25.Review of the progress notes revealed a note written by RD #24 on 5/19/26 revealed: Weekly weight was obtained (5/11: 288.4) which reflects a weight change in the past month.is currently being monitored weekly with [his/her] weights until 5/25.Review of the vital signs section of the electronic health record revealed documentation of the 288.4 lbs. on 5/11/26 but no weight was recorded in this section for 5/18/26.The RD's progress note from 5/19 failed to address the fact that a weight was due to be obtained on 5/18 but was not in the medical record.Further review of the medical record revealed an order, dated 5/8/26, to weigh every day shift every 1 month starting on the 1st for 3 days. Review of the June 2026 MAR revealed there were places to record weights for June 1, 2, and 3. Further review of the MAR revealed Nurse #25 recorded a weight of 288.4 on June 1st and 3rd. The area to document for a weight on June 2nd was noted to be blank.On 6/25/26 at 3:11 PM the Unit Nurse Manager (UM #6) reported they have between the 1st and the 5th to get the monthly weights done. She stated that the GNAs (geriatric nursing assistants) obtain the weights and report them to the nurses and that the nurses help if they need or have to. UM #6 reported that these weights go in the vital sign section. While discussing the documentation process, UM #6 reported that there is an option when documenting on the MAR to use the last recorded value.Review of the vital signs section of the electronic health record failed to reveal documentation of a weight between 5/12/26 and 6/25/26. No documentation was found to indicate the resident was refusing to be weighed.On 6/25/26 at 3:42 PM surveyor reviewed the concern with UM #6 that the RD notes indicated there would be weekly weight monitoring but there has been no weight obtained since 5/11/26; and that the 5/18 RD note failed to address the fact that no weight was obtained when due on 5/18.On 6/25/26 at 3:51 PM interview with GNA #26 revealed that after obtaining a weight they verbally tell the nurse the weight. GNA #27 reported that they either verbally tell the nurse or write the weight down on a piece of paper, she confirmed that the GNAs cannot enter the weight into the electronic health record. On 6/30/26 at 2:45 PM surveyor reviewed with the Director of Nursing the concern regarding the failure to ensure weights were obtained as ordered.

Based on interviews, observation, and record review, it was determined that the facility failed to ensure that a resident had physician orders and a care plan for the use and care of a Continuous Positive Airway Pressure (CPAP) device. This was evident for 1 (Resident #11) of 2 reviewed for respiratory care.The findings include:A CPAP (Continuous Positive Airway Pressure) machine is a medical device used to treat sleep-related breathing disorders, most commonly obstructive sleep apnea. It delivers a continuous stream of pressurized air through a tube and mask to help keep the airway open during sleep.A resident care plan is a personalized document used in nursing homes to outline a resident's specific medical, emotional, and daily living needs. It acts as a roadmap for staff to provide consistent, safe, and person-centered care.Doctor's orders are legally binding, written directives issued by a physician that specify a resident's care plan, medications, diet, and treatments. They are the required legal authorization that nursing and facility staff need to legally provide and bill for care.Resident #11 has medical diagnoses of obstructive sleep apnea, a chronic breathing disorder that occurs when the muscles in the back of the throat relax during sleep, causing the airway to become partially or completely blocked, and insomnia (persistent difficulty falling asleep, staying asleep, or achieving restorative sleep).On 6/24/26 at 12:04 PM, during an initial screening of facility residents, Resident #11 reported that they use a CPAP at times but stated that only some staff know how to use it correctly, so they do not always get to use it. The resident stated they have trouble sleeping and would like to use the CPAP. The surveyor observed a CPAP machine on the resident's bedside table.On 6/26/26 at 1:25 PM, the surveyor performed a medical record review for Resident #11 and found no physician orders or care plan addressing the resident's CPAP, including directions for use, settings, cleaning and maintenance, or related nursing interventions. The surveyor confirmed the residents' diagnoses of obstructive sleep apnea and insomnia.On 6/26/26 at 1:32 PM, the surveyor interviewed the Director of Nursing (DON) and asked what the protocol is for residents who use a CPAP. The DON stated that the facility would obtain physician orders specifying the CPAP settings and when the device is to be used, as well as orders for sterile water and cleaning and maintenance of the equipment. She stated that nurses and nursing assistants are trained in the use and care of CPAP equipment.The surveyor then asked whether she was aware that Resident #11 was using a CPAP. The DON stated that the resident began using the CPAP following a sleep study.The surveyor asked the DON to review Resident #11's medical record. After reviewing the record, the DON confirmed that the resident had no physician orders, care plan interventions, or nursing assistant and nursing staff tasks related to the use and care of the CPAP. The DON stated that she would immediately contact the physician to obtain orders and update the resident's care plan and staff tasks to address the CPAP.On 6/26/26 at 2:46 PM, the surveyor confirmed that the DON had obtained physician orders and updated the resident's care plan to include interventions related to the resident's CPAP.On 6/30/26 at 10:40 AM, the surveyor interviewed the Nursing Home Administrator (NHA), who confirmed awareness of the surveyor's concerns regarding Resident #11's CPAP. The NHA confirmed that, following surveyor identification of the deficiency, the DON obtained physician orders and updated the resident's care plan.

Based on record reviews and interviews, it was determined that the facility failed to ensure pain management was provided to residents according to professional standards of practice that included administration of pain medication according to the physician order, administer/attempt non-pharmacological interventions (NPI) prior to any as needed pain medications, routine pain medication was re-ordered in a timely manner, and to access pain medication from interim supply when needed. This was evident for 3 (Resident #6, #13, #97) of 3 residents reviewed for pain management. The findings include: 1) Resident #6 was a newly admitted resident of the facility. A review of the resident's medical record was conducted on 6/25/26 at 11:40 AM. The review revealed medical orders for pain management that included Acetaminophen (with instructions to give every 8 hours as needed for pain level 1-6), Hydromorphone (a narcotic pain medication with instructions to give every 8 hours as needed for pain level 7-10), and non-pharmacological interventions (NPI- with instructions to administer/attempt prior to administering any as needed pain medication.) A review of Resident #6's administration record for June 2026 was conducted on 6/25/26 at 12:47 PM. The review revealed the following concerns: On 6/1/26, Hydromorphone was administered for a 0/10 pain, and no documentation was found to indicate NPI was provided/attempted prior to the medication. On 6/7/26, Acetaminophen was administered with no documentation found to indicate NPI was provided/attempted prior to the medication. On 6/12/26, Acetaminophen was administered for a 0/10 pain. The findings were reviewed with the Director of Nursing (DON) on 6/26/26 at 11:05 AM. The DON reported that pain medications must be administered based on the physician orders and that NPI's must be attempted and documented prior to giving as needed pain medications. She also reported that she would review Resident #6's medical record and report back to the surveyor. On 6/26/26 at 3:46 PM, the DON confirmed the findings, verbalized understanding, and acknowledged the concerns. 2) Resident #13 was a newly admitted resident of the facility. During an interview with the resident on 6/24/26 at 10:59 AM, s/he reported having constant pain and stated, all they do is Oxycodone (narcotic pain medication) and Tylenol (Acetaminophen). A review of Resident #13's medical record was conducted on 6/25/26 at 2:35 PM. The review revealed orders for pain management that included Acetaminophen (with instructions to give every 8 hours as needed for pain level 1-4), Oxycodone (with instructions to give every 6 hours as needed for pain level 5-10), and Non-Pharmacological interventions (NPI- with instructions to administer/attempt prior to administering any as needed pain medication). Resident #13's administration record for June 2026 was reviewed on 6/25/26 at 2:38 PM. The review revealed the following concerns: There was only a total of 39 documented NPI's out of the 53 documented administration of the as needed pain medications (Acetaminophen and Oxycodone). On 6/6/26, Oxycodone was administered for a 0/10 pain. On 6/13/26, Oxycodone was administered for a 1/10 pain. On 6/21, Oxycodone was administered for a 0/10 pain. The findings were reviewed with the Director of Nursing (DON) on 6/26/26 at 11:08 AM. The DON reported that pain medications must be administered based on the physician orders and that NPI's must be attempted and documented prior to giving as needed pain medications. She also reported that she would review Resident #13's medical record to see if the nurses had documented the initial pain score and NPI's elsewhere and report back to the surveyor. On 6/26/26 at 3:46 PM, the DON confirmed the findings, verbalized understanding, and acknowledged the concerns. 3) Review of Resident #97's medical record revealed a care plan addressing alterations in comfort related to osteoarthritis and chronic pain syndrome. One of the interventions in the care plan is to administer the pain medications as ordered. Review of the 6/3/26 Minimum Data Set (MDS) assessment revealed that the resident's pain occasionally affects sleep and frequently effects day to day activities and that the resident receives regularly scheduled pain medication, including opioids (which are narcotics). Further review of the medical record revealed an order, in effect since 4/16/26, for hydromorphone 4 mg every 6 hours for pain. Hydromorphone is an opioid medication also known as Dilaudid. Review of the Medication Administration Record (MAR) revealed this medication was scheduled to be given at 5:00 AM, 11:00 AM, 5:00 PM, and 11:00 PM. Review of the MAR for June 2026 revealed that the doses that were due to be administered on 6/19/26 at 11:00 AM and 5:00 PM were not administered. Nurse #17 had documented a 9 indicating there was a corresponding nursing note. Review of the progress notes revealed a note written by Nurse #17 at 1:09 PM which just repeated the order but did not provide documentation to indicate why the hydromorphone was not administered when due at 11:00 AM. The note written by Nurse #17 at 6:57 PM also repeated the order but included: contacted pharmacy should be here on evening medication delivery. Review of the drug control sheet for the hydromorphone 4 mg revealed that on 6/19/26 at 5:50 AM one tablet was removed and the quantity remaining was 0. On 6/20/26 at 12:40 AM staff documented receiving 30 tablets of the hydromorphone. On 6/29/26 at 4:25 PM the Unit Nurse Manager (UM#6) reported that the facility did have an automated medication delivery system that staff can access when medications have not yet been delivered from the pharmacy. This is known as an interim supply of medication. Review of the inventory list (titled Cubex Inventory) for the interim supply revealed 10 tablets of Dilaudid 2 mg are kept in the supply. Further review of the medical record failed to reveal documentation to indicate the interim supply of hydromorphone was accessed by the nursing staff on 6/19/26. On 6/29/26 at 4:30 PM Nurse #21reported that if they are out of a scheduled narcotic they will call the physician or nurse practitioner to obtain a new prescription, get a new C-2 form (paperwork required for narcotics), the provider will then e-sign or staff will fax it for a signature. Once the new prescription is obtained then nursing staff call the pharmacy and they can give us an access code to pull from the back up supply. If available, the medication is pulled from the backup supply. When asked if there is a process for re-ordering regularly scheduled medication before they run out, Nurse #21 responded: scheduled full time nurses will re-order when it's getting low, some nurses just brush it under the rug, if I see that only one is left I ask if it's been re-ordered. On 6/29/26 at approximately 4:35 PM the Director of Nursing (DON) confirmed that the Cubex Inventory was an available medication list. Surveyor then reviewed the concern that the hydromorphone is included on the list but was not accessed when the resident's supply ran out. On 6/30/26 at 2:45 PM surveyor reviewed with the DON the concerns regarding the failure to ensure the pain medication was re-ordered in a timely manner and the failure to access the interim supply. As of time of survey exit on 6/30/26 at 4:15 PM no additional documentation was provided regarding these concerns.

