Every finding on record at Bel Aire Center

Based on interview and record review, the facility failed to provide education and ensure nursing competencies regarding the application and monitoring of an Unna boot (compression dressing impregnated with healing agents) for 3 of 3 nursing staff. As a result, Resident #1 developed a large necrotic ulcer on his/her foot requiring admission to the hospital which later resulted in a below the knee amputation.Findings include:Per record review, Resident #1 had a BIMS (Brief Interview of Mental Status) of 14, indicating no cognitive impairment. Resident #1's medical diagnoses include peripheral vascular disease (PVD) (a disorder of blood vessels that affects blood flow to the limbs), type 2 diabetes mellitus with diabetic neuropathy, and a history of peripheral artery disease (PAD; a disorder of blood vessels that affects blood flow to the limbs) with revascularization (surgical procedure performed to restore blood flow to the leg). Per record review of care plan Resident #1 is at risk for skin breakdown related to advanced age, fragile skin, DM (diabetes mellitus), created on [DATE]. Per record review, a [DATE] Physician note reveals that Unna boots were applied to Resident #1 in response to increased edema, soreness, and redness. Resident #1 had a physician order for Unna boots starting on [DATE] to be applied to lower extremities 2 times a week. Per review of Resident #1's Treatment Administration Record for [DATE], Unna boots were applied on [DATE] and changed on [DATE] by Nurse #1. Per record review of [DATE] and [DATE] skin checks, there is no documentation of a wound on Resident #1's right foot prior to application of the Unna boot.Per record review, Resident #1 was transferred to the Emergency Department (ED) on [DATE] for tachycardia (increased heart rate) and chest pain.Per review of Hospital Emergency Department notes dated [DATE], Resident #1 had Unna boots applied the day before ([DATE]) and reported increasing leg pain. S/he denied having any ulcers, blisters or redness on her right foot prior to application of Unna boots. Per review of the Hospital admission History and Physical Report dated [DATE], bilateral Unna boots were removed in the ED, and a large wound measuring 4 cm (centimeters) x 3 cm was found on the right dorsal (upper) foot that was very painful for Resident #1.Per review of a Hospital Physician note dated [DATE], [Resident #1] was being treated with Unna boots in the nursing home, and it seems [s/he] might have had one that was too tight and caused [him/her] pressure injury.Per review of the Hospital Discharge summary dated [DATE], it was noted that tight Unna boots were placed on Resident #1 by the Skilled Nursing Facility. On arrival to the Emergency Department s/he had a large necrotic ulcer on his/her right dorsal foot that was likely ischemic (condition of blood flow being blocked or reduced) in nature and complained of severe pain. Surgical debridement (removal of nonviable tissue) was performed on [DATE], and it was determined that the wound was unlikely to heal due to the extent of the ulcer and comorbidities. Resident #1 was being transferred to a tertiary center for management of this ischemic ulcer and likely associated osteomyelitis [bone infection]. Likely to require an amputation. Per interview with Resident Representative #1 on [DATE] at 10:03 AM, Resident #1 was transferred to another hospital on [DATE] for a below-the-knee amputation, which occurred on [DATE]. The resident was scheduled for a second surgery to amputate above the right knee but died before that could occur.Per interview with the Facility Medical Director on [DATE] at 1:18 PM, she stated that the hospital notified her that (Resident #1's) Unna boot was applied incorrectly.Per review of facility training records, no Unna boot training or competency, including how to apply or monitor the use of, was found for 3 of 3 nurses (Nurses #1, #2, and #3) prior to Resident #1 being transported to the ED on [DATE]. Nurse #1 who applied Resident #1's Unna boots on [DATE] and [DATE], did not have record of wound care competencies.Per interview with the DON and Facility Administrator on [DATE] at approximately 12:50 PM, they both confirmed there is no wound care or Unna boot training or competencies on record for Nurse #1. They failed to provide documentation of training on Unna boot application and monitoring for any nursing staff prior to [DATE].

Based on interview and record review, the facility failed to ensure care plans were updated with a new intervention for 1 of 3 residents sampled (Resident #1). As a result, the resident sustained a necrotic ulcer on his/her right foot related to improper application of an Unna boot (compression dressing impregnated with healing agents) requiring admission to the hospital which later resulted in a below the knee amputation. Findings include: Per record review, Resident #1 had a BIMS (Brief Interview of Mental Status) of 14, indicating no cognitive impairment. Resident #1's medical diagnoses include peripheral vascular disease (PVD) (a disorder of blood vessels that affects blood flow to the limbs), type 2 diabetes mellitus with diabetic neuropathy, and a history of peripheral artery disease (PAD; a disorder of blood vessels that affects blood flow to the limbs) with revascularization (surgical procedure performed to restore blood flow to the leg). Per record review of care plan Resident #1 is at risk for skin breakdown related to advanced age, fragile skin, DM (diabetes mellitus), created on [DATE]. Per record review, a [DATE] Physician note reveals that Unna boots were applied to Resident #1 in response to increased edema, soreness, and redness. Resident #1 had a physician order for Unna boots starting on [DATE] to be applied to lower extremities 2 times a week. Per review of Resident #1's Treatment Administration Record for [DATE], Unna boots were applied on [DATE] and changed on [DATE] by Nurse #1. Per record review of [DATE] and [DATE] skin checks, there is no documentation of a wound on Resident #1's right foot prior to application of the Unna boot.Per record review, Resident #1 was transferred to the Emergency Department (ED) on [DATE] for tachycardia (increased heart rate) and chest pain.Per review of Hospital Emergency Department notes dated [DATE], Resident #1 had Unna boots applied the day before ([DATE]) and reported increasing leg pain. S/he denied having any ulcers, blisters or redness on her right foot prior to application of Unna boots. Per review of the Hospital admission History and Physical Report dated [DATE], bilateral Unna boots were removed in the ED, and a large wound measuring 4 cm (centimeters) x 3 cm was found on the right dorsal (upper) foot that was very painful for Resident #1.Per review of a Hospital Physician note dated [DATE], [Resident #1] was being treated with Unna boots in the nursing home, and it seems [s/he] might have had one that was too tight and caused [him/her] pressure injury.Per review of the Hospital Discharge summary dated [DATE], it was noted that tight Unna boots were placed on Resident #1 by the Skilled Nursing Facility. On arrival to the Emergency Department s/he had a large necrotic ulcer on his/her right dorsal foot that was likely ischemic (condition of blood flow being blocked or reduced) in nature and complained of severe pain. Surgical debridement (removal of nonviable tissue) was performed on [DATE], and it was determined that the wound was unlikely to heal due to the extent of the ulcer and comorbidities. Resident #1 was being transferred to a tertiary center for management of this ischemic ulcer and likely associated osteomyelitis [bone infection]. Likely to require an amputation. Per interview with Resident Representative #1 on [DATE] at 10:03 AM, Resident #1 was transferred to another hospital on [DATE] for a below-the-knee amputation, which occurred on [DATE]. The resident was scheduled for a second surgery to amputate above the right knee but died before that could occur.Per interview with the Facility Medical Director on [DATE] at 1:18 PM, she stated that the hospital notified her that (Resident #1's) Unna boot was applied incorrectly.Per record review of Resident #1's care plan, his/her care plan was not updated to include the application and management of Unna boots.Per the facility's Skin Integrity and Wound Care Management policy, staff will monitor and observe the patient for changes and review and revise the care plan as indicated. Per interview with Director of Nursing (DON) on [DATE] at 11:00 AM, he confirmed that all new nursing interventions should be incorporated into the care plan.

Based on observation, interview, and record review, the facility failed to implement infection control policies regarding Enhanced Barrier Precautions (EBP; staff use of gown and gloves during high contact care) for 1 of 1 sampled residents. Findings include: Per the facility's Enhanced Barrier Precautions policy, reviewed on 4/1/2026 at 2:00 PM, patients with wounds or indwelling medical devices, regardless of multidrug-resistant organism colonization status, should be on EBP.Per observation on 4/1/2026 at 1:45 PM, the Wound Care Specialist failed to put a gown on before changing Resident #2's wound vac (a device that uses negative pressure to promote wound healing) and performing wound care. When interviewed immediately after wound care, she stated she felt she did not need to wear a gown. Per interview on 4/1/2026 at 2:10 PM, the Director of Nursing (DON) confirmed that Resident #2 should be on EBP due to wound status/presence of a wound vac, and that the nurse providing wound care should have worn a gown to prevent cross-contamination between the wound and clothing.

