Every finding on record at Autumn Lake Healthcare at Riverview

Based on interviews, observations and record reviews, it was determined that the facility failed to provide adequate linen for residents. This was evident for two ([NAME] and Swan) out of four units observed during the recertification survey.The findings include:On 06/08/2026 at 8:26 AM, an interview with Resident #253 was conducted. They reported that the facility staff did not have enough linen and there were not enough bed sheets. The resident alleged that they were put in wheelchairs in the morning due to lack of bed sheets to make clean beds. On 06/08/2026 at 1:26 PM, an interview with Resident #128 was conducted. They reported that there were no sheets to make their bed and that the facility had a shortage of linen. At this time, the surveyor observed Resident #128's bed without any sheets. On 06/11/2026 at 12:37 PM, the surveyor observed room [ROOM NUMBER] bed 1 ([NAME] unit) with no bed sheets on and the resident was sitting in a wheelchair. A brief interview with Staff #28, Geriatric Nursing Assistant (GNA), was conducted. She reported that she had called the laundry department and requested for bed sheets to be delivered to the unit. She also added that in the morning, the linen carts are delivered late, and it is not enough, which affected the GNAs workflow. The surveyor also observed [NAME]'s linen cart and closet without any linens in storage. On 06/11/2026 at 1:09 PM, another interview with Staff #29, GNA, on swan unit was conducted. She reported the unit did not have enough linens for residents. The staff showed the surveyor the linen closet which had no towels or bed sheets. Similarly, the linen cart on the swan's unit hallway had no linens or towels. On 06/11/2026 at 1:15 PM, an interview with Staff #30 was conducted. When asked if they were aware of the linen shortage in the units, the staff reported that the GNAs were hiding linens and was unsure why. On 06/11/2026 at 1:19 PM, an interview with Staff #34, Environmental Services Director, was conducted. He reported that each resident is supposed to have 3 flat sheets, 3 fitted sheets, 3 pillowcases and 6 wash clothes per day. On 06/11/2026 at 1:24 PM, a review of the facility's document titled, linen par level, failed to show that linen supplied to all units were sufficient for residents. According to the document, Heroin unit had 31 beds, however, the sheets sent to the unit for the 7am- 3pm shift were for 30 beds. On 06/12/2026 at 9:42 AM, an interview with the facility administrator was conducted. She reported that the document submitted was for delivery schedule. When asked what the par levels for linen were supposed to be, she reported that she was unsure, however, she had identified that the linen shortage was an ongoing problem for the facility.

Based on record review, observation and interview, it was determined that the facility failed to maintain infection prevention and control regarding enhanced barrier precautions while providing high contact care. This was evident for four (Resident #12, #24, #147 & #223) out of seven residents reviewed for respiratory care. The findings include: Enhanced Barrier Precautions (EBP) are infection control measures, primarily for nursing homes, requiring healthcare workers to wear gloves and gowns during high-contact resident care activities (like bathing, dressing) to prevent spreading multidrug-resistant organisms (MDROs) to hands and clothing, even if blood/body fluid exposure isn't expected, extending standard precautions for residents with multidrug-resistant organisms (MDROs) or at high risk (wounds, devices). Personal Protective Equipment (PPE) refers to specialized gear like gloves, gowns, masks, and goggles that create a barrier to protect healthcare workers from infectious materials (blood, body fluids, germs) and prevent them from spreading infections to patients or others. 1) On 06/08/2026 at 10:08 AM, Geriatric Nursing Assistant (GNA#25) was observed providing a bed bath to Resident #12 while wearing gloves only. Observation revealed Enhanced Barrier Precautions signage was posted on the resident's door and at the bedside, indicating that both a gown and gloves were required during high-contact care activities. GNA #25 was not wearing a gown while performing the bed bath. When asked what precautions Resident #12 was on, GNA #25 stated she did not know. When asked whether appropriate PPE was required during bathing and direct resident care, GNA #25 stated she was not sure. On 06/08/2026 at 10:14 AM, Registered Nurse (RN #26) and Licensed Practical Nurse (LPN #27) were interviewed regarding facility expectations for caring for residents on Enhanced Barrier Precautions. RN #26 stated staff were expected to wear gowns and utilize appropriate PPE when providing direct care to residents on EBP. During a concurrent observation, RN #26 and LPN #27 confirmed that GNA #25 was not utilizing the required PPE while providing care to Resident #12. On 06/09/2026 at 10:22 AM, review of Resident 12's clinical record revealed an active physician order for Enhanced Barrier Precautions. 2) On 06/08/2026 at 10:57 AM, GNA #22 was observed providing a bed bath to Resident #24 while wearing gloves only and without a gown. When asked about the required process for providing direct care to a resident on Enhanced Barrier Precautions, GNA #22 stated she was supposed to wear a gown and acknowledged that appropriate PPE should have been utilized. On 06/09/2026 at 10:29 AM, review of Resident #24's clinical record revealed an active physician order for Enhanced Barrier Precautions. On 06/12/2026 at 8:50 AM, during an interview, the Infection Preventionist (IP), when asked about the facility's expectation regarding PPE, she stated staff were expected to follow precaution signage posted on resident doors and at the bedside. The IP further stated that staff providing direct care activities, including bathing and incontinent care, were expected to wear both gowns and gloves when caring for residents on Enhanced Barrier Precautions. When informed of the surveyor's observations, the IP acknowledged the concerns. On 06/12/2026 at 8:58 AM, the Director of Nursing (DON) was informed of the concerns. The DON acknowledged the observations and stated staff re-education would be provided. 3) On 06/09/2026 at 2:12 PM, surveyor observed Staff #21 changing soiled linens on Resident #223's bed. On 06/09/2026 at 2:20 PM, an interview with Staff #21 was conducted. She reported that she was not aware that the Enhanced Barrier Precautions (EBP) were for Resident #223, she thought it was for the roommate. Staff acknowledged that she did not wear the indicated personal protective equipment. Staff also acknowledged that she had not seen the sign above Resident's #223's bed that indicated EBP precautions were to be followed when changing soiled linens. On 06/09/2026 at 2:35 PM, an interview with Staff #6, Unit Manager, was conducted. She reported that all Geriatric Nursing Assistants (GNAs) had been trained to wear a gown and gloves when bathing and changing linens of residents who had EBP signs. On 06/11/2026 at 11:18 AM, a review of the facility provided list of residents on EBP precautions failed to include Resident #223. The review of Resident #223's medical record revealed an active order for EBP precautions. On 06/11/2026 at 11:20 AM, an interview with Staff #20, facility's infection prevention nurse, was conducted. She reported that Resident #223 should be on the list of residents on EBP precautions and that staff are expected to wear gown and gloves while changing soiled linens. On 06/11/2026 at 11:33 AM, the facility administrator was notified of the concerns. 4) On 6/10/26 at 8:28 AM, the surveyor observed GNA #15 providing Resident #147 a bed bath while not wearing a yellow PPE (personal protective equipment). It should be noted that GNA#15 was wearing gloves while providing this care. The surveyor did observe an EBP sign on Resident #147's door and a PPE bag with both gloves and gowns hanging on Resident #147's door. A review of Resident #147's EMR (electronic medical record) on 6/10/26 at 9:27 AM revealed that Resident #147's EMR (electronic medical record) contained an order for Enhanced Barrier Precautions (EBP) for a history of ESBL (extended-spectrum beta-lactamase, a group of bacterial enzymes that make bacteria resistant to many common antibiotics) infection.