Based on medical record review and interview it was determined that the facility failed to ensure residents were from from unnecessary medications. This was found to be evident for one (Resident #4) out of eight residents who were reviewed for medication usage. The findings include:On 6/26/26 review of Resident #4's medical record revealed an order for metoprolol succinate 25 mg to be administered in the evening for atrial fibrillation (Afib) and to hold if the pulse was 60 or less.Afib is an irregular heartbeat. People with Afib are at a higher risk of serious complications such as heart attack or stroke.Review of the June 2026 Medication Administration Record (MAR) revealed that on June 2, 3, and 17, 2026 the resident's pulse was documented as less than 60 and the metoprolol was administered to the resident.On 6/26/26 at 10:28 AM the Unit Nurse Manager (UM #2) confirmed that she would expect the staff to hold the metoprolol if the pulse was less than 60. After review of the MAR for the metoprolol for June 2, 3 and 17, UM #2 stated that is an issue.On 6/26/26 at 11:09 AM further review of the medical record revealed the resident had an order, in effect from 5/20/26 to 6/24/26 for Midodrine 10 mg every 8 hours for hypotension (low blood pressure) and to hold if the SBP was equal to or greater than 140. SBP stands for systolic blood pressure and is represented by the top number of a blood pressure reading.Further review of the medical record revealed a note written by the primary care nurse practitioner (NP #6) on 6/24/26, which revealed a plan to Continue Midodrine - add hold if SBP >=95.A new order was written on 6/24/26 at 2:49 PM, for Midodrine 10 mg to be given every 8 hours for hypotension. This order also included: HOLD (DO NOT GIVE) if SBP 95 or greater.Review of the June MAR revealed that on 6/24 at 10 PM; 6/25 at 2 PM and 10 PM ; and on 6/26 at 6 AM the recorded SBP was above 95 and the Midodrine was administered.On 6/26/26 at 12:51 PM surveyor reviewed the concern with the Director of Nursing (DON) that since the parameters to hold the Midodrine were recently changed, there have been multiple occasions when the medication was administered when the SBP indicated it should have been held. The DON indicated she was aware of issue with the metoprolol and indicated she would make the physician aware of the issue with the Midodrine.

Based on interview, observations, and record review it was determined that the facility failed to ensure that controlled medications were stored in a permanently affixed compartment, medication carts were locked when unattended, and medications were kept in a secure location . This was evident for 2 of 3 medication refrigerators, 1 of 4 medication carts observed while completing the medication storage task, and a random surveyor observation.The findings include: 1) Under federal long-term care regulations, nursing facilities are required to secure high-risk controlled substances, including refrigerated controlled medications, inside separately locked, permanently affixed compartments. A facility cannot simply place narcotics inside a locked refrigerator or an unattached lockbox. The security container must be permanently affixed to the refrigerator to prevent the entire container from being removed. A controlled medication is a drug regulated by the government because it has a risk of misuse, dependence, or addiction. Review of facility Medication Storage Policy and Procedure implemented on 12/14/22 states, Narcotics and Controlled Substances are to be stored within a separately locked permanently affixed compartment. On 6/29/26 at 3:40 PM, the surveyor requested that Nurse #15 escort the surveyor to the medication storage room near the 400's hallway. The surveyor asked where refrigerated controlled medications were kept. Nurse #15 stated they were stored in a black box inside the medication refrigerator. She opened the refrigerator and removed a black lock box that was not permanently affixed to the refrigerator. When asked whether the box was supposed to be secured, she replied that she thought it used to be nailed down. On 6/29/26 at 3:51 PM, the surveyor asked Nurse #16 to escort the surveyor to the medication storage room near the 500's hallway. The medication refrigerator contained another black carry-away lock box. The surveyor asked what was stored inside the box. Nurse #16 opened it and showed the surveyor two boxes of Lorazepam (a controlled medication). She confirmed that the lock box was not permanently affixed to the refrigerator. On 6/29/26 at 3:56 PM, with Nurse #6 present, the surveyor observed the medication storage room serving the 100, 200, and 300 halls. The medication refrigerator contained a narcotics lock box that was permanently affixed. On 6/29/26 at 4:19 PM, the surveyor interviewed the Director of Nursing (DON) regarding the facility's expectations for storing refrigerated controlled medications. The DON stated that controlled medications are to be double locked and secured to the refrigerator. The surveyor informed the DON that two of the three medication storage rooms observed contained removable carry-away lock boxes rather than permanently affixed lock boxes. The DON stated that she did not think that was correct because a previous surveyor had identified the same concern and the facility had installed permanently affixed clear locking containers in response. The surveyor requested that the DON accompany the surveyor to observe the medication refrigerators. On 6/29/26 at 4:33 PM, the surveyor, DON, and Assistant Director of Nursing (ADON) toured the medication rooms. The ADON stated that the nurses had notified her of the surveyor findings and that they had immediately secured the black lock boxes to the refrigerators. The DON stated that she believed that each refrigerator had a clear permanently affixed lock box and questioned why those containers were not being used. The ADON stated that the clear locking box had just been removed from the 500's hallway medication refrigerator and that the 400's hallway medication refrigerator did not have one. She further explained that the Lorazepam boxes were too large to fit inside the clear locking containers. The surveyor confirmed that the black lock boxes in both the 400 and 500 hall medication refrigerators had been permanently affixed since the surveyor had observed them as being loose earlier in the day. The ADON stated that nurses began using the black lock boxes because the medications would not fit inside the clear locking containers. The surveyor expressed concern that staff did not recognize that any lock box used to store controlled medications must be permanently affixed and that staff failed to report that the controlled medications did not fit into the affixed containers or that the black lock boxes had not been secured. The DON confirmed that staff should have reported the issue to nursing supervisors. On 6/30/26 at 10:40 AM, the surveyor discussed the findings with the Nursing Home Administrator (NHA). The NHA stated that she would follow up with the DON regarding the controlled medication storage issues identified during the survey. 2) Review of facility Medication Storage Policy and Procedure implemented on 12/14/22 states, All drugs and biologicals will be stored in locked compartments (i.e., medication carts and that during medication pass, medications must be under direct observation of the person administering the medications or locked in the medication storage cart. On 6/29/26 at 3:51 PM, while walking through the 500's hallway, the surveyor observed an unattended medication cart that had been left unlocked. The surveyor was able to open the medication drawers. After opening one of the drawers, the surveyor waited for staff to return. Nurse #16 approached and stated that she had been only gone for a minute, but acknowledged that the medication cart should never be left unlocked and unattended and confirmed that it should have been locked. On 6/29/26 at 4:19 PM, the surveyor interviewed the Director of Nursing (DON) and asked whether it was ever acceptable to leave a medication cart unlocked while unattended. The DON stated that the expectation is to always lock medication carts when unattended. After the surveyor informed the DON of the finding, the DON stated that the nurses know better. On 6/30/26 at 10:40 AM, the surveyor discussed the findings with the Nursing Home Administrator. The NHA confirmed that the issues identified during the survey would be addressed. 3) On 6/24/26 at 2:13 PM surveyor observed Resident #117 sitting in a chair in their room. The resident had an overbed table in front of them in which a small medicine cup was sitting on. The medicine cup contained one small pill. No nurse was in the room at the time of this observation. Shortly after making this observation Nurse #21, who was assigned to care for Resident #117's roommate but not Resident #117, arrived at the room. When asked if she could identify the medication in the cup, Nurse #21 confirmed there was one pill in the cup and reported that the resident takes vitamins but was unable to definitively identify the medication in the cup. Nurse #21 indicated she would follow up regarding this observation. On 6/24/26 at 2:33 PM Nurse #23, who was assigned to care for Resident #117 at that time, reported the medication was famotidine. Nurse #23 went on to report she had just given the medication to the resident but got called away urgently and had asked Nurse #21 to watch. Famotidine, also known as Pepcid, is used to treat gastroesophageal reflux disease (GERD). On 6/30/26 at 2:45 PM surveyor reviewed with the Director of Nursing (DON) the concern regarding the medication left in the resident's room. DON indicated she was already aware of this observation.

Based on interviews, record reviews, and observations, it was determined that the facility failed to ensure that Residents received their meals at a palatable temperature. This was evident in 2 of 3 kitchen observations. The Findings include:During an initial tour of the facility on 6/24/26, several residents reported that the facility's food was usually cold by the time they received their trays. A follow-up review of the facility's service line checklist records for June 1-24, 2026, was conducted. A notation on the forms stated that item names and temperatures for all hot and cold foods should be taken prior to service and recorded. However, the review found missing item names and temperatures for breakfast and dinner on 6/3/26; for breakfast on 6/13/26 and 6/18/26; and for breakfast and lunch on 6/23/26. During an observation of the facility's tray line service for dinner on 6/25/26 at 5:08 PM, the surveyor requested a test tray. The tray included a meal slip for Resident #49. The slip noted that Resident #49 was on a regular diet and was to be served 3 oz of roast turkey, 2 oz of poultry gravy, 1/2 cup of creamed spinach, 1/2 cup of bread dressing, 1 dinner roll, 1 margarine, 1 chocolate chip cookie, and 1 serving of a cold beverage of choice. On the tray were: roast turkey, gravy, creamed spinach, bread dressing, 1 dinner roll, 1 margarine, 1 chocolate chip cookie, and cranberry juice.Before the surveyor tasted the food items, staff #28, a corporate dietary manager, was present and recorded the food temperatures: 122.3 F for the roast turkey, 126.9 F for the creamed spinach, and 70 F for the cranberry juice. A review of the facility's Hazard Analysis and Critical Control Point (HACCP) plan (ensures food safety for the immunocompromised elderly population) on 6/26/26 found that hot foods were held at 135 F or higher and cold foods and drinks at 41 F or lower. However, the test tray forResident #49 on 6/25/26 contained hot foods served below 135 F and a cold drink served above 41 F. In a follow-up interview on 6/29/26 at 10:40 AM, staff #29, the dietary manager, was asked about acceptable holding temperatures for serving food to residents. Staff #29 reported that hot foods should be at least 135 F and cold foods at or below 41 F. He added that he would continue to provide staff education to address concerns about food temperatures.

Based on observations, record review, and interviews, it was determined that the facility failed to ensure that food was prepared in a form suitable for individuals with altered ability to chew and swallow. This was evident in 1 of the 3 tray-line service observations conducted during the annual survey. The findings include:A Regular Diet, Chopped Texture requires foods to be cut into small, bite-sized pieces (usually 1/2 inch or 1.2 cm). It is designed for residents with mild chewing difficulties and must remain moist. Dry, tough, or stringy foods should be avoided to prevent choking. A Regular Diet Chopped (or mechanically altered) texture, peas must be heavily modified-pureed or creamed-so they are easily manageable and do not require intact chewing. A care plan is a guide that addresses each Resident's unique needs. It is used to plan, assess, and evaluate the effectiveness of the Resident's care. Staff use care plans to provide resident-centered care, including support, services, and resources to address Residents' needs. During an observation of the facility's tray line service for lunch on 6/26/26 at 12:18 PM, it was noted that the kitchen had run out of pureed peas and had prepared some. The surveyor requested a test tray. The tray contained a meal slip for Resident #25. A review of the slip showed that Resident #25 was on a regular chopped diet and was to be served chopped Parmesan-crusted fish fillet, white sauce, pureed buttered green peas, mashed potatoes, hot tea, sugar, salt, pepper, and chopped marble cake with white frosting. However, upon tasting the food items served on the tray for Resident #25, it was noted that the pureed peas contained significant chunks of pea skin. Staff #28, a corporate dietary manager, was present and asked whether staff tasted the pureed food to ensure it had the right texture before serving it to residents. Staff #25 responded that they did. However, an earlier observation of the preparation of pureed peas did not show that the staff tasted it before serving it to residents. Record review for Resident #25 included a care plan initiated on 1/22/25 and revised on 5/24/25, which noted that the Resident was at nutritional risk [related to] need for therapeutic and mechanically altered diet due to a previous stroke and difficulty swallowing. During a follow-up interview on 6/29/26 at 11:19 AM, staff #24, a registered dietitian, reported that a resident on a regular chopped meal required certain items, such as peas, to be pureed for the Resident's safety. Staff #24 added that pureed foods should have a pudding-like texture or be smooth and should not be chunky or rough. However, an earlier observation of Resident #25's pureed, buttered green peas revealed significant chunks of pea skin. In a subsequent interview on 6/30/26 at 11:50 AM, staff #30, a speech therapist, reported that pureed, textured food is food a resident would not need to chew to swallow, so pureed foods should not contain chunks of the food item. However, Resident #24's pureed buttered peas contained pea skin chunks.