Based on interview and record review, the facility failed to ensure residents remained as free from accidents as possible related to falls for 3 of 3 sampled residents (Residents #1, #2, and #3) by failing to ensure assistive devices functioned properly, provide adequate supervision, and create and implement effective, timely interventions that would reduce the likelihood of future falls. As a result, Resident #1 suffered a fall that resulted in pain, a fractured nose, a left humerus (upper arm bone) fracture, and rib fractures. This is a repeat deficiency for this facility, with the violations cited during the previous recertification survey dated 7/17/25. Findings include:1. Per record review, Resident #1's care plan reveals that s/he needs assistance or is dependent on staff to perform activities of daily living (ADLs) and uses a wheelchair. His/her care plan includes the focus [Resident #1] is at risk for falls related to hx [history] of falls, poor safety awareness, unsteady gait, created on 2/10/22, including an intervention for Seat belt w/c [wheelchair] for fall reminder Monitor for safe use of belt Anti lock breaks on w/c, revised on 4/14/25. Physician orders include, Resident may use seat belt in w/c as [s/he] tolerates if resident can demonstrate safe use, start date of 11/4/22, and Assist resident qshift [every shift] when up in w/c with seat belt use, start date of 11/4/22. Regular progress notes reveal that Resident #1 can demonstrate removing the seat belt easily. Resident #1 has a BIMS (Brief Interview for Mental Status) of 10 as of 9/25/25 indicating moderate cognitive impairment. A Risk Management System (RMS) report of an unwitnessed fall dated 10/3/25 reads, Resident found on the floor laying on [his/her] right side, with foot under wheelchair, laying on [his/her] right arm, blood on the floor next to the resident's face, nosebleed from right nostril, hematoma to right forehead, laying in the hallway in front of [his/her] room door. Resident's seat belt on [his/her] wheelchair was loose. The report indicated that Resident #1 complained of 6 out of 10 pain and was sent to the ER (emergency room) for evaluation and treatment.A 10/7/25 Nurse Practitioner (NP) note describes that Resident #1 suffered nasal, humerus, and rib fractures, and is staying more in [his/her] room due to embarrassment of [his/her] facial bruising and need for more assistance.Slightly anxious affect, self-conscious about [his/her] facial bruising.Per record review, nursing notes show that Resident #1 reported 7 out of 10 multiple times between 10/3/25 through 10/15/25.Per interview and observation on 10/14/25 at 10:00 AM, Resident #1 was in the dining room, in his/her wheelchair. When asked about his/her current wheelchair and seat belt, s/he explained that s/he just got a new wheelchair moments ago and the one s/he is in doesn't have a seat belt (for which s/he is care planned for to prevent falls). S/he said s/he has had a seat belt for a long time because it reminds him/her not to stand up on his/her own. When asked about his/her most recent fall, s/he explained that s/he fell on [DATE] because s/he was trying to reach for something on the ground. S/he said the seat belt had been broken for a few days and it wasn't tight around his/her waste like normal, so when s/he reached down, the belt wasn't tight enough to reminder him/her not to get up, s/he fell, and the wheelchair tipped over on him/her. S/he explained that staff were not around when this happened. S/He explained that his/her face, head, arm, and ribs were injured from the fall, and it is painful. Resident #1 is noted to have bruising under both eyes, their left arm is in a sling, and s/he grimaced in pain when moving.Per phone interview with Resident #1's Representative on 10/14/25 at 2:30 PM, s/he explained that a staff informed him/her that Resident #1's belt was broken on 10/1/25. The Representative stated that the end of the belt had been tied, as the belt clip was broken and could not be repaired, and that the belt remained loose in this state. Per interview with the Nurse Practitioner (NP) on 10/14/25 at 1:35 PM, she revealed she was aware that Resident #1's seat belt had been tied on after it had been found damaged. She confirmed that Resident #1's seat belt did not function properly the day s/he fell. S/He said the belt was loose enough not to work as a reminder but tight enough to take the chair with them when they fell. Per interview with the Maintenance Director on 10/14/25 at 1:50 PM, he stated that nursing staff had notified him that Resident #1's seat belt was broken, and upon examining the belt to confirm it was broken, he informed nursing staff that he could not fix it. The Maintenance Director stated that nursing staff told him they would just tie it on. He explained that he ordered a new belt after he was notified that it was broken but it had not come in. He explained that the order was never processed because the facility had been cut off and the account had been closed but he was never notified that it did not go through.The Maintenance Director explained that a paper maintenance log at the nursing station is used to track needed repairs instead of the facility's TELS electronic system, because the girls just won't use TELS. The Maintenance Director was unable to produce the paper maintenance logs for the period prior to 10/14/25 because the logs are thrown out when completed. When asked about the current status of the belt, he explained that he just put a new belt on Resident #1's wheelchair today (10/14/25) that was taken from another resident's chair this morning.Facility policy titled PM100 The Equipment Life Cycle System (TELS): Use of, APPLICATION: Entire Company, revised 01/08/24 states, Centers and Senior Living Communities will use The Equipment Life Cycle System (TELS) to document maintenance of all equipment, including medical equipment, located at the service location. Data entry into TELS is the responsibility of the Maintenance Department.Per telephone interview with the Administrator on 10/14/25 at 2:44 PM, he explained that the team discusses broken equipment in morning meeting. He could not recall the last time it was discussed as a team that Resident #1's belt was broken. He confirmed that repairs should be entered in and tracked in TELS.Per record review, Resident #1 did not have any new interventions in their care plan following staff's knowledge of the broken seat belt and following his/her fall on 10/3/25. While the care plan was updated on 10/3/25 to include Resident seat belt Assessed each shift for looseness and dislodged, this intervention had already been in place since 11/4/22, as per physician orders.2. Per record review, Resident #3 was admitted to the facility on [DATE] with diagnoses that include mild dementia, history of falls, and benign prostatic hyperplasia (enlarged prostate that causes urinary problems, including frequent urination at night). Resident #3's admission Minimum Data Set (MDS; a comprehensive assessment) dated 7/14/25 reveals that Resident #3 requires moderate to maximal staff assistance for mobility, including ambulation and toileting.Resident #3's care plan focuses include Resident is at risk for falls: CVA [stroke], Impaired mobility, created on 7/11/25, and Resident is incontinent of urine with potential for improved control or management of urinary elimination. Dementia, created on 7/14/25. Interventions include Encourage resident to use toilet upon awakening, after meals, nightly and PRN [as needed], created on 7/14/25, and Check and change upon rising/ac [before meals]/PC[after meals]/ and prn, created on 7/14/25.Per review of Risk Management System reports, Resident #3 had 9 unwitnessed falls from admission through 8/16/25.The is no evidence that care plan interventions for falls were developed, implemented, documented, or monitored for the following falls, based on the Risk management reports, progress notes, care plans, and Licensed Nursing Assistant point of care documentation for the following falls:On 7/23/25, Resident #3 had an unwitnessed fall in his/her room. Resident #3 reported to be trying to close the window. The care plan was not updated until 8/20/25, 28 days after the fall with Place resident in high traffic areas when awake and confused.On 7/31/25, Resident #3 had an unwitnessed fall in his/her room, resulting in a skin tear to his/her right hand. Resident #3 reported to be trying to go to the bathroom. The care plan was not updated until 8/20/25, 20 days after the fall with Offer toileting assistance to resident before and after meals, before bedtime, and between 10:30pm-11:30pm.On 8/6/25, Resident #3 had an unwitnessed fall in his/her room. Staff document Resident needs assistance with walking, forgets [s/he] can't do it by [him/herself]. The care plan was not updated until 8/20/25, 14 days after the fall with Place bed in low position when in bed.On 8/7/25, Resident #3 had an unwitnessed fall in his/her room. Resident #3 reported that s/he was going to the bathroom and hit my face on the foot board. Resident #3 stated their pain was 2/10. Resident has a history of falls. [S/He] has been educated to use the call light for assistance before getting up unassisted and was able to demonstrate activation of the call light but [s/he] is forgetful and does not remember to use the call light. [His/Her] balance is an issue and is noted to lean far right when standing. Later that evening on 8/7/25, Resident #3 had an unwitnessed fall in his/her room and was found with an open area to right forehead and reported 7 out of 10 pain. Resident #3 was sent to the Emergency Room. The care plan was not updated until 8/20/25, 13 days after these two falls with Offer toileting every 2 hours while awake on odd hours.On 8/15/25, Resident #3 had an unwitnessed fall in his/her room. Resident #3 reported that s/he was going pee and lost my balance. There are no new interventions following this fall.On 8/16/25, Resident #3 had an unwitnessed fall in his/her room. There are no new interventions following this fall until 8/20/25, 4 days after the fall when Resident #3 was moved to a new room closer to the nursing station.Per a virtual interview on 10/17/25 at 9:30 AM, the DON explained that a resident's care plan should be updated by the floor nurse during the shift that the resident fell. She confirmed that Resident #3's care plan was not updated after each fall with the new interventions until 8/20/25 following many of the above falls. She was unable to provide evidence that the interventions were implemented, documented, or monitored prior to 8/20/25.3. Per record review, Resident #2 was admitted to the facility on [DATE] with diagnoses that include dementia, schizophrenia, and seizure disorder.Resident #2's admission Minimum Data Set (MDS; a comprehensive assessment) dated 7/18/25 indicates that s/he is dependent on staff for self-care and functional cognition and needs staff assistance for mobility. His/her cognitive skills for daily decision making are marked as severely impaired.Resident #2's care plan's focuses include Resident is at risk for falls: cognitive loss, lack of safety awareness, Impaired mobility, initiated on 7/16/25, and Resident is incontinent of urine and is unable to cognitively participate in a retraining program due to cognitive loss, created on 7/16/25, with an intervention to Check and change upon rising, ac, PC, hs [at bedtime] and prn, created on 7/16/25.Per review of Risk Management System (RMS) reports, Resident #2 had 4 unwitnessed falls in September 2025; 9/4/25, 9/6/25, 9/8/25, and 9/17/25. Reports indicated that on 9/17/25 Resident #2 had gotten up from wheelchair unassisted and was walking and fell, suffered a laceration to his/her face, and was transferred to the Emergency Room.Per a 9/4/25 RMS report, on 9/4/25, Resident #2 had an unwitnessed fall in the living room out of his/her wheelchair. Staff report that Resident fell after getting up from [his/her] wheelchair unassisted and attempting to walk. [S/He] was found to be experiencing increased fidgeting and had been incontinent. Toileting before and after meals and at HS added to POC [point of care; LNA documentation] to try and reduce the risk of additional falls. This intervention was added to the care plan on 9/4/25 but is not new as it is a repeat intervention from 7/16/25. An intervention was added on 9/5/25 to Keep in higher traffic areas when up to wheelchair.Per a 9/8/25 RMS report, on 9/8/25, Resident #2 had an unwitnessed fall in the living room out of his/her wheelchair. Staff report Resident #2 should have been in a higher traffic area due to history of getting up unattended.Per a 9/17/25 RMS report, Resident #2 was left unattended in the living room again and had an unwitnessed fall in the living room resulting in a laceration to the left side of face, and was transferred to ER. Staff report that s/he had gotten up from wheelchair unassisted and was walking and fell. There was no new intervention to prevent falls created after this fall.Per a virtual interview on 10/17/25 at 9:30 AM, the DON confirmed that Resident #2's care plan was only updated to reflect a medical review after the 9/17/25 fall.