Based on family interview, record review, and Staff interviews, it was determined that the facility failed to provide quarterly statements to the Resident's Representative. This was evident for one (Resident #7) out of two residents reviewed for personal funds. The findings include:On 6/8/2026 at 12:29 PM, an interview with Resident #7's Representative (RP) was conducted. When asked if they received quarterly statements from the facility, the RP stated that they have not been receiving them. On 6/8/2026 at 12:45 PM, a review of Resident #7's chart was conducted. Resident #7's RP was charted as the responsible party. Resident #7's Brief Interview for Mental Status (BIMS) was noted as 99. A BIMS (Brief Interview for Mental Status) is the standardized test which measures orientation and recall skills on a scale from 0 to 15. The number 99 is an administrative code used by care teams to indicate that the patient was unable to complete the interview.On 6/11/2026 at 12:45 PM, an interview with Business Office Manager (Staff #33) was conducted. When asked how Quarterly statements are provided to residents or representatives, Staff #33 stated they hand statements to residents that are capable in the building and mailed to RP's if the RP is the Power of Attorney (POA). When asked if Resident #7's RP was provided a quarterly statement, Staff #33 stated no because Resident #7's RP is not the POA. When asked if Resident #7 got the statement, Staff #33 stated nobody got the statement because Resident #7 does not have cognitive capacity. On 6/11/2026 at 1:30 PM, an interview with Nursing Home Administrator (NHA) was conducted. When asked if Resident #7's family given a quarterly statement, the NHA stated no because the RP is not a POA. This surveyor stated that regulation text does not specify RP requisite of being POA to be provided Quarterly Statements. NHA stated that the facility has been following this practice for years.

Based on review of the facility investigation and staff interviews, it was determined that the facility failed to ensure that a resident remained free from verbal abuse. This deficient practice was identified for 1 of 1 residents (Resident #85) reviewed for abuse during the annual survey. The findings include: On 06/11/2026 at 1:27 PM, a review of Facility Reported Incident (FRI) #3009635 revealed an allegation of verbal/mental abuse involving Resident #85 and Staff #35, a Geriatric Nursing Assistant (GNA). According to the resident, on 05/07/2026 at approximately 6:30 PM, Staff #35 entered the resident's room, stood over the resident's bed with her hands on her hips, and stated, You tried to get me in trouble with [NAME]. Resident #85 reported feeling threatened by the interaction and stated they thought Staff #35 was going to hit them.Further review of the facility's investigation on 06/11/2026 at 1:35 PM revealed that the resident consistently reported that Staff #35 entered their room the evening following a complaint regarding care and yelled at them about getting in trouble. The resident stated they felt threatened and intimidated by the interaction and no longer wished for Staff #35 to participate in their care.The investigation further revealed that the resident's roommate reported hearing staff in the hallway state words to the effect of, they are trying to get me in trouble and they are not even assigned to me. The roommate stated the staff member sounded angry and subsequently entered the room, where the roommate heard a similar conversation occur with the resident.The facility investigation substantiated the allegation based on the consistency of the resident's statements, corroborating witness information, and confirmation that Staff #35 entered the resident's room and spoke with the resident. The facility determined the interaction constituted intimidation and verbal/mental abuse.On 06/12/2026 at 11:58 AM, during an interview, the Administrator and Director of Nursing confirmed that the facility substantiated the allegation and determined that Staff #35's actions constituted verbal/mental abuse.

Based on record review and interview, it was determined that the facility failed to complete Quarterly Minimum Data Set (MDS) assessments within 14 days after the assessment reference date. This was evident for one (Resident #185) out of three residents reviewed for resident assessments.The findings include:The Minimum Data Set (MDS) is a mandated process for clinical assessment of all residents in Medicare or Medicaid certified nursing homes. This process provides a comprehensive and accurate assessment of each resident's functional capacity and health status to assist nursing home staff in identifying health problems. MDS assessments are required for residents on admission to the nursing facility and then periodically, within specific guidelines and time frames the Quarterly MDS is to be completed no later than 14 days after the Assessment Reference Date (ARD).On 6/10/26, a surveyor review of the clinical record of Resident #185 revealed that the quarterly MDS had an ARD date of 2/4/26. Staff was required to complete the annual MDS by 2/18/26. This MDS for Resident #185 is documented as completed on 3/25/26 (Z0500B- question location in the MDS), which was 35 days after the required completion date.Of note, RN (registered nurse) #35 (Corporate MDS Coordinator) signed that this MDS as complete on 5/14/26 (Z0500); however, in section Z0400 for eleven sections RN #35 signed as the signature of person completing the assessment or entry on 6/8/26 and dietician #36 signed one section in Z0400 on 6/4/26.During an interview on 6/11/26 at 9:32 AM, LPN (licensed practical nurse) #14 (MDS Coordinator) confirmed that the February 2026 Quarterly MDSs for Resident #185 were completed late. LPN #14 also confirmed that RN #35 was the Corporate MDS coordinator and worked remotely.

Based on record review and interview, it was determined that the facility failed to transmit MDS assessments within 14 days of completing the assessment. This was evident for one (Resident #185) out of three residents reviewed for resident assessments. The findings include:According to the RAI (Resident Assessment Instrument) (2018), the MDS (Minimum Data Set) is a federally mandated assessment tool that helps nursing home staff gather information on each resident's strengths and needs. Information collected drives resident care planning decisions. That information must be encoded in the form of an MDS assessment within 7 days of when an assessment of a resident is completed. It is also a requirement that MDS information be transmitted to the Centers for Medicare and Medicaid (CMS) System within 14 days after an assessment of a resident is completed. On 6/10/26, a surveyor review of the clinical record of Resident #185 revealed that Resident #185's Quarterly MDS that had an ARD (Assessment Reference Date) date of 4/30/25 was completed on 5/14/26 (Z0500B) and required to be transmitted to CMS by 5/28/26. This MDS for Resident #185 was transmitted on 6/8/26, which was 11 days after the mandated transmission due date.During an interview on 6/11/26 at 9:32 AM, LPN (licensed practical nurse) #14 (MDS Coordinator) confirmed that the April 2026 quarterly MDSs for Resident #185 was transmitted late.

Based on record review and interview, it was determined that the facility failed to accurately document health status in the admission Minimum Data Set. This was evident for one (Resident # 50) out of 35 residents reviewed during the survey.The findings include:The Minimum Data Set (MDS) is a mandated process for clinical assessment of all residents in Medicare or Medicaid certified nursing homes. This process provides a comprehensive and accurate assessment of each resident's functional capacity and health status to assist nursing home staff in identifying health problems. MDS assessments are required for residents on admission to the nursing facility and then periodically, within specific guidelines and time frames.During a review of Resident #50's clinical records on 6/9/26 at 8:50AM, it was noted that Resident #50 was admitted to the facility for rehabilitation on 5/26/26 after spinal surgery and with a percutaneous gastrostomy tube (PEG- a flexible feeding tube placed directly into the stomach through the abdominal wall) in place. Further review of the clinical record revealed that in the admission MDS (dated 6/1/26), Resident #50 was inaccurately coded in Section H Bowel and Bladder as having an ostomy (an opening in the abdomen to allow waste-urine or stool to leave the body) (H0100C- question location in the MDS).During an interview on 6/11/26 at 9:12 AM, LPN (licensed practical nurse) #14 (MDS Coordinator) stated, No, gastrostomy (PEG) tubes are not considered an ostomy. Gastrostomy tubes should be coded in Section K. During an interview on 6/11/26 at 9:32 AM, LPN #14 stated, I checked that MDS. Resident #50 has his/her PEG coded in Section K (K0520B). Coding that Resident #50 had an ostomy (H0100C) was an error. That resident does not have an ostomy.