Based on observations, interviews, and record review, it was determined that the facility failed to adhere to infection control practices when handling clean laundry and failed to ensure appropriate Personal Protective Equipment (PPE) were donned during care for residents on Enhanced Barrier Precautions (EBP) and Contact Precautions. This was evident for 1 of 1 laundry room observed and for 2 (Resident #11, 130) of 6 residents reviewed during the infection control task. The findings include:1) Clean laundry must be protected from contamination during storage and transport. Clean linen carts are expected to remain covered, and the clean laundry room must be maintained as a protected environment. Leaving linen carts uncovered and propping open the clean laundry room door increases the risk of environmental contamination of linens intended for resident use. On 6/26/26 at 9:14 AM, the surveyor toured the lower level of the facility which contained the laundry room. As the surveyor approached the entrance of the clean side of the laundry room, the surveyor observed two linen carts containing clean folded linens positioned in the hallway. Both carts had covers; however, the covers were pulled back exposing the clean linens. No staff were present. The surveyor also observed the door to the clean side of the laundry room propped open with a container placed in the doorway to keep the door from closing. Inside the clean laundry room, two of four linen carts had covers pulled back, and clean laundry was observed on a table in the process of being folded. Laundry worker Staff #7 stated he was aware the clean laundry room door was supposed to remain closed but that it had been propped open due to the room being hot and humid. Staff #8 stated she had never been told the door could not remain open. Staff #8 further stated a fan was present in the room but could not be used due to electrical circuits tripping when in operation, as directed by the Maintenance Director. Both Staff #7 and #8 confirmed understanding that linen carts must be covered. Manager #9, identified as the Environmental Services Manager responsible for laundry operations, was observed entering the area and covering the linen carts. When questioned regarding the uncovered carts and propped door, Manager #9 initially denied that the carts had been uncovered until informed that the surveyor had observed and documented the condition. During interview, Manager #9 stated she maintains laundry records such as lint cleaning documentation but does not conduct infection control rounds. She stated she was aware the clean laundry room door is required to remain closed and that clean linen carts are required to remain covered. She further stated staff had been educated on these expectations and that the district manager had been notified regarding heat concerns in the laundry room. On 6/26/26 at 9:42 AM, the surveyor interviewed the Infection Preventionist (IP #1), who stated she conducted infection control rounds in the laundry area for a few months following the previous annual survey but discontinued routine monitoring once the area was believed to be in substantial compliance. She stated she occasionally enters the area and corrects staff when issues are identified but does not maintain any log or documentation of monitoring activities. IP #1 confirmed the expectation that clean linen carts are to remain covered, and the clean laundry room door is to remain closed. On 6/26/26 at 9:53 AM, the Nursing Home Administrator (NHA) confirmed that staff are expected to keep clean linen carts covered and the clean laundry door closed. The NHA acknowledged the facility had previously received a similar citation related to laundry practices during the prior annual survey and stated the issue would be investigated. On 6/26/26 at 11:39 AM, an anonymous staff member (Staff #13) reported that the clean laundry room door had been propped open daily for at least three months. On 6/26/26 at 10:19 AM, the NHA stated the facility was developing a plan to ensure linen carts remain covered and the clean laundry room door remains closed. 2) Enhanced Barrier Precautions (EBP) is an infection control intervention requiring staff to use appropriate Personal Protective Equipment (PPE), including gowns and gloves, during high-contact resident care activities for residents with identified risk factors such as open wounds. Resident #11 had physician-ordered Enhanced Barrier Precautions due to open wounds, requiring staff to wear gloves and gowns during high-contact care activities, including transfers. On 6/26/26 at 3:51 PM, the surveyor observed an Enhanced Barrier Precautions sign posted on Resident #11's door indicating staff must wear gloves and gowns during high-contact care activities, including transfers. Upon entry, the surveyor observed two Geriatric Nursing Assistants (GNA #12 and GNA #14) assisting Resident #11 with a transfer. Neither staff member wore gowns; both wore gloves only. GNA #12 exited the room, removed his gloves, and stated that he was Only helping to transfer her and didn't touch her. When asked about the precaution requirements, he reread the sign on the door and asked, Am I supposed to wear a gown when I am transferring the resident? The surveyor advised him to clarify requirements with the facility Infection Preventionist. GNA #12 then stated, I'm sorry, you are right, I should have also worn a gown. GNA #12 subsequently returned to the room with a gown and handed it to GNA #14. GNA #14 questioned what it was for, at which time Resident #11 stated, You are supposed to wear a gown. The surveyor then approached GNA #14 and asked her to confirm whether she was aware that a gown was required during care under EBP. GNA #14 stated, Yes, I should be wearing the gown. GNA #14 then applied the gown while still wearing the same gloves that had been used during the resident transfer. On 6/26/26 at 4:00PM, the surveyor met with the facility IP#1 who confirmed that the staff should have been wearing gowns and gloves during EBP care for Resident #11. The Nursing Home Administrator (NHA), who was present during the interview, stated staff know better regarding PPE requirements. 3) Contact precautions are infection-control measures used in healthcare settings to prevent the spread of germs transmitted through direct or indirect contact. They require strict adherence to personal protective equipment (PPE) protocols, including wearing gloves and a gown for all interactions with the patient or their environment. Resident #130 was a newly admitted resident of the facility with diagnosis that included Bacteremia. Bacteremia is the medical term for the presence of bacteria in the bloodstream. Because blood is normally a sterile environment, this condition always indicates an abnormality and requires rapid treatment to prevent life-threatening complications like sepsis, endocarditis, or organ failure. Management centers on aggressive intravenous (IV) antibiotics. On 6/24/26 at 1:48 PM, a contact precaution sign was observed on Resident #130's door with PPE supplies located in a bin by the door. Nurse #11 walked in the resident's room and was observed taking the resident's blood sugar reading. Nurse #11 had a pair of gloves on but was not wearing a gown. As she walked out of the resident's room, she was interviewed by the surveyor. During the interview, she confirmed taking the resident's blood sugar reading and was asked why she did not put a gown on. Nurse #11 answered, my understanding is we put on gowns when we do things with the wounds. She further explained that the resident was on contact precautions due to having wounds and she only dons gown and gloves when treating the wounds. A review of Resident #130's medical record was conducted on 6/26/26 at 9:01 AM. The review revealed that the resident was on IV antibiotic indicated for MRSA bacteremia that started on 6/16/26. (MRSA -Methicillin-resistant Staphylococcus aureus is a type of staph bacteria that is highly resistant to many common antibiotics.) The review also revealed the order to put the resident on contact precautions related to MRSA with the same start date of 6/16/26. During an interview with the Director of Nursing (DON) on 6/26/26 at 9:32 AM, the concern was discussed that staff failed to don the appropriate PPE before entering Resident #130's room. The DON reported that she was already aware and acknowledged the concern.

Based on complaint and facility reported incident review, medical record review, and staff interview, it was determined the facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded. This was evident for 5 (#16, #4, #10, #5, #3) of 16 residents reviewed during a complaint survey.The findings include: The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident.1a) On 6/2/26 at 9:40 AM a review of complaint 2672573 and Resident #16's medical record was conducted.A review of Resident #16's November 2025 Medication Administration Record (MAR) documented that Resident #16 received the antibiotic Clindamycin and the anticonvulsant Gabapentin.Review of Resident #16's MDS assessment with an Assessment Reference Date (ARD) of 11/16/25, Section N0415, High-risk drug classes, failed to capture the use of the antibiotic and the anticonvulsant.1b) Review of Resident #16's February 2026 MAR documented the resident received insulin injections every day and Maxitrol (antibiotic and steroidal) Ophthalmic Solution drops. Resident #16 also received Tylenol PRN (when needed) on 2/13/26.Review of Resident #16's MDS assessment with an ARD of 2/16/26, Section N0415, High-risk drug classes, failed to capture the use of the hypoglycemic and the antibiotic. Review of Section J0100B, received PRN (when necessary) pain medications or was offered and declined was coded, no. The facility failed to capture the PRN pain medication.1c) Review of Resident #16's May 2026 MAR documented the resident received Torsemide (diuretic) every day and the antibiotic eye drops Neomycin.Review of Resident #16's MDS assessment with an ARD of 5/14/26, Section N0415, High-risk drug classes, failed to capture the use of the diuretic and the antibiotic.On 6/4/26 at 9:50 AM the MDS assessments were reviewed with MDS Coordinator #11 who confirmed the findings.2a) On 6/3/26 at 7:52 AM a review of facility reported incident 2672641 and Resident #4's medical record was conducted.A review of Resident #4's annual MDS assessment with an ARD of 11/21/25, Section N0415, High-risk drug classes, coded that Resident #4 received an anticoagulant during the 7-day look back period.Review of Resident #4's November 2025 MAR documented that Resident #4 received Eliquis (anticoagulant), however it was stopped on 11/11/25. Resident #4 did not receive an anticoagulant within the look back period.2b) Review of Resident #4's February 2026 MAR documented that Resident #4 received insulin every day. Review of Resident #4's MDS assessment with an ARD of 2/21/26 failed to capture the hypoglycemic use.On 6/4/26 at 9:50 AM the MDS assessments were reviewed with MDS Coordinator #11 who confirmed the findings.3a) On 6/3/26 at 8:30 AM a review of facility reported incident #2734781 and Resident #10's medical record was conducted. A review of a 1/20/26 at 14:11 (2:11 PM) change in condition note documented that staff were called to Resident #10's room as the resident was observed kneeling against the bed with the upper body on the bed and the legs between the wheelchair. A 1/21/26 at 21:19 (9:19 PM) care plan progress note and evaluation documented IDT (interdisciplinary team) fall review 1/20/26, patient was observed kneeling against the bed with upper body on the bed and legs between the wheelchair. Review of Resident #10's admission MDS Assessment with an ARD of 1/21/26, Section J1800 any falls since admission/entry or reentry or prior assessment, was coded no. The facility failed to capture the fall on 1/20/26. Continued review of the 1/21/26 MDS assessment, Section J0100B, received PRN (when necessary) pain medications or was offered and declined was coded, no. Review of Resident #10's January 2026 MAR documented the resident received PRN Tylenol on 1/21/26 at 12:36 PM. Continued review of Resident #10's January 2026 MAR documented the resident received the medications glipizide, metformin, and Lispro injection which are medications to treat diabetes mellitus. Continued review of the 1/21/26 MDS assessment, Section N0415, High-risk drug classes - failed to capture hypoglycemic (low blood sugar) medications.3b) Review of Resident #10's MDS assessment with an ARD of 2/3/26, Section N0415, High-risk drug classes, also failed to capture the hypoglycemic (low blood sugar) medications.On 6/4/26 at 9:50 AM the MDS assessments were reviewed with MDS Coordinator #11 who confirmed the findings.4) On 6/3/26 at 10:54 AM a review of facility reported incident #3012483 and Resident #5's medical record was conducted.Review of Resident #5's March 2026 MAR documented the resident received insulin every morning for diabetes mellitus and Apixaban twice per day for atrial fibrillation. Atrial fibrillation, also known as AFib is a heart arrhythmia, causing the heart's upper chambers to be out of rhythm with the lower chambers. It requires medical management such as medication to prevent complications like blood clots and stroke.Apixaban is an anticoagulant used to prevent blood clots.Review of Resident #5's MDS assessment with an ARD of 3/19/26, Section N0415, High-risk drug classes, failed to capture the insulin (hypoglycemic) and the Apixaban (anticoagulant).On 6/4/26 at 9:50 AM the MDS assessment was reviewed with MDS Coordinator #11 who confirmed the findings.5a) On 6/4/26 at 9:10 AM a review of complaint #2672595 and Resident #3's medical record was conducted.Review of Resident #3's January 2026 MAR documented that Resident #3 received Aspirin (antiplatelet) every morning and insulin every day.Review of Resident #3's MDS assessment with an ARD of 1/4/26, Section N0415, High-risk drug classes, failed to capture the use of the antiplatelet and the hypoglycemic medications. 5b) Review of Resident #3's April 2026 MAR documented that Resident #3 received Mupirocin ointment (antibiotic) for an abscess on the inner thigh.Review of Resident #3's MDS assessment with an ARD of 4/4/26, Section N0415, High-risk drug classes, failed to capture the use of the antibiotic ointment.On 6/4/26 at 9:50 AM the MDS assessments were reviewed with MDS Coordinator #11 who confirmed the findings.