Based on interview and record review, the facility failed to ensure that a resident was free from physical restraints for 1 of 1 applicable resident (Resident #2) related to a seat belt that the resident was unable to remove on their own. Findings include:Per record review, Resident #2 was admitted to the facility on [DATE] with diagnoses that include dementia, schizophrenia, and seizure disorder.Resident #2's admission Minimum Data Set (MDS; a comprehensive assessment) dated 7/18/25 indicates that s/he is dependent on staff for self-care and functional cognition and needs staff assistance for mobility. His/her cognitive skills for daily decision making are marked as severely impaired.Resident #2's care plan's focuses include Resident is at risk for falls: cognitive loss, lack of safety awareness, Impaired mobility, initiated on 7/16/25, and Resident uses Seat Belt for safety and security, initiated on 7/16/25. Interventions include the use of a Velcro seat blet, initiated on 7/16/25.A Restraint Evaluation/Reduction, was completed for Resident #2 on 7/16/25. It reads, a restraint can only be used to treat a medical symptom and not to manage behavior, provide convenience, discipline or because of any specific diagnosis. The form indicates that the medical symptom is dementia, and the restraint/device type is a Velcro seat belt used as an enabler/reminder for safety.Per review of Risk Management System reports, Resident #2 had 4 unwitnessed falls in September 2025; 9/4/25, 9/6/25, 9/8/25, and 9/17/25. Reports indicate that on 9/17/25, Resident #2 had gotten up from wheelchair unassisted and was walking and fell, suffered a laceration to his/her face, and was transferred to the Emergency Room.Per interview on 10/14/25 at approximately 11:00 AM, the Director of Nursing (DON) stated that there are no residents in the facility with a restraint. She explained that there are only two residents in the facility that use seat belts, one being Resident #2.Per observation on 10/14/25 at approximately 12:30 PM, Resident #2 was sitting by the nursing station in his/her wheelchair. S/He did not appear to have a belt on his/her chair.Per interview on 10/14/25 at 12:38 PM, Licensed Practical Nurse #1 (LPN) explained that Resident #2 wears a seat belt all the time. The LNAs (licensed nursing assistants) are supposed to document in the Kardex (LNA documentation system) when it is used and licensed nurses should evaluate Resident #2's ability to remove the belt every shift.Per interview on 10/14/25 at 12:40 PM, LPN #2 stated that she was Resident #2's nurse for the day but is new to working with Resident #2. S/he was unsure if Resident #2 should be wearing a seat belt while in the chair. LPN #2 was observed to check Resident #2 for a seat belt and confirmed that s/he was sitting in the wheelchair without a seat belt on.Per interview on 10/14/25 at 12:42 PM, the Unit Manager stated that Resident #2 should have a seat belt on at all times when sitting in their wheelchair. In a follow up interview at 1:24 PM, the Unit Manager explained that the DON had asked her to take the seat belt off from Resident #2's wheelchair today because Resident #2 was unable to remove it on his/her own.Per interview on 10/14/25 at 1:26 PM, the DON stated that Resident #2 is not cognitively able to remove the seat belt on command. The DON confirmed that Resident #2 had a buckle seat belt on as of today and was unable to provide any information as to when s/he was switched from a Velcro belt to a buckle seat belt.Per interview on 10/14/25 at 1:35 PM, the Nurse Practitioner stated that Resident #2 used a seat belt for fall prevention and was not cognitively able to remove the seat belt on command. The NP confirmed that Resident #2's buckle seat belt would be considered a restraint.Per phone interview on 10/15/25 at 3:17 PM, Resident #2's Representative explained that Resident #2 used to have a Velcro seat belt, but it was changed to a seat belt with a button after his/her last fall. The Representative doesn't remember the facility letting him/her know of the change or getting consent for that change but had noticed a change after a visit with Resident #2 after their last fall. The Representative explained that the seat belt was used to prevent Resident #2 from falling.Per record review, Resident #2 does not have a physician order for a buckled seat belt that specifies a medical symptom, frequency of use and release time, and activities to be performed during release. Resident #2's care plan was updated on 9/30/25 to remove the use of a Velcro seat belt and change to seat belt. Resident #2's medical record, including their care plan, does not include documentation of how the use of the seat belt would treat a medical symptom that warrants the use of restraints, the type of direct monitoring and supervision that will be provided during use of the restraint, recommendations for gradual reduction, or address any risks related to the use of the restraint. The is no evidence that consent was obtained for the use of a buckle seat belt. There is no evidence of completed restraint assessments after the initial evaluation completed on 7/16/25.Per a virtual interview on 10/17/25 at 9:30 AM, the DON was unable to determine who or when Resident #2's Velcro seat belt was changed to a buckle seat belt. The DON confirmed that the restraint policy was not followed for Resident #2 because his/her seat belt was not considered a restraint.Facility policy titled NSG233 Restraints: Use of, revised 9/15/25, reads, Patients have the right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the patient's medical symptoms . Falls do not constitute self-injurious behavior or a medical symptom that warrants the use of restraints. Physical restraint refers to any manual method, physical or mechanical device, equipment, or material that meets all of the following criteria: Is attached or adjacent to the patient's body, Cannot be removed easily by the patient, and Restricts the patient's freedom of movement or normal access to their body.Removes Easily means that the manual method, physical or mechanical device, equipment, or material can be removed intentionally by the patient in the same manner as it was applied by staff.3.1 The Center will determine the presence of a specific medical symptom that would require the use of restraints and determine:3.1.1 How the use of restraints would treat the medical symptoms;3.1.2 The length of time the restraint is anticipated to be used to treat the medical symptoms, who may apply the restraint, and the time and frequency that the restraint will be released;3.1.3 The type of direct monitoring and supervision that will be provided during use of the restraint;5. Obtain physician\advanced practice provider (APP) order specifying:5.1 Type of device;5.2 Specific medical symptom;5.3 Frequency of use and release time (NOTE: PRN orders are not acceptable);5.4 Activities to be performed during release.6. Patients with the restraint will be reassessed monthly for three months, then quarterly and with any significant change in condition or in accordance with state regulations.8. Consent must be obtained prior to the application of the restraint. The patient, or the patient representative if applicable, has the right to refuse the use of a restraint and may withdraw consent to use the restraint at anytime. Refusal must be documented in the medical record.10. Develop a plan of care for the use of the restraint. The care plan should be updated accordingly to include the development and implementation of interventions, recommendations for gradual reduction and address any risks related to the use of the restraint.

Based on interview and record review, the facility failed to ensure one resident (Resident #1) of three sampled residents was free from significant medication errors which resulted in a resident developing DVT [Deep Vein Thrombosis] and being transferred to the emergency department. Findings include: Per record review of Resident #1's EMR [Electronic Medical Record] Resident #1 has diagnoses of a right femur fracture, muscle weakness, anxiety, and atrial fibrillation [a condition where the heart beats irregularly]. Resident #1 has a BIMS [Brief Interview of Mental Status] score of 7 as of 8/4/25, indicating Resident #1 has cognitive impairment. The resident is dependent on staff for ADLs [Activities of Daily Living] and hygiene.Per record review, Resident #1 was admitted to the hospital on [DATE] for a hip fracture and was discharged on 8/1/25.Per record review of Resident #1's discharge summary from the hospital on 8/1/25 contains a medication reconciliation section with the order Enoxaparin 40 mg [milligram/ 0.4 mL [milliliter] injectable solution 0.4 milliliters subcutaneous (under the skin) every 24 hours for 30 days.Per record review of Resident #1's August 2025 MAR [Medication Administration Record] Resident #1 was prescribed Enoxaparin Sodium Solution 40 mg [milligrams]/ 0.4 ml [milliliter]: Inject 40 mg subcutaneously one time a day for prevent blood clotting for 10 days. The order is written to start 8/2/25. S/he was administered the medication from 8/2/25 to 8/11/25. Three licensed nursing staff members administered this medication over the 10-day period.Per record review of the facility's OPS424 Medication Reconciliation policy [last revised 12/16/24] states, 3. For patients admitted from the hospital: 3.1 obtain and review copies of the Medication Administration Records (MARs), Treatment Administration Records (TARs), transfer forms, and Physician's Order Sheets (POS). 3.1.1 Verify MAR/TAR information with transfer forms and POS, if available.3 Clarify medication orders with clinical staff from transferring hospital, when necessary 5.4 Any discrepancies discovered during reconciliation will be reported to the physician/APP [Advanced Practice Physician] before finalizing the current list of medications.Per record review of Resident #1's progress note written by the NP [Nurse Practitioner] on 8/26/25 at 11:44 AM states, Acute visit for DVT [Deep Vein Thrombosis] documented by ultrasound after ER [Emergency Room] transfer on 8/24 with reported 10 cm x 5.5 cm area of pain and redness which was enlarging. It was additionally noted that Lovenox [an injection that is used to help prevent blood clots] therapy was ordered for 30 days on discharge summary and given for 10 days; lapse of expected therapy for 12 days.Per record review of the ultrasound performed on 8/24/25 at the emergency department states, Impression: There is superficial thrombophlebitis involving a subcutaneous vein in the anterior right thigh as well as the great saphenous vein at the saphenofemoral junction. The latter extends into the anterior aspect of the common femoral vein, as an equivalent to deep venous thrombosis.An interview with the NP was conducted on 9/2/25 at 10:02 AM. The NP stated that the discharge order is checked when reconciling medication. She stated two nurses are supposed to check the order. She discussed she was called the morning of the visit to the emergency department visit by staff discussing the thigh swelling with a bruise type area. She stated, This was a med [medication] error. This should not have happened.An interview was conducted with LPN [Licensed Practice Nurse] #1 on 9/2/25 at 10:09 AM. LPN#1 stated she transcribed the orders from the resident's discharge papers. She stated, I did not hand off the check to the next person. I'm not sure if I should have. I wasn't alone that day but I'm not sure what happened. I don't know the process.[After the resident was sent to the hospital] They did an in-service education with a quiz.I still don't know the process. I'm trying to figure it out myself.An interview was conducted with the DON [Director of Nursing] on 9/2/25 at 10:50 AM. The DON stated, Most days orders come in and unit clerk puts them in. She wasn't here that day. Then [the medication is] recheck [ed] from admitting nurse, checked again by a second time.The order was not checked a second time.