Based on medical record review and staff interviews, it was determined that the facility failed to develop and implement a comprehensive, person-centered care plan to address identified pressure injuries. This was evident for one (Resident #75) out of two residents reviewed for pressure injury during the facility's recertification/complaint survey.The findings Include:On 06/11/2026 at 8:18 AM, review of Resident #75's clinical record revealed multiple pressure injuries. Review of wound assessments and treatment documentation revealed ongoing wound care interventions. However, review of the resident's care plan failed to reveal a care plan addressing the resident's identified pressure injuries, including the location of the pressure injuries, associated risks, goals, and individualized interventions.On 06/11/2026 at 8:56 AM, in an interview with the Unit Manager, Licensed Practical Nurse (LPN #12), when asked who was responsible for initiating and updating care plans, she stated that baseline care plans were initiated upon admission by all the nurses and that she was responsible for updating resident care plans. When asked whether a resident with pressure injuries a targeted pressure injury care plan should have, LPN #12 stated that such a care plan should be in place.On 06/11/2026 at 8:58 AM, after review of Resident #75's care plan by LPN #12, she stated that the resident did not have a care plan specifically addressing the resident's pressure injuries. LPN #12 acknowledged that a pressure injury care plan should have been developed. LPN #12 further stated that the resident had transferred from another unit and that a pressure injury care plan identifying the specific wounds and corresponding interventions should have been implemented.On 06/11/2026 at 11:47 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that Unit Managers were responsible for updating care plans. When asked whether a resident with pressure injuries should have a corresponding care plan, the DON acknowledged that such a care plan should be in place. When informed that Resident #75 did not have a care plan addressing the resident's pressure injuries, the DON acknowledged the concern.On 06/11/2026 at 11:52 AM, following surveyor inquiry, the Unit Manager (LPN #12) developed a care plan addressing the resident's pressure injuries, including wound locations and corresponding interventions.

Based on interviews and record review, it was determined that the facility failed to ensure participation of a resident in the care planning process. This was evident for one (Resident #12) out of three residents reviewed for care plan during the facility's recertification/complaint survey. The findings include:The care plan provides an opportunity to see if it meets the residents' needs by reviewing what strategies are working and which are not. It can also identify changes in the resident's condition or behavior that will require revisions of the care plan. Care conferences are usually held on a regular basis, often quarterly, but can be scheduled more frequently if needed based on the resident's condition.MOLST stands for Medical Orders for Life-Sustaining Treatment. It is a bright, easy-to-read medical form that turns one's end-of-life care wishes into real doctor's orders. It must be signed by a licensed doctor, nurse practitioner, or physician assistant.MDS stands for Minimum Data Set. It is a standardized, federally mandated clinical assessment tool used in Medicare and Medicaid-certified nursing facilities. It evaluates a resident's physical, psychological, and psychosocial well-being to determine their care needs and drive facility funding.BIMS stands for Brief Interview for Mental Status. It is a standardized screening test used by healthcare providers, primarily in nursing homes, long-term care, and post-acute care facilities to evaluate a patient's cognitive function. BIMS is a quick baseline check to monitor memory, attention, and orientation over time.On 06/08/2026 at 9:47 AM, during an interview, Resident #12 stated that he/she received notification of a care plan meeting scheduled for April 2026 and expected to participate. The resident stated the meeting did not occur and he/she was not informed of the reason it was not held.On 06/09/2026 at 10:22 AM, review of Resident #12's Minimum Data Set (MDS) assessment dated [DATE] in his/her electronic health record (EHR) revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating he/she was cognitively intact.On 06/09/2026 at 10:45 AM, further review of the resident's electronic health record (EHR) revealed a care plan documentation entry dated 04/15/2026 at 11:21 PM stating, Resident #12 and family were invited but not in attendance. Resident prefers to remain in bed. Resident is social, one-on-one. All care plans and MOLST were reviewed and no changes at this time. Resident remains Long Term Care. Continue to monitor and support.On 06/09/2026 at 10:55 AM, in an interview with the Social Worker Assistant (Staff #5), when asked about the process for care plan meetings, she stated care plan meetings were conducted quarterly and residents were notified by invitation. Staff #5 also stated residents and/or family members were expected to respond to the invitation and select a meeting time. When asked why Resident #12 was not present at the meeting, she stated that because Resident #12 did not respond to the invitation, a care plan meeting time and venue were not scheduled. When asked how the facility determined the resident did not wish to participate, Staff #5 stated that if a resident did not respond, it was assumed the resident was not interested in attending the meeting.On 06/09/2026 at 11:22 AM, in an interview with the Unit Manager (RN #7), when asked about the process of care plan meeting, she stated that stated that Social Services department distributed a list of residents due for care plan review and identified residents who responded to invitations. When asked about Resident #12's care plan meeting that was scheduled for April 2026, RN #7 stated the list did not indicate Resident #12 wanted a care plan meeting. RN #7 further stated previous care plan meetings for Resident #12 had been conducted in the resident's room because the resident preferred to remain in the room and was unsure why the resident did not participate in the April 2026 care plan review.On 06/09/2026 at 12:28 PM, the Director of Nursing was informed of the concern and acknowledged the facility's process as a concern.

Based on interviews and record reviews, it was determined that the facility failed to ensure medications were administered within the facility's established medication administration time frames. This was evident for three (Resident #18, #231 & #252) out of seven residents reviewed for medication administration. The findings include:1) On 6/8/2026 at 8:43 AM, an interview with Resident #18 revealed that he/she did not receive their medications on time. On 6/10/2026 at 9:10 AM, record review revealed that there was an active order for Apixaban (blood thinner) 5 milligrams by mouth every 12 hours. At the same time, it was revealed that Apixaban was administered late on the following dates: -6/2/2026 - Scheduled for 8:00 AM; administered at 9:23 AM-6/3/2026 - Scheduled for 8:00 AM; administered at 9:26 AM-6/4/2026 - Scheduled for 8:00 AM; administered at 9:30 AM-6/5/2026 - Scheduled for 8:00 PM; administered at 9:42 PM-6/9/2026 - Scheduled for 8:00 AM; administered at 9:54 PM 2)On 6/8/2026 at 1:09 PM, an interview with Resident #231 revealed that he/she did not receive their medication on time. On 6/10/2026 at 9:15 AM, record review revealed an active order for Apixaban 5mg by mouth twice daily. At the same time, it was revealed that Apixaban was administered late on the following dates: -6/1/2026 - Scheduled for 8:00 AM; administered at 9:23 AM. -6/2/2026 - Scheduled for 8:00 AM; administered at 9:24 AM. -6/3/2026 - Scheduled for 8:00 AM; administered at 9:31 AM. -6/5/2026 - Scheduled for 8:00 PM; administered at 9:27 PM. -6/9/2026 - Scheduled for 8:00 PM; administered at 9:48 PM. On 6/11/2026 at 9:30 AM, review of the facility's medication administration policy revealed that scheduled medications were expected to be administered within one hour of the scheduled administration time. On 6/11/2026 at 9:39 AM, an interview with the Director of Nursing revealed that the expectation was that any medication administered more than one hour past the scheduled time was considered late. On 6/11/2026 at 9:49 AM, the concerns were brought up with the Director of Nursing and she indicated that she understood. 3) On 06/08/2026 at 11:34 AM, an interview with Resident #252 was conducted. They reported that medications were not given on time. On 06/08/2026 at 1:04 PM, a review of Resident #252's medical records was conducted. The review of the Medication Administration Records revealed the following: On 06/05/2026 Metoprolol Tartrate Oral Tablet 25 MG was ordered for 8 AM, resident was given the medication at 11:22 AM, Aspirin Oral Tablet Chewable 81 MG (Aspirin) and Famotidine Oral Tablet 40 MG (Famotidine) was ordered for 9 AM, the medication were given at 11:22 AM. On 06/10/2026 at 12:46 PM, the administrator was asked to provide the facility's Medication Administrator Policy. The review of this policy indicated that medication should be administered within 60 minutes prior to or after scheduled time unless otherwise ordered by physician. On 06/11/2026 at 9:39 AM, an interview with the Director of Nursing (DON) was conducted. She confirmed that any medication given an hour after the scheduled time is considered a late administration, unless the nursing staff had a note that indicated why the medication was given late. At this time, the DON was made aware of the concerns identified.