Based on medical record review and interview, it was determined the facility staff failed to administer medications and treatments as ordered by the physician. This was evident for 1 (Resident #1) of 5 residents reviewed for complaints during a complaint survey. The findings include:Review of Resident #1's medical record on 6/2/26 for Complaint 3016513 revealed the Resident was admitted to the facility in September 2025 following a hospitalization.Review of the Resident's February, March and April 2026 Medication and Treatment Administration Records revealed the facility staff failed to administer the following medications and treatments:1) Zosyn 3.375 grams intravenously every 8 hours for bacteremia on 2/1, 2/2 and 2/6/26 at 6 AM2) Methocarbamol 500 mg four times a day for muscle spasm on 2/1, 2/2, 3/7, 3/19, 4/11 and 4/16/26 at 6 AM3) Iodosorb to right medial toes/right lateral foot daily for wound care on 3/9 and 3/10/26Interview with the Director of Nursing on 6/4/26 at 11:30 AM confirmed the Surveyor's findings for Resident #1.

Based on record review and staff interviews, the facility failed to provide the resident or representative with an outcome and/or resolution following the conclusion of a grievance investigation for 1 (Resident 5) of 1 sampled resident.Findings included:A review of a facility policy titled, Resident and Family Grievances, dated 12/23/22 with a review date of 11/3/2025, revealed .Policy Explanation and Compliance Guidelines.10. Procedure: . e. The Grievance Official, or designee, will keep the resident appropriately apprised of progress towards resolution of the grievances.g. In accordance with the resident's rights to obtain a written decision regarding their grievance, the Grievance Official will issue a written decision on the grievance to the resident or representative at the conclusion of the investigation. The written decision will include, at a minimum: i. The date the grievance was received. ii. The steps taken to investigate grievance, iii. A summary of the pertinent findings or conclusions regarding the residents' concerns. iv. A statement as to whether the grievance was confirmed or not confirmed. v. Any corrective action taken or to be taken by the facility because of grievance. vi. The date the written decision was issued. For investigations regarding allegations of neglect, abuse, injuries of unknown source, and/or misappropriation of resident property, a report of the investigative results will be submitted to the State Survey Agency, and other officials in accordance with State law, within five working days of the incident.A resident demographic record revealed the facility admitted Resident (R) 5 on 3/19/24. The resident had a medical history that included cerebral infarction, aphasia, heart failure, atherosclerotic heart disease, type 2 diabetes mellitus, cardiomyopathy, protein-calorie malnutrition, hypothyroidism, depression, atrial fibrillation, chronic kidney disease stage 4, cognitive communication deficit, traumatic brain injury, and recent pleural effusion.An annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/12/25 revealed R5's Brief Interview for Mental Status (BIMS) score was 15/15, indicating s/he was cognitively intact. However, a quarterly MDS dated [DATE] revealed a BIMS score of 3/15, indicating severe cognitive impairment following a recent hospital stay.The grievance report dated 9/5/25 was reviewed and addressed three topics, one of which addressed an allegation of abuse. The alleged verbal/mental abuse was reported to have occurred on 9/4/25. It was witnessed by a family friend who reported it to the complainant, who then reported it during the resident's care meeting on 9/5/25. The complainant reported that Licensed Practical Nurse (LPN4) called the resident a racist, banged on his/her bed, and bullied the resident. The allegation of abuse was not addressed in the outcome or resolution. An interview with Guest Services (GS) 9 on 11/19/25 at 12:20 p.m. revealed she had received a grievance form from Registered Nurse (RN) 12 on 9/5/2025. When asked to review the grievance forms related to the alleged verbal abuse by LPN6 and the bowls and containers dated 9/5/25, GS9 noticed the primary complaint was regarding the nurse's alleged verbal/mental abuse. Still, the majority of the resolution addressed the paper bowls and containers, noting that the facility replaced them and that the resident and the family were satisfied with the resolution. When she reviewed the grievance, she said that there did not appear to be a resolution included for the complaint regarding LPN6, and there was no evidence of education provided to staff regarding abuse. An interview with Assistant Director of Nursing (ADON) 3 on 11/18/25 at 1:35 p.m. revealed she was involved in the grievance regarding LPN6's alleged verbal abuse. ADON3 gave the same account as GSC9 regarding the resolution of the grievance dated 9/5/25. ADON3 said she reviewed the resident's record with RP2 without any concerns noted, and this was related to the care plan meeting that was held on the same day. ADON3 confirmed the grievance did not appear to address the resolution or outcome of the alleged verbal/mental abuse by LPN6, and there was no evidence of education provided to staff regarding abuse. In an interview with RN12 on 11/18/25 at 2:55 p.m., RN12 reviewed the grievance forms dated 9/5/25 and stated that she became aware of the alleged verbal abuse by Responsible Party (RP) 2 on 11/5/25 during R5's care plan meeting. RN12 initiated the grievance form and submitted it to GS9 for processing, further explaining that GS9 would then follow up with the appropriate department or person, such as the Administrator or Director of Nursing (DON) 2. RN12 did not witness the incident and was only present during the care plan meeting when RP2 reported the allegations. In an interview with the DON2 on 11/18/25 at 3:10 p.m., she reviewed the grievance dated 9/5/25 regarding LPN6's behavior and alleged verbal/mental abuse. She said the incident occurred on 9/4/25 and was brought to the facility's attention by RP2 at R5's care plan meeting, along with complaints regarding the bowls and containers. DON2 confirmed that the alleged verbal abuse was not addressed in the grievance resolution, and there was no report made of the alleged verbal abuse. She also confirmed there was no education provided as a means of preventing potential verbal/mental abuse within the grievance investigation. In an interview on 11/19/25 at 3:30 p.m., the Administrator stated the complaints made by RP2 at the care plan meeting were not considered verbal abuse, saying, They just didn't want LPN6 assigned to her, when asked why the self-report was not made. When asked about the outcome or resolution to the allegation of verbal/mental abuse, the Administrator said they obtained LPN6's statement and the resolution was documented in the grievance investigation; however, she was unable to point out the statement or the resolution, stating, it (the outcome) covered everything. There was no evidence of education provided to staff regarding abuse.