Based on interview and record review, the facility failed to ensure residents received adequate interventions to prevent accidents for 2 residents [Residents #25 & #35] of 4 sampled residents. Findings include:1) Per review of Resident #25 medical record, Resident #25 has medical diagnoses of COPD [Chronic Obstructive Pulmonary Disease], history of a TIA [Transient Ischemic Attack, a transitory blockage of blood to the brain], muscle weakness, and anxiety. Resident #25’s BIMS [Brief Interview of Mental Status, a tool to assess cognitive function in residents] score was 3, indicating the resident is cognitively impaired. Resident #25’s MDS [Minimum Data Set, an assessment tool for clinical evaluation of residents] states that Resident #25 is dependent on staff for ADLs [Activities of Daily Living] and hygiene and is occasionally incontinent of bowels. Per record review of a physician progress note written on 7/7/25 at 12:00 AM states, “Per nursing documentation [s/he] had a fall around 22:30 on 7/2/25 and another at 03:00 on 7/3/25. [Resident #25] was noted to have a skin tear of [his/her] right forearm after the first fall. Later in the morning on 7/3/25, [s/he] was noted to have a large hematoma over the left scapula and appeared short of breath. SpO2 [Oxygen Saturation level] at the time was 79% on RA [room air] so home nocturnal oxygen was applied with improvement, and provider was contacted to request to send pt [patient] to ED [Emergency Department]. In the ED, it was also apparently reported that someone had seen bleeding from [Resident #25]’s left ear. No blood was noted on exam. FAST ultrasound of thorax was performed and demonstrated right and left pleural effusions (an accumulation of fluid in the pleural space of the lungs) but no other abnormalities. Chest x-ray showed chronic left pleural effusion and possible tiny right pleural effusion…CT of head demonstrated acute intra-axial hemorrhage of left frontal lobe measuring 1.8 x 1.6 cm without associated midline shift or upward or downward herniation, with a small subarachnoid component present superficial to intra-axial hemorrhage.” Per record of Resident #25’s care plan states, “Resident is at risk for falls r/t [related to] weakness and deconditioning. History of frequent falls and poor safety awareness.” This was added on 6/19/25. Interventions after the fall on 7/2/25 were added and included the following: “Send to ED for evaluation, Observe for changes in medical status, pain status, mental status and medication side effects that may contribute to cognitive loss/dementia/delirium and can lead to increase fall risk. report MD as indicated .Implement the following safety precautions: Remind resident often not to self transfer and to use [his/her] call bell to ring for assistance. Ensure resident has call bell within reach at all times, and Resident now resides in the room closest to the nurse's station for increased safety monitoring.” Per record review of a nurse progress note written 7/12/25 at 5:04 AM states, “Staff heard a noise at 0415, found [Resident #25] on the floor between [his/her] bed and the wall. Assessed for injuries, small laceration above right eye, raised area above left eye, 2 skin tears on left shin, areas both bleeding, bleeding stopped, areas cleansed, dressing applied, two assist up off the floor, called lumina [physician], updated, she ordered to send to ER for evaluation and treatment.” Per record review of a physician note written on 7/14/25 at 2:23 AM states, “Called regarding [Resident #25], who sustained a fall. Reports a recent history of a fall that resulted in a brain bleed. The current fall involved hitting [his/her] head again, causing a bleeding scalp laceration. Advised to send the patient to the hospital for evaluation due to the new head injury in the context of a recent intracranial hemorrhage…The patient [Resident #25], experienced a fall today, 07/12/2025. This fall resulted in a head injury with an associated bleeding laceration. This event is concerning given a recent history of another fall that caused a brain bleed. Due tothe [sic] repeat head trauma and active bleeding, immediate transfer to a hospital for emergency assessment was done. Vital signs could not be obtained at the time of the call given patient was transported to ed [Emergency Department].” Per record review, there were no additional medical documents from the Emergency Department found in the EMR [Electronic Medical Record]. Resident #25’s care plan was not updated after the fall on 7/12/25. Per record review of the facility’s “OPS416 Person-Cenetered Care Plan” policy [last revised 10/24/22] states, “7. Care plans will be:…7.2 Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly assessments, and as needed to reflect the response to care and changing needs and goals; and 7.3 Documented on the Care Plan Evaluation Note.” Per record review of the facility’s “NSG215 Falls Management” policy [last revised 3/15/24] states, “Patients experiencing a fall will receive appropriate care and post-fall interventions will be implemented…PURPOSE to ensure the patient-centered care plan is reviewed and revised according to the patient’s fall risk status. 2. Implement and document patient-centered interventions according to individual risk factors in the patient’s plan of care. 2.1 Adjust and document individualized intervention strategies as patient condition changes.” An interview was conducted with the DON [Director of Nursing] on 7/16/25 at 2:02 PM. The DON confirmed Resident #25 did not have any additional interventions in his/her care plan after second fall. The DON was unable to produce any additional neurological checks. She was unable to provide any additional documentation related to the fall on 7/12/25 in the patient’s medical record. Works Cited: Pleural Effusion. Cleveland Clinic. https://my.clevelandclinic.org/health/ diseases/17373-pleural-effusion. Accessed 7/24/25. Transient Ischemic Attack. Mayo Clinic. https://www.mayoclinic.org/diseases- conditions/transient-ischemic-attack/symptoms-causes/syc-20355679. Accessed 7/22/25. 2) Per record review, Resident #35 was admitted to the facility with diagnoses that include weakness, cognitive impairment, and a history of falling. Review of Resident #35’s Care Plan reveals the resident is identified as “at risk for falls: Impaired mobility, history of stroke, and left-sided weakness.” Per interview with the resident and h/her sister on 7/15/25 at 1:01 PM, the sister stated the resident has had multiple falls since admission and was recently found on the bathroom floor. Per review of Progress Notes for Resident #35 dated 6/3/25, “Registered Nurse asked this writer to check on [Resident #35] because she heard a bang. This writer found [Resident #35] sitting on [h/her] bottom leaning against the closet door. [S/he] was assisted to sitting position then assisted to the bed to sit on.” An interview was conducted with the Director of Nursing [DON] on 7/16/2025 at 1:55 PM. The DON stated that a new intervention should have been added to the resident's care plan to prevent future falls after the fall on 6/3/25 but was not. The DON reported that DON stated intervention for the 6/3/25 fall was listed in an incident report but not included in the care plan. The Incident report lists a Physical Therapy screen/evaluation to be conducted for the resident on 6/5/25. An interview was conducted with the Physical Therapist [PT] on 7/17/2025 at 12:49 PM. The PT reported that a screening had been attempted with Resident #35 after the fall on 6/3/25 but the resident had refused to be evaluated or participate in any therapy sessions that may have prevented future falls. The therapist confirmed that without a therapy evaluation nothing about the resident's care or treatment was changed. Per interview with the DON on 7/17/25 at 1:30 PM, the DON confirmed the therapy screening and evaluation was the only new intervention to be attempted to prevent future falls and was rejected by the resident. The DON confirmed the facility failed to evaluate the effectiveness of the intervention, and no other alternative interventions were considered or implemented to prevent future falls for the resident.

Based upon observation, interview, and record review, the facility failed to provide sufficient nursing staff to maintain the highest practical physical, mental, and psychosocial wellbeing of the facility's residents. Findings include:Per observation on 7/16/25 at 11:53 AM, Resident #4 was observed in his bed when s/he was delivered his/her breakfast. S/he rang his/her call light at 11:53 AM. Resident #4's call light was answered at 12:15 PM. It took 23 minutes for the call light to be answered. S/he discussed with the nursing staff who entered the room that s/he needed to use the restroom.Per observation on 7/17/25 at 9:27 AM, a call light went off for Resident #6. The call light was answered at 9:58 AM. The call light was not answered for 31 minutes. Per observation at 9:58 AM Resident #1 stated to the licensed nursing staff member that s/he needed hygiene care.An interview was conducted with Resident #40 on 7/15/25 at 11:36 AM. S/he stated, Sometimes I have to wait so long it soaks through my briefs into my clothes. I can't get up to go; if I could, I would. It usually happens around 4:00 PM. S/he discussed this is usually the change of shift. S/he stated, They [the nursing staff] tell me 'There's only two of us' or 'I'm covering this side all by myself.' Resident #40 has a BIMS [Brief Interview of Mental Status] score of 14, indicating s/he has no cognitive impairment.An interview was conducted with Resident #5 on 7/15/25 at 1:05 PM. Resident #5 discussed that s/he does not feel the facility has enough staff. S/he discussed that s/he has had to wait up to 45 minutes to an hour for his/her call light to be answered and that this happens several times a week. S/he discussed that they have had episodes of incontinence in bed from having to wait for staff to answer his/her call light. Resident #5 had a BIMS score of 15, indicating they have no cognitive impairment.An interview was conducted with Resident #4 on 7/16/25 at 11:41 AM. Resident #4 stated, There is not enough staff. Resident #4 discussed that nursing staff often say We are busy when answering his/her call light. S/he discussed that it often takes over ten minutes for call lights to be answered. Resident #4 had a BIMS score of 15, indicating they did not have any cognitive impairment.An interview was conducted with LPN [Licensed Practical Nurse] #1 on 7/16/2025 at 1:06 PM. She stated she smelled odors due to lack of care. She discussed that she had to work overtime or pick up extra shifts on a weekly basis. She discussed that she could not get her work done stating, I tried everything just to stay afloat. LPN #1 discussed that numerous family members have complained about the staffing. She stated that she often did not take breaks, and when she did they were between five and ten minutes.An interview was conducted with LNA #1 [Licensed Nursing Assistant] #1 on 7/17/25 at 9:08 AM. She stated she must work extra shifts several times a month. She stated working extra shifts and overtime was aggravating. LNA #1 stated some days the nursing staff do not get breaks because LNAs are helping with breakfast. She discussed that breakfast interferes with hygiene care, such as showers. She discussed that care is late due to working at breakfast. She discussed that meals often come late because nursing staff are attending to other job duties prior to breakfast such as residents' personal care. She stated because of giving care prior to breakfast, it often comes from approximately 10:00 AM to 10:30 AM. She discussed that lunch starts at 11:30 AM and thus residents do not have an adequate amount of time between meals. LNA #1 stated residents have made comments about low staffing. An interview was conducted with Resident #31's family representative on 7/17/25 at 10:20 AM. S/he stated Resident #31 does not always get the help he/she needs. S/he stated, They [the staff] tell us don't worry but the family representative was worrisome. S/he stated there was an issue with staffing. The family representative discussed that s/he is at the facility with Resident #31 a couple of hours a day and does not see staff repositioning the resident in wheelchair. The family representative stated an LNA stated to him/her I did a 14 hour shift today because I know that if I didn't stay, the elders on the floor wouldn't get the care they needed. The LNA also discusses they do not always have two staff available to operate the Hoyer lift.Per record review of grievances, Residents #3, #6 #9 #13 #15 #18 #35 and #42 wrote grievances for 6/3/25 that stated that two licensed nursing staff members refused to answer call lights the previous night. Resident #6's grievance says that they [the two licensed nursing staff members] stated, It's a rule to not help them [residents] at night. The residents continued to have concerns with staffing even after the grievances were filed.