Based on record review and interview, it was determined that the facility failed to provide necessary services. This was evident for one (Resident #253) out of five residents reviewed for ADLS (activities of daily living).The findings include:During screening on 6/8/26 at 11:53 AM, Resident #253 reported that he/she had only one shower since arriving at the facility on 5/29/26. Resident #253 stated, That was 10 days ago and the only reason I got that shower was I put up a fuss. I cannot shower on my own, especially washing my hair. I need help. I had a stroke. A review of Resident 253's EMR (electronic medical record) revealed that Resident #253 was admitted on Friday, May 29, 2026 with diagnosis including but not limited to, stroke with left-sided hemiplegia (paralysis).During a follow up interview on 6/9/26 at 1:29 PM, Resident #253 stated, I have had only one shower since I came here. I came on Friday, 5/29. I was told my shower day was Wednesday. Wednesday (6/3/26) came and I did not get a shower. On Thursday (6/4/26), when I complained about not getting a shower, GNA (geriatric nursing assistant) #9 gave me a shower. That place is like Grand Central Station. I made sure they pulled my curtain for privacy. No, I never refused a shower. I was begging them to give me one.During an interview on 6/9/26 at 1:41 PM, LPN (licensed practical nurse) #8 stated that the shower schedule is on the bottom of the unit assignment sheets. LPN # 8 stated, The facility has a shower refusal form that the staff fills out when a resident refuses a shower. Then the form is placed in the resident's chart. After reviewing Resident #253's medical record, LPN #8 confirmed there were no shower refusal forms in Resident #253's medical record.During an interview with GNA #9 on 6/9/26 at 2:34 PM, GNA #9 stated, I did shower Resident #253 on Thursday (6/4/26). It was not his/her scheduled shower day but I did it more for the issue that she had not had a shower in a while.since prior to admission here.A review of [unit] Assignment sheets for Saturday, 5/30/26, Wednesday, 6/3/26, and Saturday, 6/6/26 revealed that Resident #253's room was assigned to have a shower on day shift on these days. A review of Resident #253's shower documentation revealed there was not documentation of Resident #253 having a shower at any time during his/her eleven day stay at the facility. A review of Resident #253's task schedule in the EMR confirmed that Resident #253 was documented as scheduled to shower on Wednesdays and Saturdays. A review of Resident #253's admission MDS (Minimum Data Set) assessment documented in Section F Preferences for Routines and Activities in response to the question How important is it to you to choose between a tub bath, shower , bed bath or sponge bath?, Resident #253 responded, Very Important. The resident had three scheduled opportunities to receive assistance with a shower. During these three opportunities, the facility failed to provide the necessary care and services to maintain good grooming and personal hygiene.Resident #253 was discharged from the facility on Tuesday, 6/9/26.

Based on observations and interviews, it was determined that the facility failed to ensure that a resident had a call bell near reach. This was evident for one (Resident #8) out of eight residents reviewed for call bells during the recertification survey.The findings include:On 06/08/2026 at 9:47 AM, during unit round, the surveyor observed Resident #8 without a call bell near reach.On 06/08/2026 at 11:58 AM, an interview with Resident #8 was conducted. Resident reported that since they moved into their room, they've not had a call bell. The surveyor looked around the resident's bed and was unable to locate a call bell. On 06/08/2026 at 12:01 PM, an interview with Staff #4 was conducted in the resident's room. Staff looked under the resident's bed and was unable to retrieve the call bell. On 06/09/2026 at 1:58 PM, an interview with Staff # 6, Unit Manager, was conducted. She reported that it was the facility's expectation that all residents should have a call bell near reach at all times. At this time, the surveyor discussed the call bell concerns with the unit manager. On 06/09/2026 at 2:08 PM, the Director of Nursing (DON) was notified of the concerns.

Based on record review and staff interview, it was determined that the facility failed to implement care plan interventions to report a significant weight loss to the physician and Registered Dietitian. This was evident for one (Resident #2) out of two residents reviewed for nutrition and hydration.The findings include:On 6/8/2026 at 12:46 PM, a review of Resident #2's records was conducted. Resident #2 had a decline of 9.2 lbs (5.7%) from 5/6/2026 (162.2 lbs) to 6/1/2026 (153.0 lbs). This weight was documented by Staff #7. On 6/9/2026 at 10:23 AM, a review of the progress notes revealed that there was no Dietician or Provider notes regarding the weight change. The last Dietician note was on 5/27/2026 and addressed a progressive weight gain over 3 months leading up to the 5/6/2026 documented weight. Dietician documented to monitor for weight changes, labs, and percent of meal intakes. On 6/9/2026 at 10:40 AM, an interview with Staff #7 was conducted. When asked when the nursing staff would notify a Dietician or provider of weight changes, Staff #7 stated the dietician is notified when there is a significant weight change. When asked about Resident #2's weight change, Staff #7 stated that in this case they might do a reweight because of inaccurate scales and if we see a discrepancy like this. When asked if they had notified the dietician, Staff #7 stated they have not notified the dietician because they are waiting for a reweight to verify the weight. When asked if the resident had been reweighed, Stated #7 stated not yet but they are due for one. On 6/9/2026 at 11:58 AM, a review of the care plans was conducted. Resident #2 has a nutritional problem care plan with an intervention to Monitor/record/report to medical doctor as needed for signs and symptoms of malnutrition including significant weight loss: 3lbs in 1 week, >5% in 1 month, >7.5% in 3 months. This care plan intervention was created and last revised on 12/1/2025. On 6/9/2026 at 12:17 PM, an interview with the Director of Nursing (DON) was conducted. When asked what the expectation is for when the weight is reviewed and recognized that there has been a significant change, the DON stated the weight is reweighed. When asked when the weight is entered in the Electronic Health Record (EHR) will it alert the care giver if the weight change is significant, the DON stated yes, it will. This surveyor made the DON aware of Resident #2's recent 5.7 % weight loss over the past month with no provider or dietician note addressing the change. On 6/10/2026 at 8:30 AM, an interview with DON was conducted. When asked if the Resident had been seen by the dietician, the DON stated no but the dietician would see the resident today (6/10/2026) and a reweight would be completed. On 6/10/2026 at 8:49 AM, a review of Resident #2's chart was conducted. The resident was reweighed and weighed at 153.6 lbs on 6/9/2026. There was no dietician or physician notes addressing the resident's weight.