Based on interviews and record reviews, the facility failed to 1.) ensure misappropriation of resident property was reported immediately, not later than 24 hours, to the administrator and to other officials for one of one facility-reported incident reviewed for misappropriation of resident property and 2.) implement its abuse policy and procedure for immediately reporting an allegation of staff-to-resident verbal abuse to the State Agency, local law enforcement, and to Adult Protective Services within the required time frame. This was for 1 (Resident 6) resident sampled for misappropriation of property and 1 (Resident 5) of 6 sampled residents reviewed for abuse. Findings included: The facility policy titled, Abuse, Neglect, and Exploitation, dated 11/13/2023 with a review date of 10/17/25, .V. A., An immediate investigation is warranted when suspicion of abuse, neglect, or exploitation, or reports of abuse, neglect, or exploitation occur. VII. Reporting/Response. A. 1. Reporting of all alleged violations to the Administrator, state agency.within specified timeframes. b. Not later than 24 hours if the alleged violation involves. misappropriation of resident property and does not result in serious bodily injury. A resident record indicated that the facility admitted Resident (R) 6 on 08/16/2025. The record states that the resident had a medical history including diagnoses of anemia, coronary artery disease, and hypertension.An annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/22/2025, revealed R6's Brief Interview for Mental Status (BIMS) score of 15/15, indicating R6 was cognitively intact. Care plans and progress notes were reviewed without any concerns. The resident's record included an inventory sheet upon admission, listing upper and lower dentures and a pair of eyeglasses; however, it did not include R6's wallet or its contents. Daily observations of the entire facility, from 11/17/2025 to 11/20/2025, were conducted during the survey. The observation revealed that no surveillance cameras were noted within the facility. The two witnesses identified in the facility's investigation as having been in R6's room on 8/26/24 were not available for interviews. The housekeeper was no longer employed with the facility, and the Geriatric Nurse Aide (GNA) was unavailable for interview.In an interview with Guest Services (GS) 9 on 11/18/2025 at 12:00 p.m., she stated she assisted in investigating the incident as part of the grievance process. GS9 received a call from Licensed Practical Nurse (LPN) 5 at approximately 4:30 p.m. on 8/26/2025. LPN5 also initiated the missing items form at that time. GS9 and the Assistant Director of Nursing (ADON) 3 were notified and immediately began the investigation. GS9 confirmed that suspected resident misappropriation of property should be reported to the Administrator immediately. She also stated that there are no cameras within the building for reviewing activities. GS9 stated that R6's family said she would check the hospital for the wallet and report back. R6's family member reported to GS9 on 8/28/2025 at 11:00 a.m. that the wallet was not found at the hospital with R6. GS9 then reported the missing wallet to the Administrator on 8/28/2025 at 11:05 a.m. GS9 confirmed she did not report the missing wallet to the Administrator when it was reported on 8/26/25, stating, We were waiting for (R6's sister) to report back from the hospital. She added that she did not follow up with the family member during this time. GS9 reviewed the missing item investigation form and confirmed it had not been completed or resolved. In an interview on 11/18/2025 at 1:45 p.m., ADON3 stated LPN5 reported the missing wallet to her and GS9 on 8/26/2025 at approximately 4:30 p.m. ADON3 stated missing items should be reported to the Administrator immediately.An interview with LPN5 on 11/18/2025 at 2:02 p.m. revealed that he received a report of the missing wallet from a family member of R6 at approximately 4:30 p.m. on 8/26/2025. She initiated a missing item form and called GS9 and ADON3 immediately to report the missing item. LPN5 confirmed that missing items should be reported immediately, which she did by contacting GS9 and ADON3 to initiate the form and by contacting GS9 and the supervisor, ADON3. An interview with a family member of R6 on 11/19/2025 at 1:49 p.m. revealed that the resident was sent to the hospital on 8/26/2025, around the time of his/her in-house dialysis appointment. When the family member went to the facility to retrieve R6's items on 8/26/2025 between 4:00 p.m. and 4:30 p.m., she discovered R6's wallet was missing and immediately reported it to the nurse. The wallet was the only item that was missing. It had been in R6's room the previous day, wrapped inside a pair of dark-colored sweatpants s/he was going to wear for an outside appointment on 8/26/25 after dialysis. R6's family member stated that R6 never had the chance to put on the clothing that was prepared for the appointment. On 11/19/25 at 1:55 p.m., a call was placed to R6. There was no answer. A voicemail was left, but the survey's conclusion received no return call.In an interview with ADON3 on 11/19/15 at 2:00 p.m., he stated that R6 was in the hospital for a few days and returned to the facility in a different room. R6's original room was a single room without a roommate. ADON3 did not report the missing item to the Administrator.An interview with the Administrator on 11/19/25 at 4:00 p.m. revealed that she was notified of the missing wallet by GS9 on 8/28/25 at 11:05 a.m. The Administrator stated they did not consider the item to be missing nor suspicious of misappropriation until confirmed by the family member that it was not at the hospital; however, she did confirm that a missing item was reported to the facility on 8/26/25 at approximately 4:30 p.m., indicating suspected misappropriate would be no different than suspected abuse as outlined in the facility policy which would require an investigation to determine if it was verified, not verified, or inconclusive. The facility investigation was reviewed. It was discovered that the missing items form was initiated but not completed for the missing wallet. Statements obtained from the housekeeper and a GNA who had been in the room revealed that the housekeeper did not see a wallet, and the GNA did see one on the bedside table after the housekeeper reported being in R6's room. No alleged perpetrators were identified, and the facility does not have surveillance cameras. There was documentation on staff training regarding the misappropriation of property. The investigation concluded that the allegation was inconclusive, noting that insufficient information prevented verification of what happened to the wallet. 2.A review of a facility policy titled Abuse, Neglect, and Exploitation, dated 11/13/23 with a review date of 10/17/25, revealed .V. A., An immediate investigation is warranted when suspicion of abuse, neglect, or exploitation, or reports of abuse, neglect, or exploitation occur. VII. Reporting/Response. A. 1. Reporting of all alleged violations to the Administrator, state agency.within specified timeframes. b. Not later than 24 hours if the alleged violation involves abuse, .and does not result in serious bodily injury. Further review of the abuse policy revealed, .Compliance Guidelines: .3. Prevention: . The facility will identify, correct, and intervene in situations in which abuse, neglect, and/or misappropriation of resident property is more likely to occur. A resident demographic record revealed the facility admitted R5 on 3/19/24. The resident had a medical history that included cerebral infarction, aphasia, heart failure, atherosclerotic heart disease, type 2 diabetes mellitus, cardiomyopathy, protein-calorie malnutrition, hypothyroidism, depression, atrial fibrillation, chronic kidney disease stage 4, cognitive communication deficit, traumatic brain injury, and recent pleural effusion.An annual MDS with an ARD of 2/12/25 revealed R5's BIMS score was 15/15, indicating s/he was cognitively intact. However, a quarterly MDS dated [DATE] revealed a BIMS score of 3/15, indicating severe cognitive impairment following a recent hospital stay. The grievance report dated 9/5/25 was reviewed and addressed three topics, one of which concerned an allegation of abuse. The alleged verbal/mental abuse was reported to have occurred on 9/4/25. It was witnessed by a family friend who reported it to the complainant, who then reported it during the resident's care meeting on 9/5/25. The complainant reported that LPN4 called the resident a racist, banged on his/her bed, and bullied the resident. The allegation of abuse was not addressed in the outcome or resolution. There was no evidence to support the allegation reported to the State agency, nor was there evidence that education was provided to staff following a report/allegation of suspected abuse. In an interview on 11/17/25 at 3:45 p.m., Responsible Party (RP) 1 talked about an incident with a nurse that was witnessed by family friends, for which R5's other adult daughter (RP2) had filed a complaint and a grievance. RP1 said to ask RP2 about that incident, stating it was something about eyedrops and calling (parent) a racist. An interview with ADON3 on 11/18/25 at 1:35 p.m. revealed that she was involved in the investigation of the grievance regarding LPN6's alleged verbal abuse. ADON3 gave the same account as GS9 regarding the resolution of the grievance dated 9/5/25. ADON3 said she reviewed the resident's record with RP2 without any concerns noted, and this was related to the care plan meeting that was held on the same day. ADON3 confirmed the grievance did not appear to address the resolution or outcome of the alleged verbal/mental abuse by LPN6, and there was no evidence of education provided to staff regarding abuse. ADON3 deferred to the Administrator and Director of Nursing (DON) 2 to answer the remaining questions regarding LPN6. In an interview with Registered Nurse (RN) 12 on 11/18/25 at 2:55 p.m., RN12 reviewed the grievance forms dated 9/5/25 and stated that she became aware of the alleged verbal abuse by RP2 on 11/5/25 during R5's care plan meeting. RN12 initiated the grievance form and submitted it to GS9 for processing, further explaining that GS9 would then follow up with the appropriate department or person, such as the Administrator or DON2. RN12 did not witness the incident and was only present during the care plan meeting when RP2 reported the allegations.In an interview with DON2 on 11/18/25 at 3:10 p.m., she reviewed the grievance dated 9/5/25 regarding LPN6's behavior and alleged verbal/mental abuse. She said the incident occurred on 9/4/25 and was brought to the facility's attention by RP2 at R5's care plan meeting, along with complaints regarding the bowls and containers. DON2 confirmed that the alleged verbal abuse was not addressed in the grievance resolution, and there was no report made of the alleged verbal abuse. She also confirmed there was no education provided as a means of preventing potential verbal/mental abuse within the grievance investigation. An attempt was made to contact LPN6 on 11/19/25 at 11:18 a.m. No return call was received. During an interview with the complainant, who is also RP2 on 11/19/25 at 11:25 a.m., she said she is not R5's Power of Attorney (POA). She said she and RP1 are R5's responsible parties and emergency contacts, equally. When asked the reason for the 20-day delay in reporting, RP2 stated, I was coordinating with getting email addresses, making sure everything was good, and I was worried about retaliation. The more we say something, the care becomes worse. RP2 could not give examples of retaliation or worsening care or treatment. When asked if grievance had been filed with the facility and if a resolution had been provided, RP2 answered, They were aware of it; we talked about it in the care plan meeting. I do not know. They never got back to me. However, RP2 then said that GS9 and a social worker told her that LPN6 would no longer see R5. RP2 said that LPN6 did not work with R5 after the incident, adding that there were no additional concerns. An interview with GS9 on 11/19/25 at 12:20 p.m. revealed she had received a grievance form from RN12 on 9/5/2025. When asked to review the grievance forms related to the alleged verbal abuse by LPN6 and the bowls and containers dated 9/5/25 GS9 noticed the primary complaint was regarding the nurse's alleged verbal/mental abuse. Still, the majority of the resolution addressed the paper bowls and containers, noting that the facility replaced them and that the resident and the family were satisfied with the resolution. When she reviewed the grievance, she said that there did not appear to be a resolution included for the complaint regarding LPN6, and there was no evidence of education provided to staff regarding abuse. In an interview on 11/19/25 at 3:30 p.m., the Administrator stated the complaints made by RP2 at the care plan meeting were not considered verbal abuse, saying, They just didn't want LPN6 assigned to her, when asked why the self-report was not made. When asked about the outcome or resolution to the allegation of verbal/mental abuse, the Administrator said they obtained LPN6's statement and the resolution was documented in the grievance investigation; however, she was unable to point out the statement or the resolution, stating, it (the outcome) covered everything. She acknowledged there was no evidence of education provided to staff regarding abuse related to the grievance.

Based on medical and administrative record review and staff interview, it was determined that the facility failed to ensure that residents were free from significant medication errors as evidenced by a resident being administered medications that were ordered for their roommate. These findings were evident for 1 (Resident #263) of 6 residents reviewed for complaints during the annual survey. This was identified during the investigation of # MD000178787. The facility provided evidence that an action plan was developed, and corrective measures were implemented on 6/11/22, immediately after the facility was made aware of the incident to remove the immediacy of the noncompliance and correct the deficient practice.On 11/10/22 a determination of immediate jeopardy (IJ) was made with the potential for past non-compliance. A review of the facility's corrective actions revealed that the facility was in substantial compliance at the start of this survey. The findings include: Diabetic medications assist the body in regulating the amount of circulating blood sugar. A side effect of these medications is that a patient ' s circulating blood sugar level can become too low (hypoglycemia )and can cause blurred vision, weakness, confusion, passing out, or seizures. If left untreated hypoglycemia can lead to death per the Centers for Disease Control (CDC) website 2019. On 11/4/22, a review of complaint #MD00178787 revealed that Resident #263 ' s family member alleged that Resident #263 was given his/her roommate ' s medication (Resident# 422) n error on 6/11/22. A medical record review on 11/3/22, for Resident #263 revealed that Resident #263 was a [AGE] year-old admitted to the facility for pain management and rehabilitation. A medical record review on 11/4/22 at 10:30 AM, for Resident #422 revealed a medication administration record (MAR) that documented the following medications were ordered to be given at 9:00 AM: Metformin HCl 1000mg (diabetic medication), Tradjenta 5 mg (diabetic medication), Glyburide 10 mg (diabetic medication), Alprazolam 0.5mg (anxiety medication), amlodipine besylate tablet (blood pressure medication), Atenolol 12.5mg (blood pressure), Senna-Plus 8.6-50 mg (bowel management), aspirin 81mg tablet, CentaVite/Antioxidants (supplement), Duloxetine HCl 30mg, Duloxetine 60mg (antidepressant) Lovenox solution Prefilled syringe 40 mg.(prevent blood clots), magnesium 400 mg (supplement), one dose of MiraLAX powder (laxative), and methocarbamol 500 mg (muscle spasms medication). Review of the progress notes for Resident #263 revealed a note written by LPN #52 on 6/11/22 at 1:27 PM that stated, Resident administered duloxetine 30mg aspirin 81 mg and duloxetine 60mg during morning pass, medication doctor made aware of medication error, residents [family members name] made aware of medication error, resident monitored for side effects of drug none noted at this time. Then on 6/12/22 at 9:55 AM, a progress note was written that read that Resident #263 had become lethargic, sweaty, and unable to communicate. In addition, it was noted that the resident ' s blood sugar level had been 38 milligrams per deciliter of blood (mg/dL). (A level of blood sugar above 250 mg/dL or under 50 mg/dL is abnormal and requires medical emergency treatment. The optimal blood sugar level is generally between 70 and 130 mg/dL per the Centers for Disease Control and Prevention (CDC) 2021) On 11/3/22 at 2::15 PM, a review of the facility census at the time of the incident (6/11/22) revealed Resident #263 and Resident #422 were roommates at the time of the incident. A medical record review on 11/4/22 at 10:30 AM, for Resident #422 revealed a medication administration record (MAR) that documented the following medications were ordered to be given at 9:00 AM: Metformin HCl 1000mg (diabetic medication), Tradjenta 5 mg (diabetic medication), Glyburide 10mg (diabetic medication), Alprazolam 0.5mg (anxiety medication), amlodipine besylate tablet (blood pressure medication), Atenolol 12.5mg (blood pressure), Senna-Plus 8.6-50mg (bowel management), aspirin 81mg tablet, CentaVite/Antioxidants (supplement), Duloxetine HCl 30mg, Duloxetine 60mg (antidepressant) Lovenox solution Prefilled syringe 40 mg.(prevent blood clots), magnesium 400mg (supplement), one dose of MiraLAX powder (laxative), and methocarbamol 500 mg (muscle spasms medication). On 11/7/22, the surveyor obtained Resident #263 ' s emergency department (ED) records for 6/12/22, from the acute care hospital. A review of those records revealed the following documentation, Acute hypoglycemia secondary to medication error given accidentally to the patient at rehab [rehabilitation] facility. We were able to call [ facility name] and spoke with [name of RN #10] at [facility name] and she confirmed with me the medications that were given to the patient were metformin 1000mg, glyburide 10 mg, and Tradjenta 5mg. As the glyburide will get out of [her/his] system, [her/his] blood sugars will keep improving . ' ' . Further review of the hospital documentation revealed that while in hospital, Resident #263 had a decline in mental status and was found to have a blood sugar of 32 mg/dL. The physician documented that Resident #263 required critical care over a 35-minute period. In addition, it was noted that this critical care time was performed to assess and manage the high probability of imminent, life-threatening deterioration. On 11/4/22 at 1:50 PM, during an interview with the Director of Nursing (DON), she reported that LPN #52 initially reported that he administered 2 medications in error to Resident #263 that were ordered for Resident #422. DON reported that she had called Resident #263 ' s family member to determine what they had witnessed. DON reported that, on 6/12/22, when Resident #263 was sent to the hospital due to a low blood sugar level, she reviewed the roommate ' s medical record and found that Resident #422 had been ordered 3 medications to treat diabetes. DON stated that, when she found this out, she called LPN #52 for an interview and he reported that he had been untruthful and in fact administered all the medications ordered for Resident #422 to Resident #263 in error. The DON stated she notified the acute care hospital of the actual medications that had been given in error. The DON provided copies of her written statements regarding each interview. ____________________________________________________________________________ On 11/4/22 at 2:00 PM, a review of the statements regarding the incident revealed that Registered Nurse (RN) #16 stated she had been the Manager on Duty (MOD) on 6/11/22, when the medication error for Resident #263 had occurred, and was notified by Registered Nurse (RN) Supervisor #53 of the incident. Upon notification, RN #16 contacted LPN #52 via telephone and provided education regarding medication administration and the use of armbands and A and B signs to identify the residents. In addition, there was a statement written by the Director of Nursing (DON) that on 6/12/22, she called LPN #52 to inquire about the medication error and interviewed Resident #263 ' s family member who had witnessed the medication error. A subsequent Interview with the DON on 11/4/22 was conducted. During the interview, the DON reported that, prior to the medication error that occurred on 6/11/22, agency nurses were given a quiz Rights of medication administration prior to the start of their first shift at the facility. When the surveyor requested the quiz for Nurse #52, the DON was unable to provide the quiz. The DON stated the agency nurse started on a weekend and the quiz was not completed. The DON reported that following the medication error, the education process was changed to ensure that all agency nurses received medication administration education prior to the start of their first shift. Furthermore, on 11/09/22 at 1:26 PM, the DON reported that through their investigation, they determined that Resident #263 did not have an armband on at the time of the medication error. She went on to report that residents now get their arm band at the front desk prior to going to their room and that resident ' s picture is uploaded into the electronic health record. The administrator and DON were informed on 11/10/22 at 8:24 AM that this deficient practice was an immediate Jeopardy. The following are the corrective actions the facility implemented: 1. The agency nurse [who made the medication error] was educated immediately by the supervisor (on site) and facility ' s nurse practice educator via telephone on the rights to medication administration, reading orders completely before completing them, identifying residents with armbands, and using A and B signs that are displayed boldly in the resident rooms. The nurse was removed from the assignment. The staffing agency was made aware of the error. In compliance on 6/11/22. 2. Ensure the facility ' s semi private [resident] room door tags are labeled with an A and a B. In compliance on 6/11/22. 3. Ensure all agency employees have completed education prior to arrival to their assigned unit/acceptance of medication cart. In compliance on 6/12/22. 4. Educate all unit managers/supervisors using the forms 10 Rights of Drug Administration and Agency Medication Administration. These forms will be signed by the facility ' s supervisor and the employee/agency staff prior to the agency nurse starting their shift. In compliance on 6/11/22. 5. Facility-wide education with all facility staff nurses on medication administration and the 10 rights to drug administration. In compliance on 6/11/22. 6. Facility-wide education on the new processes for admissions. New admissions will come in through the front door and will be identified by self, family, or Emergency Medical Services (EMS), and an armband will be placed at that time at the receptionist desk. A photo will be taken at the front desk and uploaded into Point Click Care (electronic medical record system) at the receptionist desk. During the evening/night hours, the manager on duty (MOD) or unit manager/shift supervisor will take the picture and upload it into PCC and apply the armband after correctly identifying the resident. After arrival at the unit, the charge nurse and geriatric nursing assistant will verify the armband and the room door tag have been properly placed. In compliance on 6/14/22. 7. Provide education to the managers on duty and unit managers regarding the new identification band [arm band], door tag procedure, and resident pictures and uploading into PCC at the time of admission. In compliance on 6/13/22. 8. Collaborate and attend a Zoom meeting with the staffing agency to discuss the poor practices that led to medication errors. In compliance on 6/14/22. The facility was in substantial compliance as of 6/14/22.