Based upon observation and interview, the facility failed to ensure expired medications were stored or disposed of properly, and medications were secured. Findings include:Findings include:1) On 07/15/2025 at 3:12 PM, two medications were observed to be expired in 1 of 3 medication carts. The medications were Docusate Sodium (a medication to alleviate constipation) 100 mg [milligram] tab which expired on 1/2025. The other medication was Guaifenesin (a medication used to alleviate coughing) 16 fl oz [ounce] with an expiration date of 5/2025. The nurse assigned to the med cart confirmed that both medications were expired.2) Per review of the facility's policy titled Medication Storage Storage of Medication reviewed on 1/25, it states that Medication rooms, cabinets and medication supplies should remain locked when not in use or attended to by persons with authorized assess. Per review of the facility's policy titled Medication Administration General Guidelines reviewed on 1/25, it states During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse. No medications are kept on top of the cart. The cart must be clearly visible to the personnel administering medications when unlocked. On 07/15/2025 at 10:51 AM, the medication treatment cart was observed to be unlocked. At 10:59 AM the Director of Nursing (DON) who was assigned to the medication cart confirmed that it should have been locked.On 07/16/2025 at 9:25 AM, a Registered Nurse (RN) was observed dropping a Senna pill (medication to help alleviate constipation) on her medication cart and then walking away to the other medication cart to get more Senna pills, leaving behind the Senna pill unattended along with a medication pack of Benzonatate 100 mg tablets (a medication used to help alleviate coughing). The RN then walked past the medications left out on the cart (the Senna pill and Benzonatate pack) to a resident's room. When the RN returned from giving medications she confirmed that she had left out the Senna pill on the medication cart and the whole packet of Benzonatate pills.On 7/17/2025 at 11:24 AM, the medication treatment cart directly in front of the nurses' station was observed to be unlocked and one of the drawers partially opened on A-Wing. There were three staff in the hallway and two self-propelling residents in the hallway, both with a diagnosis of dementia. At 11:31 AM, the nurse was approached whose medication treatment cart was unlocked. She confirmed that it should have been locked.

Based on record review and interview, the facility failed to obtain required consents and maintain accurate records regarding influenza and pneumococcal vaccines for 3 out of 5 residents [Residents #2, 15, 50]. Findings include:1) Per record review of Resident #2's immunization records, Resident #2's representative declined having the administration of the influenza vaccine with the representative and the provider signing and dating the Influenza Vaccine Informed Consent document on 9/12/2024. On 10/10/2024, Resident #2 received the Influenza vaccination and there was no updated consent form in the Residents Electronic Health Records.2) Per record review of Resident #15's immunization records, the Resident did not sign the pneumococcal vaccine form, nor was it indicated whether the Resident wished to receive the vaccination. The provider, however, did sign and date the form and it is dated 4/22/2025.3) Per record review of Resident #50's immunization records, the Resident did not sign the pneumococcal vaccine form. A nurse signed where Resident #50 should have signed, and in the signature of a licensed nurse, the nurse had signed their name again.Per interview, it was confirmed by the DON on 7/17/2025 at 12:44 PM that Resident #2 did not have an Influenza vaccine consent form in the chart and that the pneumococcal vaccine for both Resident #15 and #50 was filled out incorrectly and needed to be updated.

Based on observation and interview, the facility failed to ensure one resident [Resident #4] of 3 sampled residents was treated with respect and dignity regarding personal medical equipment. Findings include:Per record review of the facility's OPS206 Resident Rights Under Federal Law policy [last revised 2/1/23] states, Purpose: to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of their self-esteem and self-worth.The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility.Per record review, Resident #4 has major diagnoses of BPH [Benign Prostatic Hyperplasia, a condition that causes an enlargement of the prostate), Type II Diabetes Mellitus, and spinal stenosis (a condition that causes a narrowing of spaces in the spinal canal). Resident #4's MDS [Minimum Data Set] states that Resident #4 is dependent on staff for ADLs [Activities of Daily Living] and hygiene. Resident's BIMS [Brief Interview of Mental Status] score was 15, indicating Resident #4 was not cognitively impaired.Per record review of Resident #4's care plan states, Monitor [foley catheter] for odor, color, consistency, and amount .provide privacy and comfort.provide privacy bag. This section of the care plan was last revised on 6/25/25. Per observation on 7/15/25 at 10:30 AM, Resident #4's foley bag was not covered with a privacy bag. The foley was draining yellow urine. An interview was conducted with LPN#1 on 7/15/25 at 2:38 PM. LPN #1 confirmed that the foley bag had no privacy bag and stated, I'll go do that now.Per observation on 7/16/25 at 9:51 AM, Resident #4's foley bag still did not have a privacy bag over it and the foley was draining yellow urine.Per interview with Resident #4 on 7/16/25 at 10:03 AM, Resident #4 stated I would like it properly covered, especially if I were in public.Per observation on 7/17/25 at 10:40 AM, Resident #4's foley bag was not covered with a privacy bag and was draining yellow urine.

Based on interview and record review, the facility failed to treat and manage 1 of 2 sampled resident's pain [Resident #40] per physician orders and plan of care. Findings include:Per record review, Resident #40 was admitted to the facility with diagnoses that include Arthritis: multiple sites. Per interview with the resident on 7/15/2025 at 11:33 AM, Resident #40 stated I have pain in my neck [a pinched nerve]. I have pain patches for my neck. I had them for 2 days, then none yesterday and none yet today. They told me they don't have an order for one.Per review of Physician Orders for Resident #40, an order dated 7/11/25 reads Lidocaine External Patch (4 % Lidocaine). Apply to Left side of posterior neck topically in the morning for neck muscle/skeletal issues for 10 Days -Start Date 7/11/2025 8:00 AM.Review of Resident #40's Medication Administration Record [MAR] for July 2025 reveals on 7/14/25 a marking for NN [Nursing Note] for the pain patch administration. Review of Nursing Notes dated 7/14/25 at 11:46 AM regarding the pain patch reveal the notation unavailable. Further review of Nursing Notes on 7/14/25 record Ask resident if they are having pain. Document pain level and new onset in supplementary documentation and document location of pain. If not new initiate non-pharmacological interventions and document interventions and effectiveness. Nursing documentation notes Resident #40 complaining of posterior neck pain with no non-pharmacological interventions attempted to relieve it. Review of Resident #40's Care Plan reveals interventions that include Administer medications as ordered and observe for effectiveness and side effects and report to Physician as indicated. An interview was conducted with the Director of Nursing [DON] on 7/16/2025 at 1:55 PM. The DON stated that if a medication is unavailable the resident's physician should be notified to order a hold or a substitute. The DON confirmed there was no documentation that the physician was notified Resident #40 did not receive h/her pain medication as ordered and no attempt to relieve the pain through non-pharmacological interventions.

Based on record review and interview the facility failed to have a consent form for 1 [Resident 42] out of 5 residents for Covid-19 vaccination. Findings include:Per record review of Resident #42's immunization records, the Resident did not have a covid vaccine consent form.Per interview, on 7/17/2025 at 12:44 PM it was confirmed by the Director of Nursing (DON) that it wasn't completed and needed to be done.