Based on observation, interview and record review, it was determined that the facility failed to be consistent with professional standards regarding supplemental oxygen requirement. This was found to be evident for two (Resident #15 and #147) out of four residents reviewed for Respiratory Care. The findings include: The facility's Oxygen Administration Policy: Policy Explanation and Compliance Guidelines: 1. Oxygen is administered under orders of a physician, except in the case of an emergency. In such case, oxygen is administered and orders for oxygen are obtained as soon as practicable when the situation is under control. (implemented 1/27/23) 1). Review of Resident #147's EMR (electronic medical record) revealed that the resident was admitted on [DATE]. During screening on 6/8/26 at 10:48 AM, Resident #147 was observed to be utilizing supplemental oxygen at 3 L (liters) of flow via a nasal cannula. On 6/10/26 at 8: 34 AM, Resident #147 was observed utilizing a nasal cannula supplying 3L of supplemental oxygen. A review of Resident #147's EMR (electronic medical record) revealed no active order for supplemental oxygen in Resident #147's active orders. During an interview on 6/11/26 at 8:49 AM, LPN (licensed practical nurse) #18 confirmed that Resident #147 was utilizing supplemental oxygen and that there was no active order in Resident #147's chart for this intervention. 2). On 6/8/2026 at 11:44 AM, an observation of Resident #15 was made. The resident was receiving 3 liters per minute of Oxygen via nasal cannula. On 6/10/2026 at 12:26 PM, a review of Resident #15's orders was conducted. The resident was ordered 2 liters per minute of Oxygen via nasal cannula continuously on 4/14/2026. On 6/10/2026 at 12:47 PM, a review of Resident #15's care plans was conducted. There are no care plans regarding Oxygen use. On 6/10/2026 at 1:22 PM, an interview with the Unit Manager (Staff #7) was conducted. When asked if they oversaw the care plans, Staff #7 said yes. When asked if a resident with orders for oxygen should have oxygen use care planned, Staff #7 said yes. This surveyor made Staff #7 aware of no oxygen use care plan for Resident #15. Staff #7 stated that they were not aware of oxygen use being new for this resident and did not realize that it had not been care planned yet. This surveyor made Staff #7 aware of Resident #15 being observed on 3 liters per minute of oxygen and not the ordered 2 liters per minute. Staff #7 confirmed this observation with the surveyor at this time.

Based on interviews and record reviews it was determined that the facility failed to ensure that residents received an annual dental visit. This was evident for two (Resident #13 and #85) out of four residents reviewed for dental services. The findings include: 1)On 6/8/2026 at 9:44 AM, an interview with Resident #13 revealed that he/she had not seen the dentist in a while. On 6/10/2026 at 12:16 PM, record review revealed that the resident was last seen by a dentist on 2/27/2024. 2)On 6/8/2026 at 9:08 AM, an interview with Resident #85 revealed that he/she had not seen the dentist in a while. On 6/10/2026 at 12:09 PM, record review revealed that the resident was last seen by a dentist on 4/2/2024. On 6/12/2026 at 10:40 AM, the concerns were addressed with the Director of Nursing.

Based on record review and staff interview, it was determined that the facility failed to ensure the accuracy and completeness of the clinical record for one (Resident #119) of five residents reviewed for advance directives during the facility's recertification/complaint survey. The findings include:MOLST stands for Medical Orders for Life-Sustaining Treatment. It is a bright, easy-to-read medical form that turns one's end-of-life care wishes into real doctor's orders. It must be signed by a licensed doctor, nurse practitioner, or physician assistant.On [DATE] at 10:43 AM, review of Resident #119's paper medical record revealed a Medical Orders for Life-Sustaining Treatment (MOLST) form indicating that informed consent had been obtained from the resident's guardian of person as per authority granted by court and other legal authority in accordance with all provisions of the Health Care Decisions Act. Review of the paper medical record and electronic health record (EHR) failed to reveal documentation of a current court-appointed guardian or other legal authority for Resident #119.On [DATE] at 10:57 AM, further review of the EHR revealed a Nurse Practitioner's progress note dated [DATE] documenting communication with the resident's surrogate, identified as the resident's cousin.On [DATE] at 11:06 AM, an interview was conducted with the Social Work Assistant (Staff #5) in the presence of the Nursing Home Administrator (NHA) and Director of Nursing (DON). Staff #5 stated the resident's previous legal guardian had died prior to the resident's admission to hospice services. Staff #5 stated that the guardian's son subsequently became involved in the resident's care; however, no legal guardianship documents existed. Staff #5 further stated the resident's cousin was the next of kin and did not possess legal authority to act as guardian. When informed that the MOLST documented informed consent had been obtained from a legal guardian and other legal authority, Staff #5 stated the information was inaccurate and required correction. During the same interview, the NHA confirmed the resident's legal guardian was deceased and acknowledged that the documentation on the MOLST regarding legal guardian and legal authority involvement was inaccurate.On [DATE] at 1:03 PM, after the surveyor's intervention, a revised MOLST form was completed to correct the inaccurate information. The NHA stated education would be provided regarding the accurate completion of MOLST documentation.

Based on record review and interview, it was determined that the facility's designated hospice interdisciplinary team member failed to ensure documentation regarding hospice care was available and communicated with the facility staff. This was evident for one (Resident #147) out of to residents reviewed for hospice. The findings include: A review of Resident #147's electronic medical record (EMR) on 6/10/26 at 10:04 AM revealed Resident #147 was admitted to [Hospice] services on 5/12/26 for metastatic colon cancer. Further review of Resident #147's medical record revealed the record did not have evidence of Resident #147's most recent hospice care plan, the hospice election form, the physician certification, and the names and contact information for the hospice personnel involved in Resident #147's care.During an interview on 6/10/26 at 10:47 AM, RN (registered nurse) #16 (hospice nurse) stated, We have a [hospice] IDT (interdisciplinary team) meeting every Thursday at our [the hospice] office and that is what generates the weekly care plan. I then bring the print out to the building. We used to put it in the chart but the charts were getting to big. Now we take it directly to Medical records because the charts were getting too big. I'll bring it [Resident #147's care plan] tomorrow. During an interview on 6/10/26 at 11:27 AM, the NHA (Nursing Home Administrator) and DON (Director of Nursing) confirmed that these documents were missing from Resident #147's chart.

Based on interviews, observations and record review, it was determined that the facility failed to serve residents meals that matched their tickets. This was evident for seven (Resident #74, #115, #146, #171, #193, #203 & #251) out of thirty-three residents observed during dining.The findings include: The findings include: On 06/08/2026 at 9:20 AM, during breakfast dining observation, review of meal tickets revealed coffee was listed as part of the beverages for residents. Observation revealed coffee was not served. Geriatric Nursing Assistant (GNA #24) stated that dietary unit had informed nursing staff that coffee was unavailable because the kitchen did not have coffee cups. 1) On 06/08/2026 at 9:22 AM, Residents #74, #115, #171, #193, and #203 stated they had not received coffee with their breakfast meals. Observation of the residents' meal trays confirmed coffee was not present. Review of each resident's meal ticket revealed coffee was listed as the assigned breakfast beverage. Geriatric Nursing Assistant (GNA#24), who was present during the observation, stated the residents had not received coffee for the past two days despite routinely requesting coffee with breakfast. 2) On 06/11/2026 at 9:23 AM, during a follow-up dining observation, Resident #146's breakfast tray contained cranberry juice. Review of the resident's meal ticket revealed orange juice was listed as the ordered beverage. When asked about the discrepancy, Resident #146 stated a preference for cranberry juice and reported not liking orange juice. GNA #24 confirmed Resident #146 routinely drank cranberry juice and stated family members had previously requested cranberry juice for the resident. On 06/11/2026 at 10:12 AM, when the Director of Nursing (DON) was informed of the concerns, she stated staff had reported that coffee had not been consistently available on the units. When informed that Resident #146's meal ticket did not reflect the resident's beverage preference, the DON stated the concern would be investigated. On 06/11/2026 at 11:34 AM, the DON provided an updated meal ticket for Resident #146 reflecting cranberry juice as the resident's preferred beverage. 3) On 06/08/2026 at 8:56 AM, an interview with Resident #251 was conducted. They reported that the meals served do not match what they ordered. They showed the surveyor their breakfast tray and reported that they were not served coffee, even though they had ordered it. A review of the meal ticket was conducted. The review revealed that the resident had requested coffee. On 06/11/2026 at 10:12 AM, an interview with the Director of Nursing (DON) was conducted. She reported that it was brought to her attention by staff that residents are not served coffee regularly because it was not being delivered to the units. Additionally, the DON reported that she had identified that some menu tickets did not have sections for residents to request certain items such as hot tea. DON was made aware of the concerns identified by the survey team.