Based on review of medical records and other pertinent documentation, observations, and interviews, it was determined that the facility failed to ensure adequate supervision to prevent falls as evidenced by: 1) Failure of the geriatric nursing assistant (GNA) to remain with a resident who, due to a stroke and resulting muscle weakness and cognitive impairment, required total assistance with bathing during a shower. The resident sustained an unwitnessed fall during the shower. This fall resulted in a leg fracture, transfer to the hospital and subsequent surgical repair. 2) Failure of the GNA to provide supervision to a resident with severe dementia, who required extensive assistance with mobility, after assisting the resident to the toilet. The resident subsequently got off the toilet, started to walk and fell . This fall resulted in a fracture to the resident's nose. 3) Failure to ensure a resident who was dependent on staff for turning and positioning was turned in bed in a manner to prevent the resident from falling out of bed during care resulting in abrasions, bleeding, pain, and a change in mental status which required a transfer to an acute care hospital. All three of these falls resulted in actual harm to the residents. This was found to be evident for 3 (Residents #14, #114, #501 ) out of 15 residents reviewed for accidents during the survey. The findings include: 1.) On 10/12/22 at 2:29 PM, during an interview, an observation of Resident #14 revealed the resident had an abrasion on the top of his/her nose. At that time, Resident #14 indicated that s/he had sustained the abrasion when s/he fell out of bed and hit his/her head. On 10/20/22 at 1:40 PM, a review of Resident #14's medical record was conducted.There was a care plan, Resident #14 has had an actual fall and remains at risk for falls: weakness, ESRD, had the intervention Staff educated to positioning when providing care, which was added to the care plan on 9/19/22. The intervention did not indicate how the resident was to be positioned during care. Also, there was a care plan, Resident #14, requires assistance for ADL care in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, toileting, initiated on 7/12/22, which included the interventions, provide resident with extensive assist of 2 for bed mobility, and provide extensive assist of 1 for bathing. There care plan had not been updated to reflect the resident was totally dependent, requiring 2 person physical support for bathing. Review of Resident #14's quarterly assessment with an ARD (assessment reference date) of 7/18/22 documented the resident had a BIMS (Brief Interview for Mental Status) score of 11, indicating the resident had moderate cognitive impairment. The assessment documented Resident #14 was dependent on staff for ADLs (activities of daily living) and required extensive assistance with 2 person physical assist for bed mobility, and 1 person physical assist for bathing. The resident's quarterly assessment with an ARD of 10/4/22 documented Resident #14 required 2 person physical assist for bed mobility and was totally dependent with 2 person physical support for bathing. In a Change of Condition note, on 9/16/22 at 9:30 PM, the nurse documented Resident #14 had a fall off the bed during a bed bath and was observed lying on his/her left side, face down, bleeding from open wounds on the forehead and bridge of his/her nose bridge and the resident was sent to the emergency room for further assessment and management. In a telehealth evaluation note, with an effective date of 9/16/22 at 10:32 PM, and date of service of 9/16/22, 9:15 PM, the physician documented Resident #14 was on Eliquis (anticoagulant) (blood thinner), had a fall from his/her bed with a head injury, and was bleeding from his/her nasal bridge, right and left forehead, and right chin. The physician further documented Resident #14 was witnessed to have hit his/her head hard against the ground, was acutely confused, and the resident was unable to answer questions, and gave the disposition to transfer the resident to the emergency department. On 10/23/22 at 11:25 AM, a review of ED (emergency department) documentation revealed on 9/16/22 at 11:12 PM, in an ED provider note, the physician documented Resident #14 presented to the ER (emergency room ) for trauma following a fall, that the resident reported he/she fell face forward while getting a bath and, per EMS (emergency medical services) the resident was on Eliquis. The physician also wrote that Resident #14 was reporting diffuse (widespread back pain), and per nursing home staff, the resident had a change in mental status. The physician documented Resident #14 had an abrasion to the right forehead, an abrasion on the bridge of the nose, an abrasion to the right knee and the resident had tenderness to palpation (method of examination by feeling with the fingers or hands) below the paraspinal (around the spine) area in the C-T (cervical, thoracic) and L-spine (lumbar) spine. The ED documentation indicated Resident #14 underwent CT (computerized tomography) scans (used to visualize parts of the body to diagnose disease or injury) of his/her head, spine, facial bones, chest, abdomen, and pelvis and documented the results of the scans. In a Medical Decision Making and Plan of Care, in the ED note, the physician wrote that the Resident #14 had presented to the emergency room as a code trauma (trauma patient requiring trauma team response expected) following a fall at the nursing home with a change in mental status, that he/she arrived boarded and collared (spine immobilized with a cervical neck collar and backboard) and a trauma scan was ordered as the resident was on Eliquis. The images showed no acute traumatic injuries, the resident was stable and discharged back to the facility. On 10/24/22 at 10:13 AM a review of the facility's fall investigation revealed on 9/17/22 at 12:56 AM the nurse documented that a GNA (geriatric nursing assistant) was attempting to change Resident #14 and complete ADL care, the resident was on his/her right side, with the GNA on the left side of the bed, when the resident fell off the bed during the bed bath. The nurse indicated the GNA witnessed the fall, and the nurse observed the resident lying on the left side, face down, bleeding from open wounds on forehead and nose bridge. In an undated, handwritten incident report, Staff #39, GNA wrote that after giving Resident #14 a bed bath, in an attempt to dress the resident, Staff #39 rolled the resident away from him/herself and the resident flipped over the bed onto the floor, hitting his/her head and face. On 10/25/22 at 4:00 PM, during an interview, Staff #39, GNA indicated that on the evening of 9/16/22, he/she was giving Resident #14 a bed bath when the resident fell out of bed. Staff #39 stated that after cleaning the resident, he/she turned the resident away from her, onto his/her side to put a brief under him/her, when the resident rolled out of bed. Staff #39 indicated the height of the bed was in a position that allowed the GNA to give care. Staff #39 indicated the bed did not have side rails and the resident was on an air mattress. Staff #39 stated he/she thought the mattress may have partially come off the bed because the incident happened so fast and there was a floor mat, but the resident flipped over and hit his/her head on the floor. Staff #39 stated that following the incident he/she was given an education and told to roll the resident towards him/her, not away, and, if the resident could not assist in turning, Staff #39 was to call another person to assist with turning the resident. On 10/26/22 at 2:56 PM, during an interview, Staff #40, LPN, stated that at the time of Resident #14's fall, the GNA came out of the resident's room and told Staff #40 that he/she had been giving Resident #14 a bed bath and the resident had rolled out of bed. Staff #40 stated that when he/she went to the room, the resident was observed lying on the floor, next to one side of the bed, with the wash basin on the opposite side of the bed, and indicated Resident #14 fell when the GNA rolled the resident away from him/herself. Staff #40 stated that at that time, Resident #14 was bleeding on the bridge of the nose and forehead, that he/she tried to stop the bleeding, and when the bleeding stopped, the resident was assessed, and the resident was alert and talking. Staff #40 stated 911 was called, and because Resident #14 was on a blood thinner and hit his/her head, the resident was sent to the hospital to be evaluated. Staff #40 stated he/she was familiar with Resident #14, and the resident could follow directions, however, the resident needed help with everything except eating or drinking. Staff #40 stated the resident was on an air mattress and indicated the resident needed 2 people to assist in turning. On 11/2/22 at 11:00 AM, the above concerns were reviewed with the Nursing Home Administrator and the Director of Nurses. 16218 2.) On 11/7/22 review of Resident #114's medical record revealed the resident was admitted to the facility with diagnosis that included but not limited to a stroke with related right sided hemiplegia (muscle weakness or paralysis). The resident received occupational, physical and speech therapy during this admission. Review of the Admission Minimum Data Set Assessment (MDS), with an Assessment Reference Date of 10/15/19 revealed the resident had unclear speech with slurred and mumbled words (B0600), was able to sometimes make self-understood, with this ability being limited to making concrete requests (B0700). Regarding understanding others, the resident was assessed as sometimes understands - responds adequately to simple, direct communication only (B0800). A Brief Interview for Mental Status (BIMS) was not conducted due to the resident rarely/never understanding. The staff assessment for mental status revealed both short- and long-term memory problems and that the resident had severely impaired cognitive skills for daily decision making. Further review of the Admission MDS revealed the Resident #114 had functional limitations in range of motion that interfered with daily functions or placed the resident at risk of injury on one side for both upper and lower extremities. This assessment coincides with the diagnosis of hemiplegia. The resident was also assessed as being totally dependent on staff for taking a shower. Review of the care plan addressing the resident's requirement for assistance with activities of daily living revealed the following intervention, which was initiated on 1/7/2020: Provide resident/patient with total assist of 1 for bathing. During an interview with the unit nurse manager (#10) on 11/15/22 at 9:39 AM, when asked about expectations of GNA supervision during a shower for a resident with hemiplegia, the unit nurse manager responded that those residents were at higher risk of falling, sliding out of the chair and that those were residents you would want to stay with. When asked about expectations for supervision for cognitively impaired residents when in the bathroom, she indicated that they were always a minimum assist of 1, or to give privacy, the GNA can stay outside the [bathroom] door but remain within eyeshot. Review of the initial facility report for MD00150076 revealed that, on 1/11/2020 at 12:15 PM, Resident was in the bathroom receiving a shower by GNA. Resident requested to wash their face and perineal area independently. GNA handed [him/her] supplies, made sure shower chair was locked and stepped to the door as the resident started washing [his/herself]. GNA speaking with the nurse through the door, but not leaving the doorway, heard a bang. GNA immediately turned around and observed shower chair tipped over sideways towards [his/her] right side with the resident completely out of shower chair laying on [his/her] right side. Resident stated that [she/he] was trying to stand up to the GNA . Nurse immediately assessed the resident. No signs of injuries to the head. Resident complained of right hip discomfort. Nurse notified MD [medical doctor], 911 to transport to [name of hospital] ER for evaluation. Review of the final report regarding this incident revealed clarifications regarding some of the above statements. These included: Resident requested to wash their face and perineal area independently. Clarification-GNA said to [him/her], 'here is your washcloth to wash your face and [s/he] was agreeable resident who was handed washcloth by GNA and washed [his/her] face and front area. Resident stated to the GNA that [she/he] was trying to stand up. Clarification- GNA asked [him/her] what were you trying to do and the resident responded in two words, stood up. Review of the witness statement, signed on 1/13/2020 by the Occupational Therapy Assistant #69, revealed she saw Resident #114 for therapy. Her statement revealed Sitting in wheelchair [s/he] can wash [his/her] face, brush [his/her] hair and turn the water on [His/Her] environment is the cue which means if [s/he] has supplies given to [him/her] on in front of [him/her], [s/he] will perform the task in the right room (example bathroom). I do not need to be there the entire time. I could walk out of the room to get a towel and cup of water and return and [s/he] would still be working on self-care task. If [s/he] was in the shower the cue would be wash. [S/he] has never attempted to stand independently, however [s/he] has picked cones off of the floor with therapy from a sitting position with cueing. According to the Occupational Therapy Assistant's statement, the resident never attempted to stand independently. Further review of the investigation documentation revealed a witness statement, signed by GNA #68 on 1/13/2020, that revealed she had transferred Resident #114 to a shower chair using a hoyer lift and that the resident had a mesh hoyer pad under [him/her] during the shower. The GNA washed the areas the resident could not reach as well as the resident's hair. The GNA then handed the resident the washcloth and while the resident was washing the GNA went to the door to talk to the nurse. A hoyer lift is a mechanical lift used to transport a resident from one surface to another. It requires a pad to be placed under the resident and then the pad is hooked to the lift to facilitate a transfer from a bed to a chair or vice versa. Review of the care plan revealed the resident required total assist of 2 for transfers using the hoyer lift. Further review of the final report submitted by the facility revealed the following statement: Noted GNA was in the room standing at the doorway to speak with the nurse quickly while the resident was washing. Bathroom door is directly diagonal from the main door (50 inches apart) - You can see the bathroom shower from standing at the door. Observations made during the survey of the rooms on the unit where the resident resided confirms that the bathroom was directly diagonal from the main door to the room. However, to open the door to the hallway and speak to someone in the hall, one would have to physically leave the bathroom. Further review of GNA #68's witness statement revealed the following: What did you see? I did not see [him/her] fall, I just heard bang. Review of the Fall Investigation documentation, completed by Nurse #70, revealed this was an unwitnessed fall. Additionally: Activity during incident: slid from shower chair; Was fall related to seating/positioning: Yes; Explain: when resident attempting to wash perineal area could have slid from seat on shower chair while attempting to move self in chair. Summary of Investigation: Root cause/conclusion: Resident slid from shower chair. Review of the witness statement, signed on 1/13/2020 by Nurse #70 revealed: I was standing [at the] medication cart passing medications and GNA [name of GNA #68] was standing at the doorway quickly telling me with the door open talking to me about showers she was given and this was her last shower . Further review of the investigation documentation failed to reveal documentation to indicate why GNA #68 left the resident unattended in the shower other than to inform the nurse about showers she had provided. No documentation was found to indicate the GNA needed supplies or assistance. No documentation was found to indicate the resident had requested privacy. Review of the Minimum Data Set assessment, with an Assessment Reference Date of 1/11/2020 revealed the resident continued to have short term memory problems (C0700) and severely impaired cognitive skills for daily decision making (C1000). This assessment also revealed continued total dependence on staff for showering. Further review of the final report from the facility revealed documentation that an audit was conducted on all the shower chairs with no noted concerns. Further review of the facility documentation revealed GNA #68 received one on one in-service that included: Do not leave patient unattended during shower. Residents need direct supervision while in shower. If a resident requests privacy, then make sure the resident is safe and report to the nurse. Continue plan of care regardless of where resident is being discharged to. The facility also provided documentation of training to staff in January 2020 regarding shower fall prevention. This training included but was not limited to: Don't leave resident unattended during a shower; and report to nurse if resident wants privacy with shower. Review of the Change in Condition Evaluation, with an Effective Date of 1/11/2020 at 12:15 PM and completed by Nurse #70, revealed the resident was in pain but was not cognitively able to rate their pain on a pain scale. The nurse completed assessment questions to evaluate the cognitively impaired resident. This documentation included: Repeated troubled calling out. Loud moaning or groaning. Crying. Facial grimacing. Tense. Distressed pacing. Fidgeting. Distracted or reassured by voice or touch. Further review of the final report revealed a notation that Resident noted with fracture involving the proximal right femoral shaft [right thigh]. On 11/07/22 at 3:58 PM, surveyor reviewed with the Director of Nursing the concern that the fall resulted in harm to the resident. On 11/15/22, review of the hospital emergency department report, dated 1/11/2020 revealed documentation of expressive aphasia (inability to express yourself verbally) and R hemiparesis. This report also revealed: tenderness over the right hip and contusions (bruises) on right lateral thigh. Further review of the emergency department report revealed: .The pt [patient] was put on a shower chair and left unattended. Then [s/he] fell over onto [his/her] R [right] side Pt is a limited historian due to expressive aphasia. Review of the hospital discharge summary revealed: .Work-up with x-ray was noted with fracture involving the proximal right femoral [thigh bone] shaft patient underwent a right hip peritrochanteric nailing [a surgical repair] for subtrochanteric fracture . On 11/15/22 at 11:47 AM, the surveyor informed the Administrator that review of the hospital records confirmed that the resident sustained a fracture after the fall at the facility. 3.) 2) On 11/7/22, review of Resident #501's medical record revealed the resident was admitted to the facility in 2019 with diagnosis that included but were not limited to dementia and repeated falls. Review of the resident's care plan addressing activities of daily living (ADL), with a revision date of 10/22/19, revealed the following interventions: Provide resident/patient with extensive assist of 1-2 for transfers using a pivot transfer; and Provide resident/patient with extensive assist of 1-2 for toileting. Review of the Minimum Data Set (MDS) assessment, with an assessment reference date of 11/2/19, revealed that Resident #501 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status score of 4 out of 15. The MDS assessment also revealed that Resident#501 required extensive assistance, with staff providing weight bearing support, for transfers, walking in the room and toileting. This assessment also revealed the resident had sustained at least two falls since admission, but with no injuries related to the falls. Review of facility report MD00151194 revealed the following occurred on 2/7/2020 at 8:30 AM: Resident was in the bathroom using the toilet and GNA was approximately 7 feet in the room gathering chair. Another GNA was coming into the room to assist and observed the resident standing up attempting to walk. Resident made several steps and fell forward to the ground. GNA was unable to reach the resident. Nurse immediately assessed the resident. Compression applied to the nose. Nurse notified MD [medical doctor], 911 to transport to [name of hospital] ER [emergency room ] for evaluation. Review of the final report submitted 2/11/2020 revealed: X-ray noted comminuted fracture of the anterior nasal bone [broken nose]. Resident returned to the facility with an order to follow up with ENT (ear, nose and throat). During an interview with the unit nurse manager (#10) on 11/15/22 at 9:39 AM, when asked about expectations of GNA supervision for cognitively impaired residents when in the bathroom, she indicated that they were always a minimum assist of 1, or to give privacy the GNA could stay outside the [bathroom] door but remain within eyeshot. Review of the Witness Interview Record signed by GNA #55 on 2/7/20 revealed the following: On 2/7/20 I went to take [his/her] breakfast tray and [s/he] said [s/he] had to go pee, [s/he] was sitting on the side of the bed. I laid [him/her] back down and told [him/her] I was going to be right back and went to go get another GNA. I immediately went back to [his/her] room and the resident was sitting up on the side of the bed again but this time trying to stand up. The GNA that was coming to help stated she would be there shortly and had to run something. Since [s/he] was trying to stand and walk I walked [him/her] into the bathroom, holding under arms behind [him/her] guiding [him/her] to the bathroom. I sat [him/her] down on the toilet. [S/he] was going to the bathroom and I went to grab [his/her] chair at the foot of the bed. I was pulling the chair over, the other GNA came in and observed the resident on the floor in the bathroom. [S/he] was laying on her belly with her face to the side. They did not make a noise. I did not hear him/her try to get up-[s/he] will usually yell when ready like 'mom', I was in the room while [he/she] was sitting on the toilet. Review of the Witness Interview Record signed by GNA #54 on 2/7/2020 revealed the following: .When I arrived at the room, when opening the door I had to move the resident's chair as it was in front of the doorway to the bathroom at that time. The bathroom door was opened and as I turned to go into the bathroom I saw [name of resident #113] standing close to the bathroom door and [s/he] just fell forward. I was unable to reach [him/her] quick enough to help prevent the fall. Observations made during the survey of the rooms on the unit where the resident resided revealed the bathroom door was directly diagonal from the main door to the room. When entering the room, one walks past the bathroom prior to reaching the area of the room with the resident's bed. According GNA #54's statement the resident's chair was already outside of the bathroom door when the resident fell . GNA #55's statement indicated she was not with the resident because she was getting the chair. No documentation was found to indicate the discrepancy between the two GNA statements was clarified. Review of the medical record revealed a progress note, with an effective date of 2/7/2020 at 3:35 PM and written by Nurse #44, which revealed the following: GNA in to resident room to help with ADL care - requested assistance from second GNA. Upon assessment resident attempting to self transfer out of bed, staff at bedside. Resident reported that [s/he] needed to use restroom. GNA assisted [name of Resident #501] ambulate to toilet with one assist. GNA then went to grab residents chair from bedside to bring closer to resident for transfer off of toilet. [name of Resident #501] independently stood and attempted to independently walk with pants/brief at ankles. 0830 Second GNA entered room and noted [name of Resident #501] was close to the bathroom door. GNA was unable to reach resident before resident became unsteady and fell to the ground in bathroom doorway. GNA immediately called for nurse assistance. Nurse to room .Gauze/towels held in place to nose - bleeding noted and skin break to bridge of nose. Did report pain to nose .EMS [emergency medical service] arrived at 0850 and transported [name of Resident #501] via stretcher to [name of hospital] .CT of head without contrast completed at [name of hospital] - conclusion: moderately sized right frontal scalp hematoma [bruise] .CT of facial bones without contract conclusion: comminuted fracture of the anterior nasal bone [broken nose]. Nose not set at hospital r/t [related to] swelling. Returned from [name of hospital] approximately 1430 [2:30 PM] .Apply ice q [every] shift to nose x 20 minutes. ENT [Ear, Nose and Throat] consult to be scheduled for follow up. Resident to have assistance at all times when in restroom/shower room. Further review of the medical record revealed a nursing note with an effective date of 2/8/2020 at 1:17 PM which revealed the following: .Nose remains slightly swollen, bruising to bil [bilateral] eyes, nose and rt [right] wrist area. Small dry abrasions to above upper lip and bridge of nose . Further review of the medical record revealed a nursing note with an effective date of 2/9/2020 at 1:05 PM which revealed the following: .Bruising continues to facial areas. Nose remains slightly swollen . On 11/07/22 at 3:58 PM surveyor reviewed with the Director of Nursing the concern that the fall resulted in harm to the resident. Further review of the facility provided documentation revealed One-On-One in-service training was provided to GNA #55 on 2/11/2020 regarding Fall prevention, safe resident handling and fall prevention in resident with dementia. Additionally, an Individual Performance Improvement Plan was established for GNA #55 on 2/11/2020 to address Unsatisfactory job performance, violating safety rules or contributing unsafe conditions. The facility also provided documentation of training to staff in February 2020 regarding fall prevention-bathroom. The Brief Description of the Presentation stated: BIMS - Brief interview for Mental Status, residents with scores 12 or below cannot be left in the bathroom or shower. Further review of the care plan addressing fall risk, which was initiated in July 2019, revealed the following intervention was added on 2/7/2020: Assistance at all times when in shower room/bathroom. On 11/15/22 at 4:55 PM, surveyor reviewed the concern with the Director of Nursing regarding the failure to prevent accidents for Resident #501 and #114.