Based upon interview and record review, the facility failed to report allegations of abuse to the appropriate agencies and responsible parties in the required timeframes for 1 resident [Resident #1] of 4 sampled residents. Findings include: Per review of the facility's Abuse Prohibition Policy [revised 10/24/22]: - Anyone who witnesses an incident of suspected abuse, neglect, involuntary seclusion, injuries of unknown origin, or misappropriation of patient property is to tell the abuser to stop immediately and report the incident to his/her supervisor immediately, regardless of shift worked. - The notified supervisor will report the suspected abuse immediately to the Administrator or designee and other officials in accordance with state law - All reports of suspected abuse must also be reported to the patient's family and attending physician. -Anyone who witnesses an incident of suspected abuse, neglect, involuntary seclusion, injury of unknown origin, or misappropriation of patient property must also report to outside agencies, if required. -Staff are obligated to report reasonable suspicion of a crime against the elderly to the state agency and local law enforcement. Administrators and Directors of Nursing must assist in reporting. Per record review, Licensed Nurse's Aide [LNA] #1 provided a witness statement on 7/19/24 regarding an incident that had occurred 4 days earlier on 7/15/24 involving Res.#1 and another LNA [LNA #2]. Per LNA #1's statement: I was working on A wing with [LNA #2] . [LNA #2] did not ask [Res.#1] if [s/he] would like care done, instead [LNA #2] grabbed [Res.#1] by [h/her] arm and made [h/her] walk to the bathroom. [Res.#1] wanted to go to the sink to start, [LNA #2] grabbed [Res.#1] by [h/her] arm and attempted to force [h/her] to walk backwards toward the toilet. [LNA #2] also raised [h/her] voice at [Res.#1] when [s/he] did not cooperate. [Res.#1] said ouch and other things like you're hurting me multiple times .I tried to speak softly to [Res.#1] as [s/he] asked questions like 'why were we trying to kill [h/her]' and why [h/her] daughter would put [h/her] in a place like this, although I really did not have much to say because I was in disbelief. LNA #1's statement continues with after witnessing the alleged resident abuse, I couldn't find a nurse to report this incident to until much later and there was too much going on. The next day, while the Nurse Educator and I were talking, [s/he] asked me how the previous evening had went (working with [LNA #2]) and I told [h/her] about the incident and that I didn't really know the proper steps to take, and [s/he] told me that I can go online and make a report or that I could call a number to report it. Per review of facility records, the Nurse Educator did not report the abuse allegation to the facility's DON or Administrator [ADM] and did not follow up with LNA #1 to verify the allegation had been reported to the required agencies. An interview was conducted with the Director of Nursing [DON] on 8/12/24 at 10:19 AM. The DON reported [s/he] first became aware of abuse allegations on 7/18/24 when an Adult Protective Services investigator arrived at facility. The DON stated that the Abuse Procedure is to immediately report to the charge nurse, if charge nurse is not present, to call the DON day and night regardless. The DON stated the Nurse Educator 'absolutely should' have reported the abuse allegations after speaking with LNA #1 and informed the DON and Administrator [ADM] but did not. The DON stated there was a disconnect with following the proper procedure, and the Nurse Educator dropped the ball. Per review of a report form received at the Division of Licensing and Protection on Thursday, July 18, 2024, at 2:22 PM, [3 days after the incident] the DON reported Today at around noon Adult Protective Services showed up to [NAME] Aire Center after they received a report of a LNA [#2] yelling loudly and dragging resident [Res.#1] to the toilet . There have been no reports in the building of anything like this, no documentation in the resident's chart of any situation. The DON confirmed that facility staff failed to report the allegation of abuse on 7/15/24 to the facility's DON, ADM, and the appropriate agencies and responsible parties in the required timeframes.

Based upon interview and record review, in response to allegations of abuse the facility failed to Immediately investigate the allegations and to prevent further potential abuse for 1 resident [Resident #1] of 4 sampled residents. Findings include: Per review of the facility's Abuse Prohibition Policy [revised 10/24/22]: -Initiate an investigation within 24 hours of an allegation of abuse that focuses on: whether abuse or neglect occurred and to what extent. -The employee alleged to have committed the act of abuse will be immediately removed from duty, pending investigation. Per record review, Licensed Nurse's Aide [LNA] #1 provided a witness statement on 7/19/24 regarding an incident that had occurred 4 days earlier on 7/15/24 involving Res.#1 and another LNA [LNA #2]. Per LNA #1's statement: I was working on A wing with [LNA #2] . [LNA #2] did not ask [Res.#1] if [s/he] would like care done, instead [LNA #2] grabbed [Res.#1] by [h/her] arm and made [h/her] walk to the bathroom. [Res.#1] wanted to go to the sink to start, [LNA #2] grabbed [Res.#1] by [h/her] arm and attempted to force [h/her] to walk backwards toward the toilet. [LNA #2] also raised [h/her] voice at [Res.#1] when [s/he] did not cooperate. [Res.#1] said ouch and other things like you're hurting me multiple times.I tried to speak softly to [Res.#1] as [s/he] asked questions like 'why were we trying to kill [h/her]' and why [h/her] daughter would put [h/her] in a place like this, although I really did not have much to say because I was in disbelief. LNA #1's statement continues with after witnessing the alleged resident abuse, I couldn't find a nurse to report this incident to until much later and there was too much going on. LNA #1 stated that s/he reported the abuse allegation the next day during a conversation with the facility's Nurse Educator. Per review of facility records, the Nurse Educator did not report the abuse allegation to the facility's DON or Administrator [ADM] and did not follow up with LNA #1 to verify the allegation had been reported to the required agencies. An interview was conducted with the Director of Nursing [DON] on 8/12/24 at 10:19 AM. The DON reported [s/he] first became aware of abuse allegations on 7/18/24 when an Adult Protective Services investigator arrived at facility. Per review of a report form received at the Division of Licensing and Protection on Thursday, July 18, 2024, at 2:22 PM, [3 days after the incident] the DON reported Today at around noon Adult Protective Services showed up to [NAME] Aire Center after they received a report of a LNA [#2] yelling loudly and dragging resident [Res.#1] to the toilet . There have been no reports in the building of anything like this, no documentation in the resident's chart of any situation. The DON reported that it was after this occurred that the facility launched an investigation into the abuse allegation. Per record review, during the time of the witnessed alleged abuse, and the start of the investigation 3 days later on 7/18/24, LNA #2 was not immediately taken off duty or taken off the schedule after the incident on 7/15/24. Review of the facility's LNA schedule and LNA task record reveals that LNA #2 was assigned to and provided care to Res.#1 again on 7/17/24. The DON confirmed that an investigation into the abuse allegation should have been initiated immediately on 7/15/24 after the alleged event occurred, and that the staff member involved, LNA #2, should immediately have been taken off duty and taken off the schedule to prevent further potential abuse but was not.

Based upon interview and record review, the facility failed to implement care plan interventions regarding medications and physician orders for 1 resident [Res.#1] of 4 sampled residents. Findings include: Review of Res.#1's medical record reveals the resident was admitted to the facility on [DATE], with Physician Orders that included an order for 'Metoprolol: Give 1 tablet by mouth two times a day for blood pressure. Hold Metoprolol if Systolic Blood Pressure is less than 110 or Heart Rate is less than 65.' [Metoprolol is a medication that affects the heart and circulation and is used to treat angina (chest pain) and hypertension (high blood pressure)] (https://www.drugs.com/mtm/metoprolol-succinate-er.html) [ A blood pressure reading has two numbers. The top number is called the Systolic Blood Pressure. The top number measures the pressure in the arteries when the heart beats.] (https://www.mayoclinic.org/diseases-conditions/high-blood-pressure/in-depth/blood-pressure) Review of Res.#1's Care Plan reveals the resident is identified as exhibits or is at risk for cardiovascular symptoms or complications related to heart failure. Care Plan interventions include Administer meds as ordered Review of Res.#1's medical record and Medication Administration Record [MAR] beginning on 7/13/24 and continuing through the day of the complaint investigation on 8/12/24 reveals that Res.#1's Systolic Blood Pressure and/or Heart Rate were below the physician prescribed parameters 16 times, yet the blood pressure medicine Metoprolol was still administered. Further review reveals no documentation in Res.#1's medical record of why the medication was given in error or that the physician was notified of the medication order not being followed. An interview was conducted with the Director of Nursing [DON] on 8/12/24 at 10:19 AM. The DON confirmed that the Metoprolol medication order requires the medication to be held when below certain parameters, and despite the physician ordered parameters, the medication was not administered as ordered per the resident's Care Plan on 16 occasions between 7/13 and 8/12/24.

Based upon observation, interview, and record review, the facility failed to implement an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections related to Enhanced Barrier Precautions (EBP) and residents identified as at risk. Findings include: 1.) Per the Centers for Disease Control and Prevention: Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. EBP may be indicated for residents with . wounds or indwelling medical devices and Effective implementation of EBP requires staff training on the proper use of personal protective equipment (PPE) and the availability of PPE and hand hygiene supplies at the point of care. (https://www.cdc.gov/hai/containment/PPE-Nursing-Homes.html.) Per observation on 4/22/24 at 11:30 AM, there were no residents on Enhanced Barrier Precautions (EBP) on any of the facility's resident units. Per observation, interview, and record review, it was revealed that Residents #26, #51, #17, #37, #36, #19, all were identified as having either wounds or indwelling medical devices which indicated that EBP should be implemented. Per interview on 4/22/24, staff were unaware of any requirement for Enhanced Barrier Precautions for the above listed residents and were not observed using PPE during direct care on the residents. Per observation on 4/23/24 at 8:00 AM, resident rooms #12, #13, #15, #17, #18, and #21 had EBP signs on the doors that were not on the doors the previous day. Per interview on 4/23/24 at approximately 8:10 AM, a Licensed Nursing Assistant explained that the signs were on doors of residents with wounds or catheters and they were just put there last night. Per interview on 4/23/24 at 9:05 AM, the Infection Preventionist confirmed that the signs were not up yesterday; the facility had put up the signs and started education with the staff regarding the precautions last night. Per interview with the facility's Infection Preventionist on 4/23/24 at 2:30 PM, Enhanced Barrier Precautions [EBP] including signage, staff education, placement of PPE, and resident notification were conducted after the survey team arrived on-site on the morning of 4/22/24. The Infection Preventionist confirmed that EBP should have been in place for any residents having either wounds or indwelling medical devices but was not. The Infection Preventionist stated signage, education, and notification was conducted in the afternoon of 4/22/24. 46135