Based on 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 6 (Residents #3, #1, #9, #4, #12, #10) 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. 1) On 4/27/26 at 12:40 PM a review of Resident #3's medical record was conducted and revealed Resident #3 had a history of cerebrovascular disease.Review of Resident #3's MDS assessment with an ARD of 3/2/26, Section J0100A pain management, received scheduled pain medication was coded, yes. Review of Resident #3's March 2026 Medication Administration Record (MAR) failed to produce documentation that Resident #3 received pain medication daily.On 4/30/26 at 12:45 PM Licensed Practical Nurse (LPN) #17, stated that she coded it that way because Resident #3 received Aspirin 81 mg. everyday.Review of Resident #3's March 2026 physician's orders revealed the Aspirin low dose 81 mg. chewable tablet was prescribed daily for prophylaxis. Aspirin is prescribed to prevent secondary cardiovascular events like heart attacks and strokes (cerebrovascular events).Review of the RAI (Resident Assessment Instrument) Manual documented, if the primary purpose of the drug is not to reduce the resident's pain, then it should not be coded here.On 4/30/26 at 2:00 PM the Nursing Home Administrator (NHA) and the Director of Nursing (DON) were informed of the error.2) On 4/28/26 at 8:05 AM a review of Resident #1's medical record revealed Resident #1 had a history of cerebral infarction, congestive heart failure, and vascular dementia.Review of Resident #1's progress notes revealed Resident #1 had a fall on 11/19/25 and 1/30/26. There were no injuries noted. Review of Resident #1's MDS assessment with an ARD of 2/4/26, Section J1900, Number of falls since admission or prior assessment, which was 11/11/25, documented the resident had 1 fall. The facility failed to capture the fact that Resident #1 had 2 falls during that time. Section J0100A, pain management, received scheduled pain medication regimen was coded no.Review of Resident #1's February 2026 MAR documented the daily use of Diclofenac topical gel for pain. The facility failed to capture the daily pain medication use.Further review of the February 2026 MAR documented the daily use of Aspirin 81 mg. every day for coronary artery disease.Review of Section N0415 (High-Risk Drug Classes) was not coded for an anti-platelet medication. The facility failed to capture the use of Aspirin as an anti-platelet medication. On 4/29/26 at 10:12 AM an interview was conducted with LPN #14. LPN #14 confirmed that she missed the second fall, and she confirmed the Aspirin error.3) On 4/28/26 at 11:35 AM a review of Resident #9's medical record was conducted. Review of Resident #9's MDS assessment with an ARD of 8/26/25, Section N0415 (High-Risk Drug Classes) documented the use of a hypnotic medication.Review of Resident #9's August 2025 MAR failed to produce documentation that a hypnotic medication was administered.Review of Resident #9's MDS assessment with an ARD of 11/26/25, Section N0415 (High-Risk Drug Classes) coded that a hypnotic medication was administered. There was no documentation that an antidepressant medication was administered.Review of Resident #9's November 2025 MAR failed to produce documentation that a hypnotic medication was administered, however, there was documentation that Sertraline (antidepressant) 50 mg. was administered every evening. The facility failed to capture the use of the antidepressant. The facility inaccurately coded that a hypnotic medication was given.Review of Resident #9's MDS assessment with an ARD of 12/17/25, Section N0415 (High-Risk Drug Classes) coded that a hypnotic medication was administered.Review of Resident #9's December 2025 MAR failed to produce documentation that a hypnotic medication was administered.On 4/29/26 at 10:19 AM LPN #11 was interviewed and stated that she was coding the medication Clonazepam (antianxiety medication) for the dual use of anxiety and hypnotic. LPN #11 stated they were using the USP Medicare Model Guidelines V6.0 when coding medications.Review of the USP Medicare Model Guidelines V6.0 failed to indicate that Clonazepam was a hypnotic medication.On 4/29/26 at 12:30 PM LPN #11 confirmed the errors.4) On 4/28/26 at 12:15 PM a review of Resident #4's medical record was conducted.Review of Resident #4's MDS assessment with an ARD of 1/8/26, Section J0100A pain management, received prn (when necessary) pain medication was coded, yes. Review of Resident #4's January 2026 Medication Administration Record (MAR) failed to produce documentation that Resident #4 received prn pain medication.Review of Resident #4's MDS assessment with an ARD of 4/10/26, Section N0415 (High-Risk Drug Classes) documented the use of an anti-anxiety medication.Review of Resident #4's April 2026 MAR failed to reveal that an anti-anxiety medication was administered.On 4/29/26 at 9:59 AM Licensed Practical Nurse (LPN) #12 confirmed the errors.5) On 4/29/26 at 7:38 AM a review of Resident #12's medical record was conducted and revealed Resident #12 had a history of traumatic subarachnoid hemorrhage, type 2 diabetes mellitus with diabetic neuropathy, atrial fibrillation, and atherosclerotic heart disease.Review of Resident #12's MDS assessment with an ARD of 2/3/26, Section J0100A pain management, received scheduled pain medication was coded, yes. For received prn (when needed) pain management, it was code, no.Review of Resident #12's February 2026 MAR failed to produce documentation where a pain medication was given every day. The pain reliever Tylenol was administered when needed for pain on 2/1/26 at 12:19 PM and 20:21 (8:21 PM), 1/31/26 at 10:13 AM, 1/30 at 20:36 and 1/29 at 20:10. The MAR also documented that Resident #12 received Aspirin 81 mg. every day for heart failure. The facility failed to capture the prn pain medication administration and inaccurately coded that pain medication was given daily.Continued review of the 2/3/26 MDS assessment, Section N0415 (High-Risk Drug Classes), documented that hypoglycemic medication was not administered during the look back period, however review of the February 2026 MAR documented that Resident #12 received Rybelus every day for diabetes mellitus.On 4/30/26 at 12:45 PM LPN #17 stated that she coded that way because Resident #12 received Aspirin 81 mg. everyday. The Aspirin should not have been coded as pain medication as that was not the intent for the medication. LPN #17 confirmed that she inaccurately coded the hypoglycemic medication.On 4/30/26 at 2:00 PM the Nursing Home Administrator and the Director of Nursing were informed of the MDS coding concerns.6) On 4/29/26 at 12:45 PM a review of Resident #10's medical record was conducted and revealed Resident #10 had a history of cerebral infarction (stroke) with hemiplegia and hemiparesis affecting the right dominant side.Review of Resident #10's MDS assessment with an ARD of 2/7/26 and 2/18/26, Section J0100A pain management, received scheduled pain medication was coded, yes. Review of Resident #10's February 2026 Medication Administration Record (MAR) failed to produce documentation that Resident #10 received pain medication daily.On 4/30/26 at 12:45 PM LPN) #17 stated that she coded that way because Resident #10 received Aspirin 81 mg. every day as a prophylactic. The Aspirin should not have been coded as pain medication as that was not the intent for the medication.On 4/30/26 at 2:00 PM the Nursing Home Administrator and the Director of Nursing were informed of the MDS coding concerns.