Based on review of medical records and interview with facility staff, it was determined that the facility failed to have a system in place to ensure that all new admission medications were ordered upon verification of the acute care facility's discharge instructions. The facility also failed to have an effective process in place to reconcile new admission orders [REDACTED]. As a result, a condition of Immediate Jeopardy was declared on 8/2/16 at 2:55 PM. The Nursing Home Administrator and the Director of Nursing were informed at that time of the need to prepare and implement an action plan to remove the condition of Immediate Jeopardy. On 8/2/16 at 5:33 PM, The Immediate Jeopardy was abated. The facility put a plan in place to remove the immediacy. This was evident for 1 of 38 (Resident #298) resident's reviewed during Stage 2 of the facility's annual Medicare/ Medicaid Survey. Resident # 298 was admitted to the facility on [DATE] at 4:20 PM from an acute care facility with a history of non- small cell [MEDICAL CONDITION]. While in the hospital, due to acute mental status changes, the resident was diagnosed with [REDACTED]. Resident #298, while in the hospital, was started on the medication [MEDICATION NAME] for cerebral [MEDICAL CONDITION] (swelling of the brain.) The resident started [MEDICAL CONDITION] therapy in the hospital on [DATE], and was to continue to 6/23/16. Review of Resident #298s medical record revealed the medication list on the discharge summary from the acute care facility which included [MEDICATION NAME] ([MEDICATION NAME]) 4 mg every 6 hours. Review of the June 2016 physician's admission orders [REDACTED]. Further review revealed a progress note on 6/17/16 at 4:21 PM which noted the resident had a change in mental status, inability to hold self-up, and vomited on the way to [MEDICAL CONDITION]. The note indicated that they were unable to do a [MEDICAL CONDITION] treatment due to the resident's condition. The note continued for labs to be drawn immediately, and [MEDICATION NAME] to be given. On 6/17/16 at 5:36 PM, Nurse Practitioner (NP) #1 examined the resident for a reported change in mental status, and noted that the patient did not receive the [MEDICATION NAME] that was to be ordered upon admission. The [MEDICATION NAME] was given stat (immediately) on 6/17/16 at 3:50 PM. Interview of LPN #3, on 8/2/16 at 9:30 AM, revealed that [MEDICAL CONDITION] called and said if the resident wasn't on [MEDICATION NAME] then the resident should be. LPN #3 stated I looked at the chart and realized the [MEDICATION NAME] was missed. At that time, I notified NP #1. Interview of the Medical Director (who was also the physician who wrote the H&P on 6/16/16) on 8/2/16 at 1:03 PM stated I was informed about the missed medication during a weekly meeting and was not happy. Interview of the Director of Nursing (DON) on 8/2/16 at 1:25 PM, stated there is a process in place whereby the night shift nurses check the orders at night time. The DON continued to state that the nurse pulls the orders up in the computer and compares to the discharge summary. The DON stated he/she was made aware on 6/17/16. v