Based on interview and record review the facility failed to provide activities of daily living care based on resident preference for 3 of 21 residents sampled (Residents #43, #209, and #15). Findings include: 1. Per record review, Resident #43's care plan reveals the following focus [Resident #43] is at risk for decreased ability to perform ADL(s) [activities of daily living] in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, toileting related to: CVA [stroke], created 3/2/2023. Interventions include Provide resident/patient with extensive assist of 1 for dressing; Provide resident/patient with extensive assist of 2 for transfers using a mechanical lift; Provide resident/patient with extensive assist of 1 for eating. Per observation and interview on 4/23/24 at 8:33 AM, Resident #43 was awake and in bed. S/He stated that s/he would like to be up and in the dining room eating breakfast right now but has to wait until there is enough staff to get him/her up. Per observation at 10:45 AM, staff brought Resident #43 to the dining room for breakfast in his/her wheelchair. Per interview at 11:48 AM, Resident #43 explained that s/he is not able to get out of bed and eat breakfast when s/he wants to because staff are too busy. S/He said that s/he is hungry and by the time s/he eats breakfast, lunch is shortly after. S/He explained this happens almost every day. 2. Per record review, Resident #209's care plan reveals the following focus [Resident #209] is at risk for decreased ability to perform ADL(s) in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, toileting related to: Limited mobility, L hip fx s/p ORIF [left hip fracture status post open reduction and internal fixation], created 4/06/2024. Interventions include: Provide resident/patient with extensive assist of 2 for ambulation using a walker, gait belt, and nonskid footwear. Follow with [wheelchair]; Provide resident/patient with extensive assist of 1 with [bedside commode] over toilet; Provide resident/patient with extensive assist of 1 for bathing. Per observation and interview on 4/23/24 at 8:30 AM, Resident #209 was sitting in his/her chair in his/her room. S/He stated that s/he would like to be up and eating breakfast right now but s/he has to use the bathroom first. S/He explained that the aides know that s/he is waiting to use the bathroom but they are going to come back when they are not as busy. At 9:20 AM, Resident #209 received their breakfast. At 11:57 AM Resident #209 said that s/he never got help using the bathroom this morning. S/He explained that she would like to use the bathroom before s/he eats breakfast in the morning and that never happened because staff did not have enough time. S/He was frustrated that s/he also had to wait so long for breakfast. Per interview on 4/23/24 at 8:40 AM, a Registered Nurse explained that it is typical for residents to be waiting in bed for am care and breakfast at this time of day because there are only 2 aides on. The staff try their best to get the residents up when they want to but with only two aides on, some residents have to wait a long time after they ask to get up. Per interview on 4/24/24 at 3:20 PM the Director of Nursing confirmed that all residents have the right to make their own choices, including when to get out of bed and eat meals. 50336 3. Per record review, Resident # 15's care plan reveals the following focus [Resident #15] is at risk for decreased ability to perform ADL(s) in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, toileting) related to: weakness, acute renal failure, right great toe amputated; created 05/15/2023. Interventions reveal that Resident # 15 needs assistance with ADL's. Another care area focus states: While in the facility, [Resident # 15] states that it is important that [s/he] has the opportunity to engage in daily routines that are meaningful relative to their preferences. Intervention includes I like to get up in the morning between 7am-9am. During an interview with Resident # 15 on 04/22/2024 approximately 11:30 AM, Resident # 15 states I have to be removed from my room when the staff care for my roommate. I then wait for my care in the hall outside of the room. I don't get to eat breakfast until 10:00 or 11:00 am which is too late. I would prefer to eat at 7:00 am when I am awake. I have complained to staff, but no one seems to be doing anything about it. Per observation and interview at approximately 8:45 am on 4/23/2024 Resident # 15 was outside his/her room, in the wheelchair with a night gown on, open back, and blanket on his/her lap. Resident # 15 stated I have been up since 7:00 am ready to be bathed and dressed but nobody would assist me in getting up. Now I have to wait in the hall for my turn to take a bath and get dressed. I won't get to today until 10:00 or 11:00 which happens all the time. Per interview with the Social Service Director on 04/23/2024 at approximately 4:00 pm she/he stated they were aware of Resident # 15 concerns related to being moved out of his/her room. The Social Service Director confirmed Resident # 15 has complained several times to her/him about being left in the hall while they move the roommate around. Social Service Director confirmed that there has been no resolution to this issue.

Based upon observation, interview, and record review, the facility failed to review and revise resident Care Plans related to falls for 3 Residents (Res.# 36, #37, and #47) of 28 sampled residents. Findings include: 1). Per record review, Res. #36 was admitted to the facility with diagnoses that include Alzheimer's Disease, repeated falls, lack of coordination, and abnormalities of gait and mobility. Res. #36 was assessed as at risk for falls related to a history of falls, poor safety awareness and unsteady gait, and a Care Plan was developed with interventions to prevent falls upon their admission to the facility in 2022. Review of Res. #36's medical record reveals the resident suffering multiple falls while at the facility, with the most recent falls on 2/17/24 and 3/8/24. Per nursing notes dated 2/17/24, Res. #36 was found on bedroom floor next to the door laying on [h/her] side. A Change in Condition form for the resident was completed regarding the fall, noting that the resident's Primary Care Provider responded with the following feedback: follow fall protocol. Review of the facility's 'Falls Management' policy [revision date 3/15/24] includes Implement and document patient-centered interventions according to individual risk factors in the patient's plan of care. Review of the resident's Care Plan after the fall on 2/17/24 revealed no new interventions added to prevent future falls. Further review of Res.#36's medical record reveals on 3/8/24 Res. #36 suffered another fall, resulting in a contusion and facial bruising. Nursing notes after the fall record the resident 'has a history of mental health disorders, falls, impulsiveness, wandering, anxiety about surroundings, and left and right leg extremity weakness'. Review of the resident's Care Plan after the fall on 3/8/24 revealed no new interventions added to prevent future falls. 2). Per record review, Res. #37 was admitted to the facility with diagnoses that include Alzheimer's Disease, dementia, psychotic disturbances, and fractures of the right arm, right femur [leg], and right pubis [hip]. Res. #37 was assessed as at risk for falls related to a history of falls, impaired mobility, and unsteady gait, and a Care Plan was developed with interventions to prevent falls upon their admission to the facility in 2022. Review of Res. #37's medical record reveals the resident suffering multiple falls while at the facility, including 3 falls in 3 weeks, from 3/13/24 to 4/3/24. Per review of Res.#37's medical record, a Change in Condition note dated 3/13/24 records Resident found on floor on [h/her] right side between [h/her] bed and [h/her] recliner chair .Resident hoyered [mechanical lift] off the floor onto [h/her] bed. On 3/25/24, a Change in Condition note for Res.#37 records Resident found to be sitting upright on floor at bedside. States [s/he] was trying to get into bed and slid down to floor. On 4/3/24, Nursing notes document Res.#37 was laying on right side of body, on the floor, directly by bed .Assisted from floor to wheelchair with 2 person assist. Review of the resident's Care Plan after 3 consecutive falls on 3/13, 3/25, & 4/3/24 revealed no new interventions added to prevent future falls. An interview was conducted with the facility's Director of Nursing [DON] and the Corporate Compliance Director on 4/24/24 at 10:56 AM. The DON and the Corporate Compliance Director confirmed that after multiple falls, the care plans for both Res.#36 and #37 were not updated with new interventions to prevent future falls, resulting in both residents suffering additional falls, including Res. #36 who suffered a contusion and facial bruising. 50336 3. Per record review, Resident # 47 was admitted to the facility on [DATE] and has diagnoses that include history of falls, lumbar spine fracture and orthostatic hypotension (low blood pressure drops when standing). Resident # 47 has the following care plan initiated on 08/11/2023 which states resident at risk for falls related to impaired mobility, lumber fracture, stroke with left sided weakness. Interventions include toilet after meals, offer resident to go to the bathroom every 2-3 hours, obtain resident input and anticipate needs to prevent future falls, provide verbal cues for safety, place walking device within reach to enable use of walker, and place the call bell within reach. Per record review from 08/11/2023 through 4/22/2024, Resident # 47 had 22 documented falls. Resident # 47's care plan was revised only 4 of the 22 times after a fall. Per facility policy Falls Management last revised 03/24/2024 states patients experiencing a fall will receive appropriate care and post fall interventions will be implemented. The purpose is to identify risk for falls, minimize the risk of recurrence of falls, and to ensure patient centered care plan is reviewed and revised. Per interview with a Licensed Nursing Assistant (LNA) familiar with Resident # 47's care on 4/23/2024 at approximately 2:30 pm, he/she stated that they were concerned that there isn't enough staff to keep Resident # 47 from falling. The LNA stated that often Resident # 47 has falls multiple times a day, and there are not enough interventions including adequate supervision to prevent falls and keep Resident # 47 safe.

Based on interview and record review, the facility failed to identify a resident's past history of trauma, and/or triggers which may cause re-traumatization for 2 applicable residents (Residents #26 and #11). Findings include: 1. Record review reveals that Resident #26 was admitted to the facility on [DATE] and has diagnoses that include mood disorder, major depressive disorder, and delusional disorder. Per review of Resident #26's physician orders, Resident #26 is taking Olanzapine, an antipsychotic medication, for post traumatic stress disorder (PTSD). Nurse Practitioner notes from 3/28/24, 4/3/24, and 4/11/24 reveal in the list of medications reviewed and updated that Resident #26 is taking OLANZapine Oral Tablet 5 MG (Olanzapine) Give 5 mg by mouth two times a day for PTSD. Per review of Resident #26's care plan, neither PTSD or trauma is addressed as a care plan focus or within care plan interventions. Per interview on 4/24/24 at 9:55 AM, a Licensed Nursing Assistant (LNA) explained that Resident #26 sometimes has flashbacks from being in the service. The LNA said s/he didn't think s/he was care planned for this. Per interview on 4/24/24 at 1:38 PM, the Nurse Practitioner explained s/he recently attempted a gradual dose reduction for Resident #26's Olanzapine but was not successful because s/he received reports that Resident #26 was having aggressive behaviors and flashbacks. A social service assessment used to screen for PTSD was completed 7/19/23. The assessment coded Resident #26 as negative for trauma. The screening tool used is a two question assessment that asks the resident if they have experienced any consequences from trauma in the past month. It does not ask the resident if they have experienced trauma at any point in their past. Per interview on 4/23/24 4:02 PM, the Social Service Director explained that s/he was not aware that Resident #26 had a history of PTSD. S/He confirmed that the only screening that s/he did for trauma was to ask the two questions above. S/He explained that there are no other screening tools that s/he uses to assess for trauma. 48017 2.) Per interview on 4/22/24 at approximately 1:40 PM, Resident #11 revealed that s/he has post-traumatic stress disorder PTSD. S/he is a [NAME] with a history of live combat. S/he states sudden loud noises and loud male voices all trigger him/her causing panic and a need to hide. Per record review, Resident #11 was admitted to the facility on [DATE] with diagnoses of Major Depressive Disorder and Traumatic Stress Disorder. A care plan with a date of 4/10/24 indicates an entry: Resident /Patient reports past experience of trauma as evidenced by PTSD, with an intervention of Encourage Resident/Patient to identify personal trauma and triggers and take steps to eliminate/minimize. Resident #11 has no triggers identified in his/her medical record or care plan. Per the record review, a social service assessment used to screen for PTSD was completed on 4/3/24; the assessment coded Resident #11 as positive for trauma. The screening tool used is a two-question assessment that asks the residents if they have experienced any consequences from trauma in the past month. It does not ask the resident if they have experienced trauma at any point in their past. Per interview on 4/24/24 at approximately 2:30 PM, the Director of Social Services confirmed that the only screening that s/he used for trauma was to ask the two questions above. S/he confirmed there are no other screening tools s/he uses. S/he reveals that she/he learns of a resident's PTSD by their medical record or the two-question assessment.