Based on review of complaint, medical record review, and staff interview, it was determined the facility failed to notify a resident's responsible party (RP) when there was a change in condition in a resident's medical status. This was evident for 1 (Resident #11) of 16 residents reviewed during a complaint survey.The findings include: Narcan (naloxone) is a life-saving nasal spray that rapidly reverses opioid overdoses. It is used for emergencies involving heroin, fentanyl, or prescription opioids and is safe to use even if no opioids are present. On 4/27/26 at 9:14 AM a review of complaint 2991540 alleged there was no communication with the RP when the medication Narcan had to be administered to Resident #11 for an alleged overdose. On 4/27/26 at 9:14 AM a review of Resident #11's medical record revealed progress notes that documented Resident #11 was admitted to the facility in March 2026 with diagnoses that included a nondisplaced zone 1 fracture of the sacrum, a nondisplaced fracture of the posterior column of the right acetabulum (the deep, cup-shaped socket on the right side of the pelvis that forms the hip joint by articulating with the femoral head), fracture of the right pubis (hip bone), and other chronic pain. Review of a 4/3/26 nurse practitioner initial evaluation note documented, pain and opioid management, patient is at high risk for poor function improvement in therapy without adequate pain management. The pain medication that was prescribed from the hospital and was to be continued on at the facility included Hydromorphone 6 mg (opioid) every 4 hours when needed (prn), Hydromorphone 4 mg every 4 hours prn, Tylenol 1 gram every 6 hours prn, Lidocaine cream to the back every 6 hours prn, Methocarbamol (muscle relaxant) 500 mg. every 6 hours prn, Celebrex 100 mg. twice per day, and Gabapentin 300 mg. three times a day. Review of a physician's note dated 4/8/26 at 12:42 PM documented, the patient reportedly had opioid overdose earlier this morning around a.m. and responded well to Narcan administration by nursing. Chronic pain, opioid overdose s/p Narcan. Further review of Resident #11's medical record failed to produce documentation that Resident #11's representative was notified of the incident. On 4/27/26 at 10:46 AM Licensed Practical Nurse (LPN) #4 (agency nurse) was interviewed and stated that Resident #11 was out of it and not responding when LPN #4 was doing rounds, so LPN #4 went to see if there was an order for Narcan. LPN #4 found the order and administered the Narcan and Resident #11 responded. On 4/27/26 at 10:55 AM an interview was conducted with the Director of Nursing (DON). The DON stated she would have expected the responsible party to be notified. On 4/27/26 at 1:09 PM LPN #19 was interviewed and stated the nurse administered the Narcan as the resident looked like the he/she was having an overdose. The physician saw the resident afterwards. LPN #19 stated, I don't think anyone was notified, but should have been.

Based on medical record review, administrative report reviews, facility staff, and family interviews, it was determined that the facility failed to provide residents (Resident #4 and #6) with adequate supervision and a safe environment. This resulted in harm to one resident (Resident #4) when the unattended resident fell out of a shower chair and sustained a left [CONDITION(S)] that required hospitalization . A second resident (Resident #6) with cognitive impairment was left in an unsafe environment by leaving a bed without a mattress in the resident room. This resulted in skin tears from the exposed bed-springs. This was evident for 2 of 3 residents reviewed for safe environment during the complaint survey. The findings include: 1. On admission, Resident #4's medical diagnoses were urinary tract infection, lack of coordination, age-related debility, history of falls with fractured vertebra, reduced mobility, [CONDITION(S)] and chronic pain syndrome. On 12-26-2018 the facility developed care plans for Resident #4 that included: having the participation of 1 staff with bathing because of self-care performance deficit related to activity intolerance, impaired balance, and musculoskeletal impairment. This care plan, also, required 1 staff participation during toilet use and transfers. A care plan is a written guideline of care based on the individual resident's needs developed by an interdisciplinary team which includes nursing, rehabilitation staff, and dietary that communicates to other health care professionals. A written care plan decreases the risk of incomplete, incorrect, or inaccurate care. A review of Resident #4's medical record on 5-13-2021 revealed that on 1-18-2019 the resident was found alone on the shower room floor on his/her left side. Resident #4 told the facility he/she had pain radiating from the left hip. Resident #4 was transferred to the hospital and diagnosed with acute left [CONDITION(S)]. Geriatric Nursing Assistant (GNA#4) was interviewed on 5-13-21 at 12:28 PM. GNA #4 stated, On 1-18-19, I got all the stuff ready to bathe the resident (#4) and in shower room after the shower was done, we (Resident #4 and GNA #4) had forgotten the gown. Resident (#4) asked me to go get it (the gown) since his/her room was across the hall from shower room. I left the resident, got the gown and when I returned to the shower room the resident was on the floor saying I'm sorry, I'm sorry. I called the nurse and she came and then the resident went to hospital. Resident (#4) had slipped out of the shower chair. An interview with the Director of Nursing (DON) and the Quality Assurance (QA)and Staff Development Coordinator (QA) on 5-17-21 at 9:57 AM revealed that Resident #4 was alert and oriented, his/her skin was wet from the shower and the shower floor was wet at the time of the fall. Resident #4 was not wearing non-skid socks and had slid out of the shower chair. The DON and QA staff acknowledged that Resident #4 had a history of falls, gait imbalance, had pain in the left hip and did not want to move the left leg. Resident #4 was sent to the hospital and admitted with acute left [CONDITION(S)]. The DON and QA staff were notified on 5-17-21 at 9:57 AM of the harm level deficiency for failing to provide adequate supervision and a safe environment while showering Resident #4. 2. Review of complaint MD 198 on 05/12/2021 at 10 AM revealed an allegation that Resident #6 was observed with long and short cuts on his/her arms on or around 07/17/2020. Review of Resident #6's medical record on 5/12/2021 revealed that Resident #6 was admitted on [DATE] with diagnoses that include cognitive impairment, stroke, difficulty walking, and a history of falling. During an interview with the complainant on 05/12/2021 at 2:26 PM, the complainant stated that the nursing staff reported that Resident #6 suffered cuts to his/her arms on 07/17/2020. The complainant stated that she/he could not visit Resident #6 due to the Novel Coronavirus 2019 (COVID19) restrictions and at the time. The complainant, also stated that it was around this time when he/she called the local police and requested them to perform a wellness check on Resident #6. Review of facility reported incident MD 305 on 05/12/2021 at 3 PM revealed details of how Resident #6 obtained cuts to his/her arms on or around 07/17/2020. Facility reported incident MD 305 indicated that Resident #6 was observed lying in a bed without a mattress during the 3 PM - 11 PM shift on 07/16/2020. Later that evening Resident #6 was observed with skin tears to the upper left arm and wrist on 07/16/2020 at 11:30 PM. The facility documented that Resident #6 was unable to explain how he/she had obtained the skin tears to his/her arm and wrist. In an interview with the Nurse Unit Manager#17, on 05/18/2021 at 1:08 PM, Unit Manger #17 stated that Resident #6's family had requested a new bed assignment. Resident #6's family member wanted to move Resident #6 to the bed next to the window. There are 3 beds in the room and Resident #6 had resided in the middle, second, bed of the room. Resident #6 was moved by the facility staff to the third bed which was closest to the window. Unit Manager #17 stated that Resident #6 would keep going back and lying in the second bed in the room. Unit Manager #17 stated that he/she was the person who removed the second bed mattress and that this was done as a visual cue to help guide Resident #6 to seek the third bed closest to the window. Unit Manager #17 stated that Resident #6 was found lying in the mattress-less second bed on 07/16/2020 at 11:30 PM with skin tears to his/her arms. Unit Manager #17 stated that the exposed second bed springs are what caused the skin tears to Resident #6's left arm and wrist. In a follow-up telephone interview with Unit Manager #17 on 06/04/2021 at 1:03 PM, Unit Manager #17 stated that Resident #6's mattress was initially removed by the house keeping staff under her instructions on 07/09/20. Unit Manager #17 stated that removing Resident #6's mattress was not part of the resident's care plan. Unit Manager #17 stated that when the nursing staff observed the wounds to Resident #6's arm on 07/16/20 at 11:30 PM, Resident #6's physician was notified and gave orders instructing the nursing staff to clean Resident #6's injuries with wound cleanser and apply a xeroform dressing. Unit Manager #17 stated that he/she was made aware that Resident #6 kept going back and lying on the second mattress-less bed on 07/17/20 and that is when the staff removed the second bed from the room. Unit Manager #17 stated that Resident #6 could not understand that the staff had moved his/her bed to the third bed in the room as requested by Resident #6's representative.