Based on review of medical records, facility documents, facility policy and interview with facility staff, it was determined that the facility failed to have a system in place to consistently identify and monitor a resident (#109) with documented low blood pressures after a fall, and failed to have a system in place to immediately notify the physician/nurse practitioner of documented low blood pressures in a resident with falls, whose medication regimen included 3 blood pressure medications, in addition to a diuretic. The failure of the facility to promptly notify the physician/nurse practitioner of low blood pressure readings on multiple days and failure to ask the physician/nurse practitioner if the blood pressure medications should still be administered, and the failure of the physician/nurse practitioner to review the blood pressure readings when the readings were automatically placed in the progress note placed this resident and other residents at risk for potential adverse consequences. As a result a condition of Immediate Jeopardy was declared on 8/1/16 at 12:55 PM. The Nursing Home Administrator and the Director of Nursing were informed at that time of the need to prepare and implement an action plan so as to remove the condition of Immediate Jeopardy. On 8/1/16 at 6:05 PM the Immediate Jeopardy was abated. The facility put a plan in place to remove the immediacy. This was evident for 1 of 5 (Resident #109) residents reviewed for unnecessary medications and 1 of 3(Resident #76) residents reviewed for activities of daily living. The findings include: 1) Review of the medical record for Resident #109, a [AGE] year old male with a history [MEDICAL CONDITION] with [MEDICAL CONDITION] and [MEDICAL CONDITION], hypertension and [MEDICAL CONDITIONS], revealed that the resident had 3 falls between 5/25/16 and 6/6/16. On 5/25/16, it was documented that the resident had a fall with no injuries at 19:56 PM (7:56 PM). The documented blood pressure in the medical record at the time of the fall was 80/37. The note stated that the family was made aware of the fall. A general progress note written on 5/26/16 at 6:51 AM by Licensed Practical Nurse (LPN) #2 stated MD was not notified, will pass on to 7-3 nurse to follow up and inform MD. Neuro checks continues, vitals WNL (within normal limits). The resident was seen by Nurse Practitioner (NP) #1 and a note written on 5/26/16 at 12:15 PM stated pt seen and examined today per nursing report of pt having fall yesterday and the assessment/plan was to continue neuro checks, fall precautions, remind pt to call for assist for transfers-safety measures-pt has had prior falls-continue. Rehab services and monitor. Review of the medical record for Resident #109 revealed that he/she sustained a second fall on 6/5/16 at 9:20 AM and the following was documented: GNA (geriatric nursing assistant) responded to call light and found resident on floor between toilet and wall. Pt stated that he was dizzy prior to fall. Review of the vital sign summary for 6/5/16 at 9:23 AM revealed the b/p (blood pressure) was 68/43, at 10:33 AM 78/48, at 11:42 AM 76/47, at 13:17 (1:17 PM) 103/67 and 16:47 (4:47 PM) 97/58. The change in condition note that was written at 11:48 AM on 6/5/16 documented the b/p 76/47, and that the physician was notified of change in condition on 6/5/12 via communication book. The year 2012 was documented in the note. The Nurse Practitioner signed off on the communication book on 6/6/16. Continued review of the medical record revealed a third fall on 6/6/16 at 7:20 AM. The documented b/p in the medical record at the time of the fall was 87/56. It was documented that NP #1 was notified of the fall at that time. NP #1 documented in a progress note on 6/6/16 at 7:12 PM that the resident was seen. The b/p documented in NP #1's note was 87/56. There was no documentation related to the low blood pressure. Review of the Medication Administration Record [REDACTED]. Interview of NP #1, on 7/29/16 at 11:32 AM, revealed that NP was never notified of the low blood pressures and NP #1 continued to state that he/she would expect the blood pressure medications to be held per the parameters and would expect the nurses to notify him/her. There were no b/p parameters associated with the medications. NP #1 stated I should have reviewed to make adjustment to the blood pressure medications.NP #1 was asked if he/she was aware that the low blood pressure reading was in the 6/6/16 progress note. NP #1 stated no. The Director of Nursing (DON) was asked, on 7/29/16 at 12:28 PM, if he/she was aware of the low blood pressures and the response was no. The DON was asked would you expect the physician to be notified about the low blood pressure readings and asked if the medication should be held and the response was yes. LPN #2 was asked on 8/1/16 at 8:16 AM about notification of the low blood pressures and the response was I don't remember because that was long ago. When asked who takes vital signs when a resident falls, the response was I do it manually. LPN #2 stated when the GNA takes the vitals the machine sends and it automatically populates in the medical record. I didn't see that low blood pressure. When asked about the physician not being notified, LPN #2 stated he/she didn't remember. Twenty minutes later, LPN #2 came back to the surveyor conference room and stated I know in my nursing judgement that I would not have given the blood pressure medicine with a blood pressure like that. When asked what the blood pressure was, he/she said in the 130s. When asked if it was documented the response was no. GNA #4 was asked, on 8/1/16 at 8:45 AM, what the process was when an abnormal vital sign is noted on the vital sign machine. GNA #2 stated the vital sign machine sends the numbers to corporate. When asked by the surveyor if she tells anyone about the abnormal numbers the response was, I tell the nurse. Review of the communication book that was on the Long Term Care Unit where the resident resides documented 5/26 s/p (status [REDACTED]. RN #2, who worked as a full time registered nurse for the facility was asked on 8/1/16 at 10:05 AM, can you tell me what your communication book is used for and the reply was The communication book is a way of communicating resident concerns to the Nurse Practitioner (NP) and the Physician. RN #2 stated some of the concerns that are put in the communication book would be if a medication is not effective, the nurse would make a recommendation to change the medication, the dose of the medication or the frequency of the medication and any concerns that the physician can answer that the nurses cannot, and would require the physician's assistance goes into the communication book. Review of the policy Physician/Mid-level Provider Notification had guidelines for physician notification. The urgency grid was attached to the policy which stated this urgency grid is to be used for general reference only. Judgment and resident baseline should always be the primary factor in the timing of physician notification. The 5th condition/problem was blood pressure which stated Urgent, notify physician immediately once evaluation complete if above 210/120 or below 80/50. Routine was defined as above 180/100, below 90/60. Interview of NP #2 on 8/1/16 at 11:40 PM revealed I don't expect to be notified of a low blood pressure, I demand it. NP #2 stated he/she was never made aware of the low blood pressures or dizziness until Resident #109 had a more recent fall on 7/26/16 in which NP #2 discontinued 2 of the 3 medications, ordered orthostatic blood pressures to be taken and put parameters on when to hold the [MEDICATION NAME]. Interview of the Medical Director, on 8/2/16 at 1:03 PM, revealed that he/she expected to be notified about the blood pressure. The Medical Director stated I do have concerns about the follow up with the blood pressures. 2) Review of Resident #76's medical record, on 8/2/16 at 10:30 AM, revealed low blood pressures without physician notification. Review of the vital sign summary sheet revealed documentation on 2/16/16 at 15:16 PM, the b/p of 85/43 and on 2/16/16 92/54. On 2/17/16, the b/p was 81/58, 2/18/16 95/61, 97/63, 98/51. On 2/19/16, the b/p was 77/51 and 84/47. On 2/20/16, the b/p was 84/61 and 83/62. Review of nursing notes revealed that staff failed to notify the physician, and the antihypertensive medication [MEDICATION NAME] 10 mg was given every day at 8:00 AM from 2/6/16 until 2/21/16 at 3:45 AM when the [MEDICATION NAME] was discontinued. Continued review of the medical record revealed that [MEDICATION NAME] 10 mg was restarted on 3/22/16. There were no parameters ordered. Documented b/ps after the restart of [MEDICATION NAME] were as follows: 3/30 80/42 3/31 99/56 4/1 94/65 4/2 89/56, 91/63, 99/55, 98/60 4/4 86/64, 98/62 4/5 87/59 4/6 77/45 4/7 88/57 4/13 78/47, 87/60, 92/58 There was no physician notification until 4/14/16 when the physician was notified and the medication was held. The resident was sent out to the hospital on [DATE] and the blood pressure reading on 4/15/16 was 46/30. Advised the DON of the findings on 8/2/16 at 10:58 AM.