Based on record review and staff interview the facility failed to ensure that 1 of 5 sampled residents (Resident #1) maintained adequate parameters of nutritional status. Resident #1 experienced a significant unplanned weight loss and an electrolyte imbalance. Specifically, the facility failed to identify an unplanned significant weight loss and failed to follow the facility's policy of assessing and implementing increased monitoring and implementation of nutritional interventions to maintain weight/nutritional status. The findings are as follows: Review of the electronic medical record (EMR) identifies that Resident #1 was admitted to the facility in 2021 with [DIAGNOSES REDACTED]. Reviewed the admission Minimum Data Set (MDS), completed on 1/28/21 and signed by the Registered Nurse (RN), which is a standard assessment tool for long term care residents. The assessment identified that the resident had a BIMS score (Mental Status Interview) that was unable to be calculated due to severe cognitive deficit, s/he had a functional status of requiring extensive assistance with one staff member for eating and had a height of 61 inches with a weight of 136 pounds on the day the assessment was completed. Per review of the Care Area Assessment Summary (CAAS) included in the MDS, identifies that (Nutrition Status triggered and the decision to care planning has been noted by and X see nutritional assessment 1/22). The documented weight sheet in the EMR identifies the following weights: -147.3 pounds on 1/15/21 -135.6 pounds on 1/22/21 -127.4 pounds on 1/27/21 -130.4 pounds on 1/29/21 -124.6 pounds on 2/4/21 -121.6 pounds on 2/11/21 -121.6 pounds on 2/23/21 -113.2 pounds on 3/9/21 Per review of the Nutritional Assessment, completed and signed by the Registered Dietician (RD) on 1/22/21 identifies hospital weights as: 1/13/21 at 138 pounds and 1/14/21 at 147 pounds. The resident was receiving two diuretics, [MEDICATION NAME] and [MEDICATION NAME], daily and a daily [MEDICATION NAME] antibiotic (Cipro) for chronic urinary tract infections. His/her food intake varied, and over a week's time averaged at 33%. The resident was being fed by others initially on admission but progressed to self-feeding. His/Her BMI is 21.4; slightly overweight, but acceptable and was receiving a regular as tolerated diet. Assessment identified that the RD would continue to monitor, appears to be improving and add interventions if it remains inadequate to meet needs. The RD identifies that the nutritional status will be addressed on the care plan. Per review of the care plan on 3/25/21, initiated on admission and throughout his/her stay, does not identify any care plan related to food/nutrition/hydration and weight loss. Progress note written by the RD on 1/28/21 identifies a significant weight loss of -13.5%. Some weight loss was anticipated as [MEDICAL CONDITION] resolved. The Residential Care Home (RCH) that s/he resided at reported weight fluctuated 128-131pounds over the fall and December. Variable intake depending on mood. According to the RCH manager s/he loves grapes, peeled apples, popcorn, candy bars, ginger ale, and cookies. The resident reports s/he does not like milk but is OK with cheese and yogurt. Average intake for one week is 54% which is improved. Will continue with small portions, add super cereal in the AM based on preferences, monitor weight, intake and additions interventions as needed (PRN). RD will be notified on any significant change's. The weekly weights for Resident #1 documented identify that on 1/29/21 s/he weighs 130.4 pounds and lastly on 3/9/21 s/he weighs 113.2 pounds. There are no further RD progress notes after the last note dated 1/28/21 identifying another significant weight loss. Per review of the EMR, documentation identifies that the resident was sent to the emergency room for evaluation on 3/11/21 due to abnormal lab values specifically a critical elevation level of potassium, elevated BUN, a low sodium level and an elevated white blood count. Per interview with the RD on 3/25/21 at approximately 2:30 PM, s/he was asked if s/he was aware of the burn Resident #1 suffered on 3/5/21, the ER transfer on 3/11/21, and the return on palliative care on 3/11/21. The RD responded that s/he worked both 3/5/21 and 3/11/21 but could not confirm any recollection of all that had transpired. S/he was then asked as the RD what initiatives were put in place to ensure that the resident received fluids/foods to maintain his/her weight and avoid further weight loss? The RD confirms during this interview that (I should have done a full assessment but did not). A full assessment would have triggered a care plan revision per MDS manual. Per interview on 3/29/21 at approximately 11 AM the Speech/Language Pathologist identifies that Resident #1 was seen on 1/15/21 and treated until 2/3/21. S/he had a [DIAGNOSES REDACTED]. The resident progressed after being removed from quarantine, eating in the dining room and self-feeding. Staff instruction was to minimize the risk of malnutrition/weight loss and to enhance the resident's quality of life. Per review of the facility Food and Nutrition Services policy dated (revised) 10/27/21 identifies the following: - Nutritional assessment is completed by the Dietitian or the non-dietitian designee upon admission, annually, and with changes in nutritional status. - The Dietitian completes a comprehensive or further assessment for any patients/residents determined to be of nutrition concern. - Patients/Residents with a nutritional concern are monitored at least monthly. Progress note is written when deemed necessary. - Care plans are evaluated and updated a minimum of quarterly or as scheduled according to established policies. See F 656.

Based on record review and staff interview, the facility failed to immediately notify the physician when one resident in the applicable sample of 17 (Resident #93) had a significant change of condition. Findings include: Per review of documentation provided by the facility, Resident #93 was admitted to the facility on [DATE] for rehabilitation following hip replacement surgery. At approximately 7:30 PM on 8/15/17, Resident #93 transferred from the commode to the bed with the assistance of one Licensed Nurse Assistant (LNA). The Licensed Practical Nurse (LPN) on duty was administering medications to the roommate and reported hearing through the privacy curtain, Oh, my leg, stated by Resident #93. The LNA reported to the LPN that Resident #93 sat abruptly on the bed during the transfer. The medical record showed that the LPN examined Resident #93 and found no apparent injury. Resident #93 rated pain at that time as 4 on a scale of 0-10, with 10 being the worst possible pain. Pain medication (50 milligrams [MEDICATION NAME] orally every 6 hours as needed for pain) was administered at 7:45 PM and was documented on the Medication Administration Record (MAR) as having a positive effect. The MAR further indicated that the night nurse (an LPN) administered doses of pain medication at 1:35 AM and 6:30 AM. Significantly, the LPN documented medication effects for each of these doses bad hip pain. The LPN also documented in a night shift note (8/16/17 at 4:59 AM) that Resident #93 was in bad pain all night, did not sleep well, did not tolerate being transferred to the bedside commode, and was yelling out. The incident report and a nurse note (written at 9:09 AM) indicated that a Registered Nurse (RN) examined Resident #93 at the beginning of the day shift (7:00 AM) on 8/16/17. The RN found that Resident #93 was in pain, per non-verbal symptoms exhibited, and that the right leg had swelling and deformity. Per the incident report, the physician was notified of the change of condition in Resident #93 at 8:15 AM on 8/16/17. The LPN, despite the ongoing bad hip pain during the night, did not notify the physician. During an interview on 8/29/17 at 3:15 PM, the Administrator confirmed that the LPN should have phoned the physician when the available pain medication did not provide relief to Resident #93. See also F309.

Based on record review and staff interview, the facility failed to respond appropriately to the presence or progression of pain for one of 17 residents in the applicable sample (Resident #93). Findings include: Per review of documentation provided by the facility, Resident #93 was admitted to the facility on [DATE] for rehabilitation following hip replacement surgery. At approximately 7:30 PM on 8/15/17, Resident #93 transferred from the commode to the bed with the assistance of one Licensed Nurse Assistant (LNA). The Licensed Practical Nurse (LPN) on duty was administering medications to the roommate and reported hearing through the privacy curtain, Oh, my leg, stated by Resident #93. The LNA reported to the LPN that Resident #93 sat abruptly on the bed during the transfer. The medical record showed that the LPN examined Resident #93 and found no apparent injury. Resident #93 rated pain at that time as 4 on a scale of 0-10, with 10 being the worst possible pain. Pain medication (50 milligrams [MEDICATION NAME] orally every 6 hours as needed for pain) was administered at 7:45 PM and was documented on the Medication Administration Record (MAR) as having a positive effect. However, the MAR further indicated that the night nurse (an LPN) administered doses of pain medication at 1:35 AM and 6:30 AM. Significantly, the LPN documented medication effects for each of these doses bad hip pain. The LPN also documented in a night shift note (8/16/17 at 4:59 AM) that Resident #93 was in bad pain all night, did not sleep well, did not tolerate being transferred to the bedside commode, and was yelling out. The incident report and a nurse note (written at 9:09 AM) indicated that a Registered Nurse (RN) examined Resident #93 at the beginning of the day shift (7:00 AM, 8/16/17). The RN found that Resident #93 was in pain, per non-verbal symptoms exhibited, and that the right leg had swelling and deformity. Per the incident report, the physician was notified of the change of condition in Resident #93 at 8:15 AM on 8/16/17. The LPN, despite the ongoing bad hip pain during the night, did not notify the physician. During an interview on 8/29/17 at 3:15 PM, the Administrator confirmed that the LPN should have phoned the physician when the available pain medication did not provide relief to Resident #93.