Based on medical record review and interviews with the facility staff, physician, and pharmacy consultant, it was determined that the facility failed to monitor anti coagulant therapy for a resident which resulted in an acute gastro intestinal bleed. This was evident for 1 of 6 residents selected for review. The findings included the following: On 7/17/13, the surveyor reviewed resident #1 ' s medical record. The resident had been in the hospital from 2/22/13 -2/28/13 following a fall which resulted in a fractured right femur. The discharge summary noted that her discharge was delayed for reasons including an elevated INR - she was on [MEDICATION NAME]. The INR - international normalized ratio - is a blood test done to evaluate the effects of the anti coagulant, [MEDICATION NAME]. On 2/28/13, the resident was admitted to the facility and her orders included [MEDICATION NAME] 2.5 milligrams (mg) every evening. There was an order to check her INR on3/1/13 with a goal range of 2-3. On 3/1/13, her INR was 1.73 and there were no changes to her [MEDICATION NAME] order. From 3/13/13 - 3/19/13, the resident received an antibiotic, Bactrim DS, for treatment of [REDACTED]. Bactrim can interact with [MEDICATION NAME] and the effect it has on anti coagulation. On 3/17/13, the pharmacy consultant reviewed the medications and laboratory test results. She noted the INR result from 3/1/13. There were no other INR results at that time or an order to draw another one. On 3/20/13, the resident was transferred from the facility to the hospital with generalized weakness, low blood pressure - 80/40, and decreased responsiveness. In the emergency room the resident was examined. She had bright red blood in her rectum and dark tarry stool. Her INR was done and the result was a level of 13. She received II units of plasma, II units of packed red blood cells (PRBCs), and II liters of fluids and was admitted to the coronary care unit (CCU). She was diagnosed with [REDACTED]. Once she was admitted to the CCU she received frozen plasma and vitamin K. She had a GI consult and received intravenous (IV) medication to treat her GI tract, Pantoprazole. On 7/19/13, the surveyor interviewed the physician and the consultant pharmacist; they failed to provide additional information. On 7/22/13, the surveyor again interviewed the director of nursing; she failed to provide additional information. The facility failed to monitor the resident 's response to an anticoagulant. In summary: The resident was admitted to the facility on [DATE] following a hospitalization for a [MEDICAL CONDITION]. She was being treated with an anti coagulant. The effectiveness was checked one time, 3/1/13. She developed a UTI and was treated with an antibiotic. The antibiotic is known to interact with the anticoagulant. The facility staff, physician and pharmacy consultant failed to identify the need to do a blood test to check her anticoagulation. On 3/20/13, she had a change in condition and was transferred to the emergency room . There she was diagnosed with [REDACTED]. The facility, physician and pharmacy consultant failed to monitor the resident's anti coagulant therapy which resulted in an acute GI bleed.

Based on medical record and facility investigation review, interview with the facility staff, and surveyor observation, it was evident that the facility staff failed to adequately supervise a resident's placement in bed during a bed bath; this resulted in the resident rolling from the bed thus sustaining injuries. In addition the facility staff failed to maintain supervision of the medication keys which were discovered in another resident's possession. This was evident for 2 of 13 residents selected for review. The findings included the following. 1). The facility staff failed to adequately supervise the resident's placement in bed during a bed bath. This resulted in the resident rolling from the bed thus sustaining injuries. The standard of practice is to ensure that when a resident is turned, the resident is positioned safely in the center of the bed. On September 1, 2010, surveyor review of the facility incident/ investigation revealed that resident #10 fell out of bed when the geriatric nursing assistant (GNA) was providing a bed bath, on 8/3/10. The GNA, per her handwritten statement, had turned the resident on his right side. The GNA was standing behind the resident, on the opposite side of the bed, while providing care to the resident and the resident fell out of bed. The fall resulted in head trauma, pain in the hip, back, shoulder, neck and head. Following the fall the resident was transferred to the hospital via 911, for evaluation and returned with treatments including a neck collar and narcotics for pain management. The resident was diagnosed with [REDACTED]. Surveyor review of the medical record on 9/1/10, revealed that resident #10 was admitted to the facility on [DATE]. The resident had a history of [REDACTED]. The resident was noted to be dependent on the facility staff for hygiene and required extensive assistance with the help of 1 or 2 persons for transfers, dressing, and toilet use. Surveyor interview with the Director of Nursing, Administrator, and Medical Director on 9/1/10, noted that the resident had been dependent on the facility staff for turning and positioning at the time of the fall. According to the GNA communication cardex updated 7/22/10, the resident needed the assistance of 2 persons for turning and repositioning and 1 person for dressing and grooming. In addition, the resident's bed was to be in the low position with fall mats at all times. At the time of the fall on 8/3/10, the GNA turned the resident by herself, the bed was not in the low position and the fall mats were not in place. On 8/03/10 at 10:45AM, during a bed bath, while turned on his right side, the resident fell out of bed and sustained injuries. The resident was transferred 911 at 10:55AM. The resident was transferred back to the facility on [DATE] at 3:00PM, the next day. The re-admission orders [REDACTED]. The facility staff failed to adequately supervise the resident's placement in bed during bathing causing the resident to roll from the bed thus sustaining injuries. 2). The facility staff failed to maintain supervision of the medication keys which were discovered in the resident's possession. On 9/1/10 the surveyor reviewed the facility investigation dated 7/12/10. According to the investigation resident #1 had the medication keys in her possession and refused to give them to the staff. The certified medication assistant (CMA #4) responsible for the keys had left the keys unsupervised and the resident had gotten the keys. The resident's thumb was noted to be "deformed" looking during/ following attempts to retrieve the keys. The thumb was x-rayed which was negative. The origin of the "deformity" remained unknown following the facility investigation. The medication keys unlock the cart which holds the medications for that group of residents as well as medical supplies. It is the standard of practice to maintain supervision of these keys at all time. The facility staff failed to maintain supervision of the medication keys.